Introduction ANSI X12 Standards
Introduction ANSI X12 Standards Introduction to ANSI X12 Standards 004010 Who needs to understand them? Session Objectives Standards support business activity Introduce standards documentation Introduce standards implementation guidelines Develop sample 837 transaction set NORMAL BUSINESS ELIGIBILITY VERIFICATION SERVICE CLAIMS ENROLLMENT CUST SERVICE CLAIMS PROCESSING ALLIANCE DETROIT MI ALLIANCE DETROIT MI CUST SERVICE Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 1
Introduction ANSI X12 Standards PAPER vs EDI Document - Transaction Little Envelope- Functional Group Big Envelope Postal Service - Interchange VAN Courier Delivery- Point-to-Point Human Audit Machine Audit EDI Delivery 270 837 834 FUNCTIONAL GROUP FUNCTIONAL GROUP INTERCHANGE EDI VAN INTERCHANGE FUNCTIONAL GROUP Standards Language Document Line - Transaction Segment Phrase - Composite Element Word Code - Simple Element Identifier Punctuation - Delimiters Grammar Syntax Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 2
Introduction ANSI X12 Standards SIMPLE AND COMPOSITE DATA ELEMENTS N1*PR*ABC INS CO*PI*ABC47 TOO*JP*8*F:L Levels of Standards Documentation ANSI X12 Standards Documentation Industry Implementation Guidelines Trading Partner Profiles Section I - Transaction Set Tables Table 1 Header ST BHT Table 2 Detail HL Table 3 Summary Related information usually appears together. SE Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 3
Introduction ANSI X12 Standards Functional Group ID: HC 837 Health Care Claim Table 1 – Header POS# SEG ID NAME 005 ST Transaction Set Header 010 BHT Beginning of Hierarchical Transaction REQ. DES MAX USE LOOP REPEAT M 1 M 1 LOOP ID – 1000 020 045 NM1 PER 10 Individual or Organization Name Administration Communication Contact O O 1 2 Table 2 – Detail POS# SEG ID NAME REQ. DES MAX USE LOOP REPEAT LOOP ID – 2000 1 001 003 HL Hierarchical Level PRV Provider Information LOOP ID – 2010 M O 1 1 015 040 NM1 PER Individual or Organization Name Administration Communication Contact O O 1 2 555 SE Transaction Set Trailer M 1 10 837 Health Care Claim: Professional Table 1 – Header PG POS# SEG ID NAME 62 005 ST Transaction Set Header 63 010 BHT Beginning of Hierarchical Transaction USAGE R R REPEAT 1 1 LOOP ID – 1000A SUBMITTER NAME 67 71 020 045 NM1 PER LOOP REPEAT 1 Submitter Name Submitter EDI Contact Information R R 1 2 Table 2 – Detail – Billing/Pay-To Provider PG POS# SEG ID NAME USAGE REPEAT LOOP ID – 2000A BILLING/PAY-TO-PROVIDER 77 001 HL Billing/Pay-to-Provider Hierarchical Level 84 015 LOOP ID – 2010AA BILLNG PROVIDER NAME NM1 Billing Provider Name LOOP REPEAT 1 R 1 R 1 R 1 1 Table 2 – Detail – Subscriber 573 555 SE Transaction Set Trailer Transaction Set Tables Permitted segments Required order Presence requirement How many Loops Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 4
Introduction ANSI X12 Standards RECEIVER NAME NM1 Individual or Organization Name Level: Header Syntax: 1. P0809 If either NM108 or NM109 is present, then the other is required. NM101 98 Entity ID Code M ID 2/3 * NM102 1065 Entity Type Qualifier M ID 1/1 * NM103 1035 Name Last/ Org Name O AN 1/35 * NM104 1036 Name First O AN 1/25 * NM105 1037 Name Middle O AN 1/25 * NM106 1038 Name Prefix O AN 1/10 * NM107 1039 Name Suffix O AN 1/10 * NM108 66 ID Code Qualifier X ID 1/2 * NM109 67 ID CODE X AN 2/80 * NM110 706 Entity Relat Code X ID 2/2 * NM111 98 Entity ID Code O ID 2/3 NM1 * BILLING PROVIDER NAME NM1 Individual or Organization Name Level: Header Syntax: 1. P0809 If either NM108 or NM109 is present, then the other is required. NM101 98 Entity ID Code M ID 2/3 * NM102 1065 Entity Type Qualifier M ID 1/1 * NM103 1035 Name Last/ Org Name O AN 1/35 * NM104 1036 Name First O AN 1/25 * NM105 1037 Name Middle O AN 1/25 * NM106 1038 Name Prefix O AN 1/10 * NM107 1039 Name Suffix O AN 1/10 * NM108 66 ID Code Qualifier X ID 1/2 * NM109 67 ID CODE X AN 2/80 * NM110 706 Entity Relat Code X ID 2/2 * NM111 98 Entity ID Code O ID 2/3 NM1 * Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 5
