837 Companion Guide. Introduction. Purpose

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1 837 Companion Guide Introduction The Health Insurance Portability and Accountability Act (HIPAA) requires health insurance payers in the United States to comply with the EDI standards for health care as established by the Secretary of Health and Human Services if the provider wishes to submit certain types of healthcare transactions electronically. HIPAA does not mandate providers to become electronic submitters; it simply describes the content and format of the information you (the provider of care) must supply. The ANSI X12N implementation guides have been established as the standards of compliance for claim transactions. First Health is providing the following information to serve only as a companion document to the HIPAA ANSI X12N implementation guides. The use of this document is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This companion document supplements, but does not contradict any requirements in the X12N implementation guide. Additional companion documents/trading partner agreements will be developed for use with other HIPAA standards, as they become available. In the event a PPO agreement established between you and First Health requires the use of a situational data element, we will mutually agree to the most appropriate location on the ANSI transaction for this information. Additional information on the Final Rule for Standards for Electronic Transactions can be found at The HIPAA Implementation Guides can be accessed at Purpose For providers to submit an 837 Health Care Claim & Encounter Transaction for payment for any health plan member administered by First Health (as evidenced by the EDI routing number of appearing on the plan member s ID card). 1

2 Special Notes 1. Providers may send an 837 Claim or Encounter through their existing clearinghouse relationships or through one of First Health s contracted clearinghouses which include WebMD, ProxyMed, NDC, Payer Path, UHIN and OR. If the provider s clearinghouse is not one First Health works with, the provider is responsible for verifying that their clearinghouse will pass the transaction to one of the clearinghouses First Health works with. 2. Some First Health PPO agreements will require additional situational data elements for processing. In the event of a needed situational data element, First Health will want to test with the provider to ensure the situational data element reaches First Health. First Health will not be testing with providers who use a clearinghouse to facilitate EDI. 3. First Health is not establishing direct connections with any provider of care in Following successful implementation of the HIPAA standards in October 2003, First Health will consider direct connections with preferred providers that generate a high volume of bills. 2

