West Virginia HEALTH CARE CLAIM: 837Companion Guide Companion Guides/WV-Molina 5010 (x12... · West...

West Virginia HEALTH CARE CLAIM: 837Companion Guide

Version 1.4

Revised July 22, 2014

July 22, 2014 2 837 Companion Guide

TABLE OF CONTENTS

TABLE OF CONTENTS .................................................................................................. 2

RECORD OF CHANGE .................................................................................................. 3

COMPANION GUIDE PURPOSE ................................................................................... 3

ATYPICAL PROVIDERS ................................................................................................ 4

ONE-TO-MANY PROVIDERS ........................................................................................ 5

CONTROL STRUCTURE DEFINITIONS ........................................................................ 7

ISA - INTERCHANGE CONTROL HEADER SEGMENT .......................................... 7

IEA - INTERCHANGE CONTROL TRAILER ............................................................ 7

GS – FUNCTIONAL GROUP HEADER .................................................................... 8

GE – FUNCTIONAL GROUP TRAILER .................................................................... 8

VALID DELIMITERS FOR WEST VIRGINIA MEDICAID .......................................... 8

TRANSMISSION CONSTRAINTS .................................................................................. 8

COMPANION GUIDE FOR THE 837 PROFESSIONAL TRANSACTION .................... 10

PAAS MEMBERS .................................................................................................... 15

ADDITIONAL PROVIDER INFORMATION ............................................................. 15

COMPANION GUIDE FOR THE 837 INSTITUTIONAL TRANSACTION ..................... 16

PAAS MEMBERS .................................................................................................... 22


ADDITIONAL INFORMATION FOR NURSING HOMES .............................................. 24

COMPANION GUIDE FOR THE 837 DENTAL TRANSACTION ................................. 25



RECORD OF CHANGE

DATE DESCRIPTION OF CHANGE ORIGINATOR BMS APPROVED

6/22/11 Created to reflect 5010 WV EDI

02/13/12 Updated 837I PAAS Loops WV EDI

03/08/12 Updated 837I Reporting Patient Resources for Nursing Homes

WV EDI

10/30/12 Update to clarify secondary Claim Filing Indicator(s) WV EDI

7/22/14 Patient Resource Value (HI02-2) Updated WV EDI

The Molina Healthcare Companion Guide for West Virginia Medicaid is subject to change prior to January 1, 2012 or at the instruction of the Department. Therefore, it is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing\building NX12 5010 EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any costs that the trading partner may incur that arise from or are related to changes to the companion guide.

COMPANION GUIDE PURPOSE

This companion guide document for the transaction type listed below further defines situational and required data elements that are used for processing claims for programs administered by West Virginia Bureau for Medical Services. This document is not the complete EDI transaction format specifications.


ATYPICAL PROVIDERS

This section is for Atypical providers (performing non-health care services) who will be permitted to bill using their existing Medicaid ID numbers. The EDI formatting location of Billing, Referring, and Rendering Provider Information is dependent upon the situation being billed. Below are the circumstances and EDI billing locations of this information. Billing Provider Location This is used when the Billing Provider is a servicing provider only, and or if the Billing Provider is the same as the Pay-To Provider.

Billing Provider Tax Identification

2010AA REF01 Reference Identification Qualifier

‘EI’ or ‘SY’

Billing Provider Tax Identification

2010AA REF02 Billing Provider Additional Identifier

Billing Provider Secondary Identification

2010BB REF01 Reference Identification Qualifier

‘G2’

Billing Provider Secondary Identification

2010BB REF02 Billing Provider Additional Identifier

Billing Medicaid Provider Number

Rendering Provider Name

2310B REF01 Reference Identification Qualifier

‘G2’