Introduction ANSI X12 Standards SEGMENT · An ordered collection of elements · Elements are variable length · Elements are delimited by element separators · Segment ends with segment terminator N1 * * Data Element Dictionary § Listed numerically § Same in all segments § Data & position vary § Length min & max § Code lists § Type of data HL Hierarchical Level HL * HL01 628 Hierarch ID Number M AN 1/12 HL01 628 HL02 734 HL03 735 HL04 736 * HL02 734 Hierarch Parent ID O AN 1/12 * HL03 735 Hierarch Level Code M ID 1/2 * HL04 736 Hierarch Child Code O ID 1/1 Hierarchical ID Number The first HL01 1, in subsequent HL segments the value is incremented by 1. Hierarchical Parent Number The HL02 identifies the HL01 that is the parent of this HL segment. Hierarchical Level Code “20” Billing Provider “22” Subscriber – Child to Billing Provider “23” Dependent – Child to Subscriber Hierarchical Child Code “0” No Subordinate HL Segment “1” Additional Subordinate HL Data Segment Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 6
Introduction ANSI X12 Standards Hierarchical Levels in Health Care Claims HL*1**20*1 Billing Provider HL*2*1*22*0 HL*3*1*22*1 HL*7*1*22*0 Subscriber #1 Subscriber #2 Subscriber #3 Subscriber #4 Claim Information Service Lines Claim Information Service Lines Claim Information Service Lines HL*4*3*23*0 HL*5*3*23*0 HL*8*1*22*1 HL*6*3*23*0 HL*9*8*23*0 Dependent #1 Dependent #2 Dependent #3 Dependent #1 Claim Information Claim Information Claim Information Service Lines Service Lines Service Lines Claim Information Service Lines Valid Element Types AN - Alphanumeric B - Binary Nn - Numeric (n decimals) R - Decimal (explicit) ID - Code DT - Date TM - Time AN 6/6 - Exactly 6 characters long R 7/10 - From 7 to 10 digits long LENGTH Sign & decimal are not counted in length. Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 7
Introduction ANSI X12 Standards QUALIFIER & VALUE · Pairs elements (qualifier & value) · Flexible transaction definitions · Reuse elements Reese Sally Peterson CHIEF FINANCIAL OFFICER Reese Supply Company PO Box 1432 Miamitown OH 45432-1432 Phone (513) 725-7543 Fax (513) 725-9876 sally@ohio.net STANDARDS EVOLVE · Working papers · Three times a year · Draft standards · ANSI standards · Version & release 001000 002000 002040 003000 003020 003021 004000 004010 ANSI - 1983 ANSI - 1986 Draft X12 May 89 ANSI - 1992 Draft X12 Oct 91 Draft X12 Feb 92 ANSI - 1997 Draft X12 Oct 97 CHANGES INVOICE · Simplify data. · Eliminate transactions. · Utilize status information rather than batch data. · Reengineer business processes. · Exchange information more frequently. Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 8
Introduction ANSI X12 Standards Session Summary ü Standards are based on business requirements. ü There are multiple details to coordinate. ü One person should not make all decisions. ü The business process will change over time. Presented by EDI Partners and The Healthcare Electronic Commerce Foundation (952) 927-0784 partners@ix.netcom.com (501) 661-9408 gmb803@earthlink.net Page 9
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ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 004010X098 837 JUNE 15, 2000 IMPLEMENTATION 837 Health Care Claim: Professional 1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Billing providers who sort claims using this hierarchy will use the 837 more efficiently because information that applies to all lower levels in the hierarchy will not have to be repeated within the transaction. 2. This standard is also recommended for the submission of similar data within a pre-paid managed care context. Referred to as capitated encounters, this data usually does not result in a payment, though it is possible to submit a “mixed” claim that includes both pre-paid and request for payment services. This standard will allow for the submission of data from providers of health care products and services to a Managed Care Organization or other payer. This standard may also be used by payers to share data with plan sponsors, employers, regulatory entities and Community Health Information Networks. 