3 ANSI 837 Institutional File Information Field ON 1 PROVIDER-SUPPLIER-GROUP-NAME 2010AA NM103 NM101=85,NM102=2 1 PROVIDER-SUPPLIER-GROUP-ADDRESS 2010AA N301, N302 1 PROVIDER-SUPPLIER-GROUP-CITY 2010AA N401 1 PROVIDER-SUPPLIER-GROUP-STATE 2010AA N402 1 PROVIDER-SUPPLIER-GROUP-ZIP-CODE 2010AA N403 1 PROVIDER-SUPPLIER-GROUP-PHONE 2010AA PER04 PER03=TE 3 PATIENT-CONTROL-NUMBER 2300 CLM01 4 BILL-TYPE 2300 CLM05:1-3 5 FEDERAL-TAX-NUMBER 2010AA NM109 NM108=24 (SSN). 34 (EIN) 6 STATEMENT-COVERS-FROM-DATE 2300 DPT03 DTP01=434, DTP02=RD8 6 STATEMENT-COVERS-THRU-DATE 2300 DPT03 DTP01=434, DTP02=RD8 7 TOTAL-COVERED-DAYS 2300 QTY02 QTY01 = CA 8 TOTAL-NON-COVERED-DAYS 2300 QTY02 QTY01 = NA 9 TOTAL-CO-INSURANCE-DAYS 2300 QTY02 QTY01 = CD 10 TOTAL-LIFE-TIME-RES-DAYS 2300 QTY02 QTY01 = LA 12 PATIENT-LAST-NAME 2010BA / 2010CA NM103 NM101=QC (Insured=IL), NM102=1 12 PATIENT-FIRST-NAME 2010BA / 2010CA NM104 NM101=QC (Insured=IL), NM102=1 12 PATIENT-MIDDLE-INITIAL 2010BA / 2010CA NM105 NM101=QC (Insured=IL), NM102=1 13 PATIENT-ADDRESS-STREET 2010BA / 2010CA N PATIENT-ADDRESS-STREET-ADDITIONAL 2010BA / 2010CA N PATIENT-ADDRESS-CITY 2010BA / 2010CA N PATIENT-ADDRESS-STATE 2010BA / 2010CA N PATIENT-ADDRESS-ZIP-CODE 2010BA / 2010CA N PATIENT-BIRTHDATE 2010BA / 2010CA DMG02 DMG01=D8 15 PATIENT-SEX-CODE 2010BA / 2010CA DMG03 16 PATIENT-MARITAL-STATUS NOT USED 17 ADMISSION-DATE 2300 DTP03 DTP01=435,DTP02=DT 18 ADMISSION-HOUR 2300 DTP03 DTP01=435,DTP02=DT 19 TYPE-OF-ADMISSION 2300 CL SOURCE-OF-ADMISSION 2300 CL DISCHARGE-HOUR 2300 DTP03 DTP01=096, DTP02=TM 22 PATIENT-STATUS 2300 CL MEDICAL-RECORD-NUMBER 2300 REF02 REF01=EA 24 CONDITION-CODE HI01:02 HI01:01=BG 25 CONDITION-CODE HI02:02 HI02:01=BG 26 CONDITION-CODE HI03:02 HI03:01=BG 27 CONDITION-CODE HI04:02 HI04:01=BG 28 CONDITION-CODE HI05:02 HI05:01=BG 29 CONDITION-CODE HI06:02 HI06:01=BG 30 CONDITION-CODE HI07:02 HI07:01=BG 32 OCCURRENCE-CODE HI01:02 HI01:01=BH 32 OCCURRENCE-DATE HI01:04 HI01:01=BH, HI01:03=D8 32 OCCURRENCE-CODE HI05:02 HI05:01=BH 32 OCCURRENCE-DATE HI05:04 HI05:01=BH, HI05:03=D8 33 OCCURRENCE-CODE HI02:02 HI02:01=BH 33 OCCURRENCE-DATE HI02:04 HI02:01=BH, HI02:03=D8 33 OCCURRENCE-CODE HI06:02 HI06:01=BH 33 OCCURRENCE-DATE HI06:04 HI06:01=BH, HI06:03=D8 34 OCCURRENCE-CODE HI03:02 HI03:01=BH 34 OCCURRENCE-DATE HI03:04 HI03:01=BH, HI03:03=D8 34 OCCURRENCE-CODE HI07:02 HI07:01=BH 34 OCCURRENCE-DATE HI07:04 HI07:01=BH, HI07:03=D8 35 OCCURRENCE-CODE HI04:02 HI04:01=BH 35 OCCURRENCE-DATE HI04:04 HI04:01=BH, HI04:03=D8 35 OCCURRENCE-CODE HI08:02 HI08:01=BH 35 OCCURRENCE-DATE HI08:04 HI08:01=BH, HI08:03=D8 36 OCCURRENCE-SPAN-CODE 2300 HI01:02 HI01:01=BI 3

