Standard Companion Guide: Health Care Claim: Professional .
Centers for Medicare & Medicaid Services (CMS)7500 Security BlvdBaltimore, MD 21244-1850Standard Companion GuideHealth Care Claim: Professional (837P)Based on ASC X12N Implementation Guide, Version005010X222A1Companion Guide Version Number: 6.1,May 2020
CMS 837P Version 005010 Companion Guideii
CMS 837P Version 005010 Companion Guide 2020 Noridian Healthcare Solutions, LLCDisclosure StatementThe Centers for Medicare & Medicaid Services (CMS) is committed to maintaining the integrity and security ofhealth care data in accordance with applicable laws and regulations. Disclosure of Medicare claims isrestricted under the provisions of the Privacy Act of 1974 and Health Insurance Portability and AccountabilityAct of 1996. This Companion Guide is to be used for conducting Medicare business only.iii
CMS 837P Version 005010 Companion Guide 2020 Noridian Healthcare Solutions, LLCPrefaceThis CG to the Accredited Standards Committee (ASC) X12N Technical Report Type 3 (TR3) Version 005010 andassociated errata adopted under HIPAA clarifies and specifies the data content when exchanging transactionselectronically with Medicare. Transmissions based on this CG, used in tandem with the TR3 are compliant withboth ASC X12N syntax and those guides. This CG is intended to convey information that is within theframework of the TR3 adopted for use under HIPAA. This CG is not intended to convey information that in anyway exceeds the requirements or usages of data expressed in the TR3.This CG contains instructions for electronic communications with the publishing entity, as well assupplemental information for creating transactions while ensuring compliance with the associated ASC X12NTR3s and the Council for Affordable Healthcare – Committee on Operating Rules for Information Exchange(CAQH CORE) companion guide operating rules.In addition, this CG contains the information needed by Trading Partners to send and receive electronic datawith the publishing entity, who is acting on behalf of CMS, including detailed instructions for submission ofspecific electronic transactions. The instructional content is limited by ASC X12N’s copyrights and Fair Usestatement.iv
CMS 837P Version 005010 Companion GuideTable of ContentsPreface .iv1 Introduction . 11.1 Scope . 11.2 Overview . 11.3 References . 21.4 Additional Information . 22 Getting Started . 32.1 Working Together . 32.2 Trading Partner Registration. 32.3 Trading Partner Certification and Testing Process . 53 Testing and Certification Requirements . 63.1 Testing Requirements . 63.2 Certification Requirements . 74 Connectivity / Communications. 74.1 Process Flows . 74.2 Transmission . 74.2.1 Re-transmission Procedures . 84.3 Communication Protocol Specifications . 84.4 Security Protocols and Passwords . 85 Contact Information. 95.1 EDI Customer Service . 95.2 EDI Technical Assistance . 105.3 Trading Partner Service Number . 115.4 Applicable Websites / Email . 116 Control Segments / Envelopes . 116.1 ISA-IEA . 12Delimiters – Inbound Transactions . 12Delimiters – Outbound Transactions . 136.2 GS-GE . 136.3 ST-SE . 137 Specific Business Rules. 137.1 General Notes . 137.2 General Transaction Notes . 158 Acknowledgments and Reports . 16v
CMS 837P Version 005010 Companion Guide8.1 Report Inventory . 169 Trading Partner Agreement . 1710 Transaction-Specific Information . 1710.1 Header. 1710.1.1 Header and Information Source . 1710.1.2 Loop 1000A Submitter Name. 1810.1.3 Loop 1000B Receiver Name . 1810.2 Billing Provider . 1910.2.1 Loop 2000A Billing Provider Detail . 1910.2.2 Loop 2010AA Billing Provider Name . 1910.3 Subscriber Detail . 2010.3.1 Loop 2000B Subscriber Hierarchical Level . 2010.3.2 Loop 2010BA Subscriber Name . 2110.3.3 Loop 2010BB Payer Name. 2210.4 Patient Detail . 2310.4.1 Loop 2300 Claim Information . 2310.4.2 Loop 2310A Referring Provider Name . 2510.4.3 Loop 2310B Rendering Provider Name. 2610.4.4 Loop 2310D Supervising Provider Name . 2610.4.5 Loop 2320 Other Subscriber Information . 2610.4.6 Loop 2330A Other Subscriber Name . 2710.4.7 The following table Loop 2330B Other Payer Name . 2810.4.8 Loop 2400 Service Line Number . 2810.4.9 Loop 2410 Drug Identification . 3410.4.10 Loop 2420A Rendering Provider Name . 3510.4.11 Loop 2420D Supervising Provider Name . 3510.4.12 Loop 2420E Ordering Provider Name . 3610.4.13 Loop 2420F Referring Provider Name . 3610.4.14 Loop 2430 Line Adjudication Information . 3610.4.15 Loop 2440 Form Identification Code . 3710.4.16 Transaction Set Trailer . 4011 Appendices . 4111.1 Implementation Checklist . 4111.2 Transmission Examples . 4111.3 Frequently Asked Questions . 4211.4 Acronym Listing. 42vi