3. This standard can, also, be used as a transaction set in support of the coordination of benefits claims process. Additional looped segments can be used within both the claim and service line levels to transfer each payer’s adjudication information to subsequent payers. Table 1 - Header PAGE # POS. # SEG. ID NAME USAGE REPEAT 62 63 66 005 010 015 ST BHT REF Transaction Set Header Beginning of Hierarchical Transaction Transmission Type Identification R R R 1 1 1 67 70 71 020 025 045 NM1 N2 PER LOOP ID - 1000A SUBMITTER NAME Submitter Name Additional Submitter Name Information Submitter EDI Contact Information R S R 1 1 2 74 76 020 025 NM1 N2 LOOP ID - 1000B RECEIVER NAME Receiver Name Receiver Additional Name Information R S 1 1 LOOP REPEAT 1 1 Table 2 - Detail, Billing/Pay-to Provider Hierarchical Level PAGE # POS. # SEG. ID NAME USAGE REPEAT 77 79 81 001 003 010 HL PRV CUR LOOP ID - 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Billing/Pay-to Provider Hierarchical Level Billing/Pay-to Provider Specialty Information Foreign Currency Information 84 87 88 89 91 94 96 015 020 025 030 035 035 040 NM1 N2 N3 N4 REF REF PER LOOP ID - 2010AA BILLING PROVIDER NAME Billing Provider Name Additional Billing Provider Name Information Billing Provider Address Billing Provider City/State/ZIP Code Billing Provider Secondary Identification Credit/Debit Card Billing Information Billing Provider Contact Information R S R R S S S 1 1 1 1 8 8 2 99 102 015 020 NM1 N2 LOOP ID - 2010AB PAY-TO PROVIDER NAME Pay-to Provider Name Additional Pay-to Provider Name Information S S 1 1 MAY 2000 LOOP REPEAT 1 R S S 1 1 1 1 1 51
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 103 104 106 025 030 035 N3 N4 REF Pay-to Provider Address Pay-to Provider City/State/ZIP Code Pay-to-Provider Secondary Identification R R S 1 1 5 Table 2 - Detail, Subscriber Hierarchical Level PAGE # POS. # SEG. ID NAME USAGE REPEAT 108 110 114 001 005 007 HL SBR PAT LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL Subscriber Hierarchical Level Subscriber Information Patient Information 117 120 121 122 124 126 128 015 020 025 030 032 035 035 NM1 N2 N3 N4 DMG REF REF LOOP ID - 2010BA SUBSCRIBER NAME Subscriber Name Additional Subscriber Name Information Subscriber Address Subscriber City/State/ZIP Code Subscriber Demographic Information Subscriber Secondary Identification Property and Casualty Claim Number R S S S S S S 1 1 1 1 1 4 1 130 133 134 135 137 015 020 025 030 035 NM1 N2 N3 N4 REF LOOP ID - 2010BB PAYER NAME Payer Name Additional Payer Name Information Payer Address Payer City/State/ZIP Code Payer Secondary Identification R S S S S 1 1 1 1 3 139 142 143 144 015 020 025 030 NM1 N2 N3 N4 LOOP ID - 2010BC RESPONSIBLE PARTY NAME Responsible Party Name Additional Responsible Party Name Information Responsible Party Address Responsible Party City/State/ZIP Code S S R R 1 1 1 1 NM1 N2 REF LOOP ID - 2010BD CREDIT/DEBIT CARD HOLDER NAME Credit/Debit Card Holder Name Additional Credit/Debit Card Holder Name Information Credit/Debit Card Information 146 149 150 015 020 035 LOOP REPEAT 1 R R S 1 1 1 1 1 1 1 S S S 1 1 2 Table 2 - Detail, Patient Hierarchical Level For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this the claim information is said to “float.” Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is the subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See 2.3.2.1, HL Segment, for details. PAGE # 152 154 52 POS. # SEG. ID 001 007 HL PAT NAME LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL Patient Hierarchical Level Patient Information USAGE REPEAT LOOP REPEAT 1 S R 1 1 MAY 2000