2310B REF02 Reference Identification

Rendering Medicaid Provider Number


ONE-TO-MANY PROVIDERS

This section applies to those providers who choose to link a single NPI to more than one Medicaid provider number. This method of enumeration is referred to as being a “One-to-Many” provider. There are several ways in which an NPI can locate a specific Medicaid provider number on which to process claims for the One-to-Many providers. The Molina EDI department requests that provider’s bill with all of the features that will identify the correct Medicaid number in the Molina system. Below are specific billing scenarios and examples that will assist in getting files submitted to WV Medicaid correctly for payment. One-to-Many providers, it is imperative that the provider information in the claim file(s) match the information in the Molina system for the provider(s). The values used for the NPI lookup are as follows:

NPI Number

Taxonomy code

Provider Name (First /Last or Organization)

Zip Code plus 4 / 9 digit zip code of the physical address

“Taxonomy Code”: The Taxonomy code is optional but is recommended. When submitting a Taxonomy code, the provider MUST submit with the Taxonomy code that has been assigned to them by Molina. Failure to do so could cause the providers claims to fail. If NO Taxonomy code is submitted, the NPI lookup will use the “Provider Name” and “9 digit Zip code to locate the Provider in the Molina system. Please Note: Submitters who go through a Clearinghouse, Billing Vendor or that use a third party software(s) to UPLOAD their claim files to Molina will need to reference the Implementation Guide for detailed rules and regulations when submitting a Taxonomy code. Please contact the Molina Enrollment Department for assistance in obtaining a Provider’s Taxonomy code information at 1 888 483 0793. “Provider Name”: The NPI lookup will try to match on the first 35 characters of the provider name. Some Provider name(s) may contain special characters. If the billing software prevents use of these values, contact the Molina Provider Enrollment Department at 1 888 483 0793, who will update the provider name and will remove the special characters. Example: Two Medicaid Provider IDs linked to a single NPI that have different names, but the same Taxonomy and 9 digit Zip code(s):


Molina Medical One (MDGRP), Taxonomy = 291U00000X, Zip = 123450000 Molina Medical Two (MDGRP), Taxonomy = 291U00000X, Zip = 123450000 Molina Medical One (MDGRP) When submitting a claim for “Molina Medical One (MDGRP)”, verify the name is sent in exactly as it is in the claims processing system including any special characters. This will allow the NPI lookup to distinguish the Molina Medical One (MDGRP) provider apart from the other Provider linked to the same NPI. Pease Note: If the billing software does not allow special characters, Molina can update the provider name and remove the special characters so that it will appear as: Molina Medical One MDGRP “9 digit Zip Code”: The NPI lookup will also try and match on a 9 digit Zip code of the provider’s physical address. The 9 digit Zip code must be billed as it is listed in the Molina system. The One-to-Many providers who have multiple Medicaid provider numbers with the same taxonomy code and that have the same first 5 digits of the Zip code are required to bill with the additional 4 digits of the Zip code making it a 9 digit Zip code to differentiate the providers. If the full 9 digit Zip code is submitted, and matches what is in our system but is also the same 9 digit Zip code as the other Legacy providers linked to the single NPI, the NPI lookup will then utilize the “Provider Name” to find the correct Medicaid provider to process the claim on. Example: Two Medicaid Provider IDs linked to a single NPI that have the same name, taxonomy code, but have different 9 digit Zip Codes. Molina Medical (LAB), Taxonomy = 291U00000X, Zip = 123459999 Molina Medical (LAB), Taxonomy = 291U00000X, Zip = 123450000 The 9 digit Zip code will distinguish the two providers apart. Please Note: When billing a 9 digit Zip code, do not send a dash (“– “) in the claim file so there is a 9 digit numeric value. (i.e. 123456789)


CONTROL STRUCTURE DEFINITIONS

ISA - INTERCHANGE CONTROL HEADER SEGMENT

Reference Definition Values ISA01 Authorization Information

Qualifier 00

ISA02 Authorization Information [space fill]

ISA03 Security Information Qualifier

00

ISA04 Security Information [space fill]

ISA05 Interchange ID Qualifier ZZ

ISA06 Interchange Sender ID Insert with the unique number found on your West Virginia Transaction Information Form.