4 Field ON 36 OCCURRENCE-SPAN-THRU-DATE 2300 HI01:04 HI01:01=BI, HI01:03=RD8 38 RESPONSIBLE-STREET-ADDRESS 2010BD N RESPONSIBLE-ADDRESS-ADDITIONAL BD N RESPONSIBLE-CITY 2010BD N RESPONSIBLE-STATE 2010BD N RESPONSIBLE-ZIP-CODE 2010BD N RESPONSIBLE-PARTY-LAST-NAME 2010BD NM103 NM101=QD 38 RESPONSIBLE-PARTY-FIRST-NAME 2010BD NM104 NM101=QD 38 RESPONSIBLE-PARTY-MIDDLE-INIT 2010BD NM105 NM101=QD 39A VALUE-CODE HI01:02 HI01:01 = BE 39A VALUE-AMOUNT HI01:05 HI01:01 = BE 39B VALUE-CODE HI02:02 HI02:01 = BE 39B VALUE-AMOUNT HI02:05 HI02:01 = BE 39C VALUE-CODE HI03:02 HI03:01 = BE 39C VALUE-AMOUNT HI03:05 HI03:01 = BE 39D VALUE-CODE HI04:02 HI04:01 = BE 39D VALUE-AMOUNT HI04:05 HI04:01 = BE 40A VALUE-CODE HI05:02 HI05:01 = BE 40A VALUE-AMOUNT HI05:05 HI05:01 = BE 40B VALUE-CODE HI06:02 HI06:01 = BE 40B VALUE-AMOUNT HI06:05 HI06:01 = BE 40C VALUE-CODE HI07:02 HI07:01 = BE 40C VALUE-AMOUNT HI07:05 HI07:01 = BE 40D VALUE-CODE HI08:02 HI08:01 = BE 40D VALUE-AMOUNT HI08:05 HI08:01 = BE 41A VALUE-CODE HI09:02 HI09:01 = BE 41A VALUE-AMOUNT HI09:05 HI09:01 = BE 41B VALUE-CODE HI010:02 HI010:01 = BE 41B VALUE-AMOUNT HI010:05 HI010:01 = BE 41C VALUE-CODE HI011:02 HI011:01 = BE 41C VALUE-AMOUNT HI011:05 HI011:01 = BE 41D VALUE-CODE HI012:02 HI012:01 = BE 41D VALUE-AMOUNT HI012:05 HI012:01 = BE 42 REVENUE-CODE SV HCPCS-PROCEDURE-CODE SV202:02 SV202:01 = HC 44 ACCOMMODATION-RATE 2400 SV DATE-OF-SERVICE DTP03 DTP01 = 472, DTP02 = RD8 46 UNITS 2400 SV205 SV204 = UN (UNITS) DA (DAYS) 47 CHARGES SV NON-COVERED-CHARGES 2400 SV PAYOR-NAME 2010BC NM103 NM101=PR,NM102=2 50 PAYOR-ID NUMBER 2010BC NM109 NM108=PI 51 MEDICARE-PROVIDER-NUMBER 2010AA REF02 REF01=1C 51 MEDICAID-PROVIDER-NUMBER 2010AA REF02 REF01=1D 51 BCBS-PROVIDER-NUMBER 2010AA REF02 REF01=1A 51 CHAMPUS-PROVIDER-NUMBER 2010AA REF02 REF01=1H 52 RELEASE-OF-INFORMATION-CERT. IND 2300 CLM09 53 ASSIGN-BENEFIT-CERT. IND 2300 CLM08 54 PRIOR-PAYMENT-AMOUNT 2320 AMT02 AMT01=C4 55 ESTIMATED-AMOUNT-DUE 2300 AMT02 AMT01=C5 58 INSURED-LAST-NAME 2010BA NM103 NM101=IL 58 INSURED-FIRST-NAME 2010BA NM104 NM101=IL 58 INSURED-MIDDLE-INITIAL 2010BA NM105 NM101=IL 59 PATIENT-INSURED-RELATION 2000B 2000C SBR02 PAT01 60 INSURED-SOCIAL-SECURITY-NUMBER 2010BA NM109 NM108=MI 61 INSURED-GROUP-NAME 2000B SBR04 62 INSURANCE-GROUP-POLICY-ID 2000B SBR03 63 TREATMENT-AUTHORIZATION-CODE REF02 REF01 = G1 63 TREATMENT-AUTHORIZATION-CODE REF02 REF01 = G1 63 TREATMENT-AUTHORIZATION-CODE REF02 REF01 = G1 67 PRIMARY-DIAGNOSIS-CODE HI01:02 HI01:01=BK 4