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 157 160 161 162 164 166 168 015 020 025 030 032 035 035 NM1 N2 N3 N4 DMG REF REF 170 180 182 184 186 188 190 192 194 196 197 199 200 201 203 205 206 208 210 212 214 217 219 220 221 222 224 226 227 229 231 130 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 135 155 160 175 175 175 180 180 180 180 180 180 CLM DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP PWK CN1 AMT AMT AMT REF REF REF REF REF REF 233 235 236 238 180 180 180 180 REF REF REF REF 240 241 242 244 246 248 251 257 260 263 180 180 180 185 190 195 200 220 220 220 REF REF REF K3 NTE CR1 CR2 CRC CRC CRC MAY 2000 LOOP ID - 2010CA PATIENT NAME Patient Name Additional Patient Name Information Patient Address Patient City/State/ZIP Code Patient Demographic Information Patient Secondary Identification Property and Casualty Claim Number LOOP ID - 2300 CLAIM INFORMATION Claim Information Date - Order Date Date - Initial Treatment Date - Referral Date Date - Date Last Seen Date - Onset of Current Illness/Symptom Date - Acute Manifestation Date - Similar Illness/Symptom Onset Date - Accident Date - Last Menstrual Period Date - Last X-ray Date - Estimated Date of Birth Date - Hearing and Vision Prescription Date Date - Disability Begin Date - Disability End Date - Last Worked Date - Authorized Return to Work Date - Admission Date - Discharge Date - Assumed and Relinquished Care Dates Claim Supplemental Information Contract Information Credit/Debit Card Maximum Amount Patient Amount Paid Total Purchased Service Amount Service Authorization Exception Code Mandatory Medicare (Section 4081) Crossover Indicator Mammography Certification Number Prior Authorization or Referral Number Original Reference Number (ICN/DCN) Clinical Laboratory Improvement Amendment (CLIA) Number Repriced Claim Number Adjusted Repriced Claim Number Investigational Device Exemption Number Claim Identification Number for Clearing Houses and Other Transmission Intermediaries Ambulatory Patient Group (APG) Medical Record Number Demonstration Project Identifier File Information Claim Note Ambulance Transport Information Spinal Manipulation Service Information Ambulance Certification Patient Condition Information: Vision Homebound Indicator 004010X098 837 1 R S R R R S S 1 1 1 1 1 5 1 R S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S 1 1 1 1 1 1 5 10 10 1 1 1 1 5 5 1 1 1 1 2 10 1 1 1 1 1 1 1 2 1 3 S S S S 1 1 1 1 S S S S S S S S S S 4 1 1 10 1 1 1 3 3 1 100 53
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 265 271 231 241 HI HCP Health Care Diagnosis Code Claim Pricing/Repricing Information S S 1 3 S S 1 1 276 278 242 243 CR7 HSD LOOP ID - 2305 HOME HEALTH CARE PLAN INFORMATION Home Health Care Plan Information Health Care Services Delivery 6 282 285 287 288 250 255 260 271 NM1 PRV N2 REF LOOP ID - 2310A REFERRING PROVIDER NAME Referring Provider Name Referring Provider Specialty Information Additional Referring Provider Name Information Referring Provider Secondary Identification S S S S 1 1 1 5 290 293 295 296 250 255 260 271 NM1 PRV N2 REF LOOP ID - 2310B RENDERING PROVIDER NAME Rendering Provider Name Rendering Provider Specialty Information Additional Rendering Provider Name Information Rendering Provider Secondary Identification S R S S 1 1 1 5 S S 1 5 2 1 298 301 250 271 NM1 REF LOOP ID - 2310C PURCHASED SERVICE PROVIDER NAME Purchased Service Provider Name Purchased Service Provider Secondary Identification 303 306 307 308 310 250 260 265 270 271 NM1 N2 N3 N4 REF LOOP ID - 2310D SERVICE FACILITY LOCATION Service Facility Location Additional Service Facility Location Name Information Service Facility Location Address Service Facility Location City/State/ZIP Service Facility Location Secondary Identification S S R R S 1 1 1 1 5 312 315 316 250 260 271 NM1 N2 REF LOOP ID - 2310E SUPERVISING PROVIDER NAME Supervising Provider Name Additional Supervising Provider Name Information Supervising Provider Secondary Identification S S S 1 1 5 318 323 332 333 334 335 290 295 300 300 300 300 SBR CAS AMT AMT AMT AMT S S S S S S 1 5 1 1 1 1 336 337 338 339 340 341 300 300 300 300 300 300 AMT AMT AMT AMT AMT AMT 342 344 347 305 310 320 350 353 354 355 325 330 332 340 54 1 1 1 S S S S S S 1 1 1 1 1 1 DMG OI MOA LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION Other Subscriber Information Claim Level Adjustments