ISA07 Interchange ID Qualifier ZZ

ISA08 Interchange Receiver ID WV_MMIS_4MOLINA

ISA09 Interchange Date The date format is YYMMDD

ISA10 Interchange Time The time format is HHMM

ISA11 Repetition Separator ^

ISA12 Interchange Control Version Number

00501

ISA13 Interchange Control Number

Must be identical to the interchange trailer IEA02 (defined by sending Trading Partner)

ISA14 Acknowledgment Request 1

ISA15 Usage Indicator T= Test Data P = Production Data

ISA16 Component Element Separator

:

IEA - INTERCHANGE CONTROL TRAILER

Reference Definition Values IEA01 Number of included

Functional Groups Count of included Functional Groups

IEA02 Interchange Control Number

Must be identical to the value in ISA13


GS – FUNCTIONAL GROUP HEADER

Reference Definition Values GS01 Functional Identifier Code HC = Health Care Claim (837)

GS02 Application Sender’s Code Must be identical to the value in ISA06

GS03 Application Receiver’s Code

WV_MMIS_4MOLINA

GS04 Date The date format is CCYYMMDD

GS05 Time The time format is HHMM

GS06 Group Control Number Assigned and maintained by the sender

GS07 Responsible Agency Code X

GS08 Version/Release/Industry Identifier Code

Appropriate Version Code for the claim

GE – FUNCTIONAL GROUP TRAILER

Reference Definition Values GE01 Number of Transaction

Sets Included Number of Transaction Sets Included

GE02 Group Control Number Must be identical to the value in GS06

VALID DELIMITERS FOR WEST VIRGINIA MEDICAID

Definition ASCII Decimal Hexadecimal Segment Separator ~ 126 7E

Element Separator * 42 2A

Compound Element Separator : 58 3A

TRANSMISSION CONSTRAINTS

1. Only one Interchange per transmission 2. Only one transaction type per interchange 3. Maximum of 5,000 claims per transmission 4. Single transmission file size must be less than 5MB


FIELD DEFINITIONS

Label Column Definition A The name of the loop as documented in the appropriate 837 TR3.

B A loop ID number used to identify a group of segments that are collectively repeated in a serial fashion up to a specified maximum number of times as documented in the appropriate 837 TR3.

C The field position number and segment number as specified in the appropriate 837 TR3.

D The data element name as indicated in the appropriate 837 TR3.

E The Values and Comments further describing the appropriate 837 TR3 field data that West Virginia Medicaid will accept.


COMPANION GUIDE FOR THE 837 PROFESSIONAL TRANSACTION

The 837 Professional Versions used in creating the guide.

Health Care Claim: Professional Transaction ASC X12N 837(005010X222) May 2006

Errata Health Care Claim: Professional Transaction

ASC X12N 837(005010X222A1) June 2010

Loop Name Loop ID

Field Position/ Segment

Data Element Name/Page

Number from Implementation

Guide

Valid Values And/or

Comments

A B C D E

Version/Release/Industry Identifier Code

GS08 Identification Code

005010X222A1

Beginning of Hierarchical Transaction

BHT02

Transaction Set Purpose Code

‘00’ Original


BHT06

Transaction Type Code

‘CH’ Chargeable

Submitter Name 1000A NM109 Identification Code

Insert with the unique number found on your West Virginia Transaction Information Form.

Submitter Contact Information

1000A PER03 Communication Number Qualifier

‘TE’ Telephone Minimum requirement, PER 05 –PER08 may also be sent.

Receiver Name 1000B NM103 Name Last or Organization Name

WV_MMIS_4MOLINA

Receiver Name 1000B NM109 Identification Code

WV_MMIS_4MOLINA

Billing Provider Name

2010AA NM108 Identification Code Qualifier

‘XX’ National Provider ID. Atypical Providers refer to Atypical Section.


2010AA NM109 Identification Code

Billing Provider National Provider ID.


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E

Usage changed to situational.