5 Field ON 68 SECONDARY-DIAGNOSIS-CODE HI01:02 HI01:01=BF 69 TERTIARY-DIAGNOSIS-CODE HI02:02 HI02:01=BF 70 OTHER-DIAGNOSIS-CODE HI03:02 HI03:01=BF 71 OTHER-DIAGNOSIS-CODE HI04:02 HI04:01=BF 72 OTHER-DIAGNOSIS-CODE HI05:02 HI05:01=BF 73 OTHER-DIAGNOSIS-CODE HI06:02 HI06:01=BF 74 OTHER-DIAGNOSIS-CODE HI07:02 HI07:01=BF 75 OTHER-DIAGNOSIS-CODE HI08:02 HI08:01=BF 76 ADMITTING-DIAGNOSIS-CODE 2300 HI02:02 HI01:01 = BJ 77 E-CODE 2300 HI03:02 HI03:01 = BN 80 PRINCIPLE-PROCEDURE-CODE 2300 HI01:02 HI01:01 = BR 80 PRINCIPLE-PROCEDURE-DATE 2300 HI01:04 HI01:01 = BR,HI01:03 = D8 81 OTHER-PROCEDURE-CODE HI01:02 HI01:01 = BO 81 OTHER-PROCEDURE-DATE HI01:04 HI01:01 = BO,HI01:03 = D8 81 OTHER-PROCEDURE-CODE HI02:02 HI02:01 = BO 81 OTHER-PROCEDURE-DATE HI02:04 HI02:01 = BO,HI02:03 = D8 81 OTHER-PROCEDURE-CODE HI03:02 HI03:01 = BO 81 OTHER-PROCEDURE-DATE HI03:04 HI03:01 = BO,HI03:03 = D8 81 OTHER-PROCEDURE-CODE HI04:02 HI04:01 = BO 81 OTHER-PROCEDURE-DATE HI04:04 HI04:01 = BO,HI04:03 = D8 81 OTHER-PROCEDURE-CODE HI05:02 HI05:01 = BO 81 OTHER-PROCEDURE-DATE HI05:04 HI05:01 = BO,HI05:03 = D8 82 ATTENDING-PHYSICIAN-LAST-NAME 2310A NM103 NM101 = 71, NM102 = 1 82 ATTENDING-PHYSICIAN-FIRST-NAME 2310A NM104 NM101 = 71, NM102 = 1 82 ATTENDING-PHYSICIAN-MIDDLE-INIT 2310A NM105 NM101 = 71, NM102 = 1 82 ATTENDING-PHYSICIAN-ID-CODE 2310A NM109 NM108 = 24 (EIN), 34 (SSN) 83 OPERATING-PHYSICIAN-LAST-NAME 2310B NM103 NM101 = 72, NM102 = 1 83 OTHER-PHYSICIAN-LAST-NAME C NM103 NM101 = 73, NM102 = 1 83 OTHER-PHYSICIAN-LAST-NAME C NM103 NM101 = 73, NM102 = 1 83 OPERATING-PHYSICIAN-FIRST-NAME 2310B NM104 NM101 = 72, NM102 = 1 83 OTHER-PHYSICIAN-FIRST-NAME C NM104 NM101 = 73, NM102 = 1 83 OTHER-PHYSICIAN-FIRST-NAME C NM104 NM101 = 73, NM102 = 1 83 OPERATING-PHYSICIAN-MIDDLE-INIT 2310B NM105 NM101 = 72, NM102 = 1 83 OTHER-PHYSICIAN-MIDDLE-INIT C NM105 NM101 = 73, NM102 = 1 83 OTHER-PHYSICIAN-MIDDLE-INIT C NM105 NM101 = 73, NM102 = 1 83 OPERATING-PHYSICIAN-ID-CODE 2310B NM109 NM108 = 24 (EIN), 34 (SSN) 83 OTHER-PHYSICIAN-ID-CODE C NM109 NM108 = 24 (EIN), 34 (SSN) 83 OTHER-PHYSICIAN-ID-CODE C NM109 NM108 = 24 (EIN), 34 (SSN) 84 REMARKS NTE02 NTE01=ADD 84 REMARKS NTE02 NTE01=ADD 84 REMARKS NTE02 NTE01=ADD 84 REMARKS NTE02 NTE01=ADD 85 PHYSICIAN-SIGNATURE INDICATOR 2300 CLM06 5