Coordination of Benefits (COB) Payer Paid Amount Coordination of Benefits (COB) Approved Amount Coordination of Benefits (COB) Allowed Amount Coordination of Benefits (COB) Patient Responsibility Amount Coordination of Benefits (COB) Covered Amount Coordination of Benefits (COB) Discount Amount Coordination of Benefits (COB) Per Day Limit Amount Coordination of Benefits (COB) Patient Paid Amount Coordination of Benefits (COB) Tax Amount Coordination of Benefits (COB) Total Claim Before Taxes Amount Subscriber Demographic Information Other Insurance Coverage Information Medicare Outpatient Adjudication Information 10 S R S 1 1 1 NM1 N2 N3 N4 LOOP ID - 2330A OTHER SUBSCRIBER NAME Other Subscriber Name Additional Other Subscriber Name Information Other Subscriber Address Other Subscriber City/State/ZIP Code R S S S 1 1 1 1 1 MAY 2000
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 357 355 REF Other Subscriber Secondary Identification S 3 359 362 363 366 368 370 372 325 330 345 345 355 355 355 NM1 N2 PER DTP REF REF REF LOOP ID - 2330B OTHER PAYER NAME Other Payer Name Additional Other Payer Name Information Other Payer Contact Information Claim Adjudication Date Other Payer Secondary Identifier Other Payer Prior Authorization or Referral Number Other Payer Claim Adjustment Indicator R S S S S S S 1 1 2 1 2 2 2 NM1 REF LOOP ID - 2330C OTHER PAYER PATIENT INFORMATION Other Payer Patient Information Other Payer Patient Identification NM1 REF LOOP ID - 2330D OTHER PAYER REFERRING PROVIDER Other Payer Referring Provider Other Payer Referring Provider Identification NM1 REF LOOP ID - 2330E OTHER PAYER RENDERING PROVIDER Other Payer Rendering Provider Other Payer Rendering Provider Secondary Identification NM1 REF LOOP ID - 2330F OTHER PAYER PURCHASED SERVICE PROVIDER Other Payer Purchased Service Provider Other Payer Purchased Service Provider Identification NM1 REF LOOP ID - 2330G OTHER PAYER SERVICE FACILITY LOCATION Other Payer Service Facility Location Other Payer Service Facility Location Identification S R 1 3 R R S S S S S S S S S R S S S S S S S S S 1 1 1 1 1 5 1 1 3 1 2 1 1 1 1 1 1 1 2 3 1 374 376 378 380 382 384 386 388 390 392 325 355 325 355 325 355 325 355 325 355 394 396 325 355 NM1 REF LOOP ID - 2330H OTHER PAYER SUPERVISING PROVIDER Other Payer Supervising Provider Other Payer Supervising Provider Identification 398 400 408 410 412 415 421 423 427 430 432 435 437 439 440 442 444 445 447 449 451 365 370 385 420 425 430 435 445 450 450 450 455 455 455 455 455 455 455 455 455 455 LX SV1 SV4 PWK CR1 CR2 CR3 CR5 CRC CRC CRC DTP DTP DTP DTP DTP DTP DTP DTP DTP DTP LOOP ID - 2400 SERVICE LINE Service Line Professional Service Prescription Number DMERC CMN Indicator Ambulance Transport Information Spinal Manipulation Service Information Durable Medical Equipment Certification Home Oxygen Therapy Information Ambulance Certification Hospice Employee Indicator DMERC Condition Indicator Date - Service Date Date - Certification Revision Date Date - Referral Date Date - Begin Therapy Date Date - Last Certification Date Date - Order Date Date - Date Last Seen Date - Test Date - Oxygen Saturation/Arterial Blood Gas Test Date - Shipped MAY 2000 1 1 S S 1 3 2 S R 1 3 1 S R 1 3 1 S R 1 3 1 S R 1 3 1 50 55
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 452 454 456 458 460 462 464 466 468 469 470 472 474 475 455 455 455 455 455 460 462 465 470 470 470 470 470 470 DTP DTP DTP DTP DTP QTY MEA CN1 REF REF REF REF REF REF 477 470 REF 478 479 480 482 484 485 486 487 488 489 491 495 470 470 470 470 475 475 475 480 485 488 491 492 REF REF REF REF AMT AMT AMT K3 NTE PS1 HSD HCP Date - Onset of Current Symptom/Illness Date - Last X-ray Date - Acute Manifestation Date - Initial Treatment Date - Similar Illness/Symptom Onset Anesthesia Modifying Units Test Result Contract Information Repriced Line Item Reference Number Adjusted Repriced Line Item Reference Number Prior Authorization or Referral Number Line Item Control Number Mammography Certification Number Clinical Laboratory Improvement