Billing Provider Address 2010AA N403 Postal Code

Billing Provider Zip Code must be the full 9 digits

Subscriber Hierarchical Level

2000B HL04 Hierarchical Child Code

‘0’ No subordinate HL Segment in the Hierarchical Structure

Subscriber Information 2000B SBR09 Claim Filing Indicator Code

MC

Subscriber Name 2010BA NM102 Entity Type Qualifier

‘1’ Person

Subscriber Name 2010BA NM108 Identification Code Qualifier

‘MI’ Member Identification Number

Subscriber Name 2010BA NM109 Identification Code

West Virginia Medicaid 10 digit Recipient Number

Payer Name 2010BB NM103 Name Last or Organization Name

WV_MMIS_4MOLINA

Payer Name 2010BB NM108 Identification Code Qualifier

‘PI’ Payer Identification

Payer Name 2010BB NM109 Identification Code

WV_MMIS_4MOLINA

Claim Information 2300 CLM01 Claim Submitter’s Patient Account / Identifier Number

Patient Control Number

Claim Information 2300 CLM05-3 Claim Frequency Type Code Addenda

‘1’ Original ‘7’ Replacement ‘8’ Void

Claim Information 2300 CLM06 Yes/No Condition or Response Code

‘Y’ Yes


‘Y’ Yes

Health Care Diagnosis Code

2300 HI01-2 Industry Code Diagnosis Code

Required on all claims. Transportation claims use 799.0 when unknown.


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E

Referring Provider Name 2310A NM108 Identification Code Qualifier

‘XX’ National Provider ID

Referring Provider Name 2310A NM109 Identification Code

Referring Provider National Provider ID


2310B NM108 Identification Code Qualifier



2310B NM109 Identification Code

Rendering Provider National Provider ID


2310B PRV01 Provider Code

‘PE’ Performing

SBR-Other Subscriber Information

2320 SBR09 Claim Filing Indicator Code

Please ensure to use the correct indicator code(s) when billing WV Medicaid as a secondary or tertiary payer. Do not send ‘MC’ in this Position/Segment for secondary or tertiary claims. Valid values are; ‘11’ – Other Non-Federal Programs ‘12’ – Preferred Provider Organization (PPO) ‘13’ – Point of Service (POS) 14 – Exclusive Provider Organization (EPO) ‘15’ – Indemnity Insurance ‘16’ – Health Maintenance Organization (HMO) Medicare Risk ‘17’ – Dental


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E

Maintenance Organization ‘AM’ – Automobile Medical ‘BL’ – Blue Cross/Blue Shield ‘CH’ – Champus ‘CI’ – Commercial Insurance Co ‘DS’ – Disability ‘FI’ – Federal Employees Program ‘HM’ – Health Maintenance Organization ‘LM’ – Liability Medical ‘MA’ – Medicare Part A ‘MB’ – Medicare Part B ‘OF’ – Other Federal Program ‘TV’ – Title V ‘VA’ – Veterans Affairs Plan ‘WC’ – Workers’ Compensation health claim ‘ZZ’ – Mutually Defined

Line Adjustment 2430 CAS01 Claim Adjustment Group Code

‘CR’ Correction and Reversals ‘CO’ ‘OA’ ‘PI’ ‘PR’

Line Adjustment 2430 CAS02 Claim Adjustment Reason Code

For adjustment reason codes see http://wpc-edi.com

Line Adjustment 2430 CAS03 Monetary Amount Adjusted Amount Line Level

Line Adjustment 2430 CAS04 Quantity/Adjusted Units – Line

http://wpc-edi.com/


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E

Level


PAAS MEMBERS

Required when billing for PAAS enrolled members.

WV Medicaid does not require the use of NPI when billing the PAAS approval number. Therefore the NPI “OR” Legacy ID may be submitted when billing the PAAS approval ID. Referring Provider Location Required when billing for PAAS enrolled members.