CMS 837P Version 005010 Companion Guide11.5 Change Summary . 43vii
CMS 837P Version 005010 Companion GuideList of TablesTable 1 – EDI Transactions and Code Set References . 2Table 2 – Additional EDI Resources . 3Table 3 – Control Segments / Envelope Requirements . 11Table 4 – Segment / Elements Not Accepted by Medicare . 14Table 5 – Header and Information Source. 17Table 6 – Loop 1000A Submitter Name . 18Table 7 – Loop 1000B Receiver Name . 18Table 8 – Loop 2000A Billing Provider Detail . 19Table 9 – Loop 2010AA Billing Provider Name . 19Table 10 – Loop 2000B Subscriber Hierarchical Level . 20Table 11 – Loop 2010BA Subscriber Name . 21Table 12 – Loop 2010BB Payer Name . 23Table 13 – Loop 2300 Claim Information. 23Table 14 – Loop 2310A Referring Provider Name . 25Table 15 – Loop 2310B Rendering Provider Name . 26Table 16 – Loop 2310D Supervising Provider Name. 26Table 17 – Loop 2320 Other Subscriber Information . 27Table 18 – Loop 2330A Other Subscriber Name. 27Table 19 – Loop 2330B Other Payer Name. 28Table 20 – Loop 2400 Service Line Number . 29Table 21 – Loop 2410 Drug Identification. 34Table 22 – Loop 2420A Rendering Provider Name . 35Table 23 – Loop 2420D Supervising Provider Name. 36Table 24 – Loop 2420E Ordering Provider Name . 36Table 25 – Loop 2420F Referring Provider Name . 36Table 26 – Loop 2430 Line Adjudication Information. 37Table 27 – Loop 2440 Form Identification Code. 37Table 28 – Transaction Set Trailer . 41Table 29 – Acronyms Listing and Definitions . 42Table 30 – Companion Guide Version History . 43viii
CMS 837P Version 005010 Companion Guide1 IntroductionThis document is intended to provide information from the author of this guide to Trading Partners to givethem the information they need to exchange Electronic Data Interchange (EDI) data with the author. Thisincludes information about registration, testing, support, and specific information about control record setup.An EDI Trading Partner is defined as any Medicare customer (e.g., provider/supplier, billing service,clearinghouse, or software vendor) that transmits to, or receives electronic data from Medicare. Medicare’sEDI transaction system supports transactions adopted under HIPAA as well as additional supportingtransactions as described in this guide.Medicare Fee-For-Service (FFS) is publishing this Companion Guide (CG) to clarify, supplement, and furtherdefine specific data content requirements to be used in conjunction with, and not in place of, the ASC X12NTechnical Report Type 3 (TR3) Version 005010 for all transactions mandated by HIPAA and/or adopted byMedicare FFS for EDI.This CG provides communication, connectivity and transaction-specific information to Medicare FFS TradingPartners and serves as the authoritative source for Medicare FFS-specific EDI protocols.Additional information on Medicare FFS EDI practices are referenced within Internet-only Manual (IOM) Pub.100-04 Medicare Claims Processing Manual: Chapter 24 - General EDI and EDI Support, Requirements, Electronic Claims, and Mandatory ElectronicFiling of Medicare Claims. This document can be accessed at ce/Manuals/downloads/clm104c24.pdf.1.1 ScopeEDI addresses how Trading Partners exchange professional and institutional claims, claim acknowledgments,claim remittance advice, claim status inquiry and responses, and eligibility inquiry and responses electronicallywith Medicare. This CG also applies to ASC X12N 837P transactions that are being exchanged with Medicare bythird parties, such as clearinghouses, billing services or network service vendors.This CG provides technical and connectivity specification for the 837 Health Care Claim: Professionaltransaction Version 005010.1.2 OverviewThis CG includes information needed to commence and maintain communication exchange with Medicare. Inaddition, this CG has been
Standard Companion Guide . Health Care Claim: Professional (837P) Based on ASC X12N Implementation Guide, Version 005010X222A1 . Companion Guide Version Number: 6.1, May 2020 . CMS 837P Version 005010 Companion Guide ii . CMS 837P Version 005010 Companion Guide iii
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Companion Guide, Outpatient Companion Guide and Long Term Care Companion Guide into a single Institutional Companion Guide; Updated logo, name, and hyperlinks from DPW to DHS; Updated Appendix A, Updated name from HP to HPE; Section "PROMISe specific HIPAA Data Elements" was updated to align with ASC X12 guidelines; Updated TR3
LITERARY(THEORY(An(introduction((!! ClassReader! Spring2014!! Prof.DavidMiralles,PH.D.! University!of!Oregon!! Universidad!Autónoma!de!Querétaro!