Page 260 Loop 2310A

Referring Provider Secondary Identification

2310A

REF01 Reference Identification Qualifier

‘G2’


2310A REF02 Reference Identification

PAAS Medicaid Provider Number

ADDITIONAL PROVIDER INFORMATION

Taxonomy codes will be accepted by West Virginia Medicaid. The taxonomy code submitted must be one that has been assigned to the Provider by Molina. For more information about submitting a Taxonomy code for the Rendering Provider. Billing Provider with a Pay-To Provider,*2010AA & *2310B This is another method of billing when the Billing Provider is different from the Pay-To Provider. This will work when there is a valid “Billing” provider ID present in block 2310B (Rendering) and a valid “Pay To” provider ID in block 2010AA (Billing Provider). The ID in block 2310B will then become the servicing provider and then the ID in 2010AA then becomes the Pay To.


COMPANION GUIDE FOR THE 837 INSTITUTIONAL TRANSACTION

The 837 Institutional Versions used in creating the guide.

Health Care Claim: Professional Transaction ASC X12N 837(005010X223) May 2006

Errata Health Care Claim: Institutional Transaction

ASC X12N 837(005010X223A1) October 2007

Errata Health Care Claim: Institutional Transaction

ASC X12N 837(005010X223A2) June 2010

Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E



005010X223A2


BHT02

Transaction Set Purpose Code

‘00’ Original


BHT06

Transaction Type Code

‘CH’ Chargeable

Submitter Name 1000A NM109 Identification Code

Insert with the unique number found on your West Virginia Transaction Information Form.

Submitter Contact Information

1000A PER03 Communication Number Qualifier

‘TE’ Telephone Minimum requirement, PER 05 –PER08 may also be sent.

Receiver Name 1000B NM103 Name Last or Organization Name

WV_MMIS_4MOLINA

Receiver Name 1000B NM109 Identification Code

WV_MMIS_4MOLINA


2010AA NM108 Identification Code Qualifier

‘XX’ National Provider ID. Atypical Providers refer to Atypical Section.


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E


2010AA NM109 Identification Code

Billing Provider National Provider ID. Usage changed to situational.

Billing Provider Address 2010AA N403 Postal Code

Billing Provider Zip Code must be the full 9 digits


2000B HL04 Hierarchical Child Code


Subscriber Information 2000B SBR09 Claim Filing Indicator Code

MC


‘1’ Person


‘MI’ Member Identification Number




WV_MMIS_4MOLINA


‘PI’ Payer Identification


WV_MMIS_4MOLINA

Claim Information 2300 CLM01 Claim Submitter’s Patient Account / Identifier Number


Claim Information 2300 CLM05-3 Claim Frequency Type Code Addenda

‘1’ Original ‘7’ Replacement ‘8’ Void


‘Y’ Yes


‘Y’ Yes

Discharge Hour 2300 DTP01 Date Time Period Discharge Hour

‘096’

Claim Information 2300 DTP02 Date Time Period Format Qualifier

‘TM’


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E

Admission Date/Hour 2300 DTP01 Date Time Qualifier

‘435’

Admission Date/Hour 2300 DTP02 Date Time Period Format Qualifier

‘D8’ or ‘DT’

Admission Date/Hour 2300 DTP03 Date Time Period

Institutional Claim Code 2300 CL101 Admission Type Code

Institutional Claim Code 2300 CL102 Admission Source Code

Institutional Claim Code 2300 CL103 Patient Status Code

Prior Authorization or Referral Number

2300 REF01 Reference Identification Qualifier

‘G1’ Prior Authorization Number

Prior Authorization or Referral Number

2300 REF02 Reference Identification Prior Authorization Number

Assigned Prior Authorization Number

Other Diagnosis Code 2300 HI01-2 Industry Code Diagnosis Code

Use appropriate Reference

Principal Procedure Information

2300 HI01-1 Code List Qualifier Code

‘BF’ International Classification of Diseases Clinical Modification (ICD-9-CM)

Principal Procedure Information

2300 HI01-2 Industry Code Principal Procedure Code

Principal Procedure Code

Other Procedure Information

2300 HI01-1 Code List Qualifier Code

‘BQ’ International Classification of Diseases Clinical Modification (ICD-9-CM) Procedure


2300 HI01-2 Industry Code Procedure Code

Other Procedure Code


2300 HI01-4 Date Time Period Procedure Date

Attending Physician Name

2310A NM108 Identification Code Qualifier



2310A NM109 Identification Code

Attending Physician National Provider ID


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E


2310A PRV01 Provider Code ‘AT’ Attending


2310A PRV02 Reference Identification Qualifier

‘PXC’ Health Care Provider Taxonomy Code


2310A PRV03 Reference Identification

Provider Taxonomy Code

Service Facility Secondary Information

2310E REF01 Reference Identification Qualifier

‘G2’ Facility ID Number Nursing Home based Hospice claim use only

Service Facility Secondary Information

2310E REF02 Reference Identification Pg 358

Nursing Facility Provider Number

Referring Provider Name 2310A NM108 Identification Code Qualifier


Referring Provider Name 2310A NM109 Identification Code

Referring Provider National Provider ID



Please ensure to use the correct indicator code(s) when billing WV Medicaid as a secondary or tertiary payer. Do not send ‘MC’ in this Position/Segment for secondary or tertiary claims. Valid values are; ‘11’ – Other Non-Federal Programs ‘12’ – Preferred Provider Organization (PPO) ‘13’ – Point of Service (POS) 14 – Exclusive


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E

Provider Organization (EPO) ‘15’ – Indemnity Insurance ‘16’ – Health Maintenance Organization (HMO) Medicare Risk ‘17’ – Dental Maintenance Organization ‘AM’ – Automobile Medical ‘BL’ – Blue Cross/Blue Shield ‘CH’ – Champus ‘CI’ – Commercial Insurance Co ‘DS’ – Disability ‘FI’ – Federal Employees Program ‘HM’ – Health Maintenance Organization ‘LM’ – Liability Medical ‘MA’ – Medicare Part A ‘MB’ – Medicare Part B ‘OF’ – Other Federal Program ‘TV’ – Title V ‘VA’ – Veterans Affairs Plan ‘WC’ – Workers’ Compensation health Claim ‘ZZ’ – Mutually Defined

Institutional Service Line 2400 SV202 Composite Medical

Required for all Outpatient claims


Loop Name Loop ID




Guide

Valid Values And/or

Comments

A B C D E

Procedure Identifier

Institutional Service Line 2400 SV207 Monetary Amount Line Item Denied Charge or Non-Covered Charge Amount

Line Adjustment 2430 CAS01 Claim Adjustment Group Code

‘CR’ Correction and Reversals ‘CO’ ‘OA’ ‘PI’ ‘PR’

Line Adjustment 2430 CAS02 Claim Adjustment Reason Code

For adjustment reason codes see http://wpc-edi.com

Line Adjustment 2430 CAS03 Monetary Amount Adjusted Amount Line Level

Line Adjustment 2430 CAS04 Quantity/Adjusted Units – Line Level

http://wpc-edi.com/


PAAS MEMBERS

Required when billing for PAAS enrolled members.

WV Medicaid does not require the use of NPI when billing the PAAS approval number. Therefore the NPI “OR” Legacy ID may be submitted when billing the PAAS approval ID.

Referring Provider Name

2310F NM108 Identification Code Qualifier ‘XX’ National Provider ID

Other Provider Name

2310F NM109 Identification Code PAAS Provider National Provider ID

Or


2310F


‘G2’ Medicaid Provider Number


2310F REF02 Reference Identification

PAAS Medicaid Provider Number


Attending Physician NPI Location Required when the claim being billed is for an Inpatient Bill Type. WV Medicaid does not require the use of NPI when billing the Attending Physician number. Therefore the NPI “OR” Legacy ID may be submitted when billing the Attending Physician ID. Loop 2310A


2310A NM108 Identification Code Qualifier ‘XX’ National Provider ID


2310A NM109 Identification Code Attending Physician National Provider ID

Or

Attending Physician Secondary Identification

2310A


‘G2’ Medicaid Provider Number

Attending 2310A REF02 Reference Identification Medicaid Provider


Physician Secondary ID

Number


ADDITIONAL INFORMATION FOR NURSING HOMES

Loop Name Loop

ID Field Position/ Segment

Data Element Name/Page Number from Implementation Guide

Valid Values And/or Comments

A B C D E

Admission Date/Hour

2300 DTP03 Date Time Period Admission Date and Hour

Original MDS Admit Hour

Claim Information

2300 HI01 Value Information

Patient Resource Amount and Days HI01-1 = “BE” HI01-2 = “80” HI01-5 = Covered Days HI02-1 = “BE” HI02-2 = “31” HI02-5 =Patient Resource Monetary Amount Sample EDI String

(HI*BE:80::31*BE:31::1288~) Service Facility Name

2310E REF01 Reference Identification Qualifier

‘G2’ Facility ID Number

Institutional Service Line

2400 SV202 Composite Medical Procedure Identifier

Required if SV201 – Revenue Code is 0550

SV202-1 = ‘HP’

SV202-2 = HIPPS Codes (AAA00-AAA29)


2400 SV206 Unit Rate Service Line Rate

Required when Revenue Code is 0183 0185 0189 0190 0550


2400 DTP02 Date Time Period Format Qualifier

’D8’


2400 DTP02 Date Time Period

Use the date services were first rendered


COMPANION GUIDE FOR THE 837 DENTAL TRANSACTION

The 837 Institutional Versions used in creating the guide.

Health Care Claim: Dental Transaction ASC X12N 837(005010X224) May 2006

Errata Health Care Claim: Dental Transaction

ASC X12N 837(005010X224A1) October 2007

Errata Health Care Claim: Dental Transaction

ASC X12N 837(005010X224A2) June 2010

Loop Name Loop ID Field Position/

Segment Data Element Name/Page Number from Implementation Guide

Valid Values And/or Comments

A B C D E



005010X224A2


2000B HL04 Hierarchical Level



2000B SBR09 Claim Filing Indicator Code

“MC” Medicaid


“1” Person


“MI” Member Identification Number




WV_MMIS_4MOLINA


“PI” Payer Identification


WV_MMIS_4MOLINA


Claim Information

2300 CLM01 Claim Submitter’s Patient Account


Claim Information

2300 CLM11-1 Related Causes Code

“AA” – Auto Accident “OA” – Other Accident

Claim Information

2300 CLM12 Special Program Code

“01‟ EPSDT

Referral Identification

2300 REF01 Reference Identification Qualifier

“G3” Prior Authorization Number

Referral Identification

2300 REF02 Reference Identification Referral Number

Assigned Prior Authorization Number



Please ensure to use the correct indicator code(s) when billing WV Medicaid as a secondary or tertiary payer. Do not send ‘MC’ in this Position/Segment for secondary or tertiary claims. Valid values are; ‘11’ – Other Non-Federal Programs ‘12’ – Preferred Provider Organization (PPO) ‘13’ – Point of Service (POS) 14 – Exclusive Provider Organization (EPO) ‘15’ – Indemnity Insurance ‘16’ – Health Maintenance


Organization (HMO) Medicare Risk ‘17’ – Dental Maintenance Organization ‘AM’ – Automobile Medical ‘BL’ – Blue Cross/Blue Shield ‘CH’ – Champus ‘CI’ – Commercial Insurance Co ‘DS’ – Disability ‘FI’ – Federal Employees Program ‘HM’ – Health Maintenance Organization ‘LM’ – Liability Medical ‘MA’ – Medicare Part A ‘MB’ – Medicare Part B ‘OF’ – Other Federal Program ‘TV’ – Title V ‘VA’ – Veterans Affairs Plan ‘WC’ – Workers’ Compensation health Claim ‘ZZ’ – Mutually Defined

Other Subscriber 2320 AMT02 Monetary Amount Payer Paid Amount

Other Insurance paid Amount


Billing Provider with a Pay-To Provider,*2010AA & *2310B This is another method of billing when the Billing Provider is different from the Pay-To Provider. This will work when there is a valid “Billing” provider ID present in block 2310B


(Rendering) and a valid “Pay To” provider ID in block 2010AA (Billing Provider). The ID in block 2310B will then become the servicing provider and then the ID in 2010AA then becomes the Pay To.

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