Amendment (CLIA) Identification Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Immunization Batch Number Ambulatory Patient Group (APG) Oxygen Flow Rate Universal Product Number (UPN) Sales Tax Amount Approved Amount Postage Claimed Amount File Information Line Note Purchased Service Information Health Care Services Delivery Line Pricing/Repricing Information 501 504 506 507 500 505 510 525 NM1 PRV N2 REF LOOP ID - 2420A RENDERING PROVIDER NAME Rendering Provider Name Rendering Provider Specialty Information Additional Rendering Provider Name Information Rendering Provider Secondary Identification S S 1 5 S S S S S S S S S S S S S S 1 1 1 1 1 5 20 1 1 1 2 1 1 1 S 1 S S S S S S S S S S S S 1 4 1 1 1 1 1 10 1 1 1 1 S R S S 1 1 1 5 1 509 512 500 525 NM1 REF LOOP ID - 2420B PURCHASED SERVICE PROVIDER NAME Purchased Service Provider Name Purchased Service Provider Secondary Identification 514 517 518 519 521 500 510 514 520 525 NM1 N2 N3 N4 REF LOOP ID - 2420C SERVICE FACILITY LOCATION Service Facility Location Additional Service Facility Location Name Information Service Facility Location Address Service Facility Location City/State/ZIP Service Facility Location Secondary Identification S S R R S 1 1 1 1 5 523 526 527 500 510 525 NM1 N2 REF LOOP ID - 2420D SUPERVISING PROVIDER NAME Supervising Provider Name Additional Supervising Provider Name Information Supervising Provider Secondary Identification S S S 1 1 5 529 532 533 534 500 510 514 520 NM1 N2 N3 N4 LOOP ID - 2420E ORDERING PROVIDER NAME Ordering Provider Name Additional Ordering Provider Name Information Ordering Provider Address Ordering Provider City/State/ZIP Code S S S S 1 1 1 1 56 1 1 1 1 MAY 2000
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 536 538 525 530 REF PER Ordering Provider Secondary Identification Ordering Provider Contact Information S S 5 1 541 544 546 547 500 505 510 525 NM1 PRV N2 REF LOOP ID - 2420F REFERRING PROVIDER NAME Referring Provider Name Referring Provider Specialty Information Additional Referring Provider Name Information Referring Provider Secondary Identification S S S S 1 1 1 5 S R 1 2 2 549 552 500 525 NM1 REF LOOP ID - 2420G OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER Other Payer Prior Authorization or Referral Number Other Payer Prior Authorization or Referral Number 554 558 566 540 545 550 SVD CAS DTP LOOP ID - 2430 LINE ADJUDICATION INFORMATION Line Adjudication Information Line Adjustment Line Adjudication Date S S R 1 99 1 567 569 572 551 552 555 LQ FRM SE LOOP ID - 2440 FORM IDENTIFICATION CODE Form Identification Code Supporting Documentation Transaction Set Trailer S R R 1 99 1 MAY 2000 4 25 5 57
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 STANDARD 837 Health Care Claim Functional Group ID: HC This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment. Table 1 - Header PAGE # POS. # SEG. ID NAME REQ. DES. MAX USE 005 010 015 ST BHT REF Transaction Set Header Beginning of Hierarchical Transaction Reference Identification M M O 1 1 3 020 025 030 035 040 045 NM1 N2 N3 N4 REF PER LOOP ID - 1000 Individual or Organizational Name Additional Name Information Address Information Geographic Location Reference Identification Administrative Communications Contact O O O O O O 1 2 2 1 2 2 LOOP REPEAT 10 Table 2 - Detail PAGE # 58 POS. # SEG. ID NAME REQ. DES. MAX USE 001 003 005 007 009 010 HL PRV SBR PAT DTP CUR LOOP ID - 2000 Hierarchical Level Provider Information Subscriber Information Patient Information Date or Time or Period Currency M O O O O O 1 1 1 1 5 1 015 020 NM1 N2 LOOP ID - 2010 Individual or Organizational Name Additional Name Information O O 1 2 LOOP REPEAT 1 10 MAY 2000
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE MAY 2000 004010X098 837 025 030 032 035 040 N3 N4 DMG REF PER Address Information Geographic Location Demographic Information Reference Identification Administrative Communications Contact O O O O O 2 1 1 20 2 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 216 219 220 231 240 241 CLM DTP CL1 DN1 DN2 PWK CN1 DSB UR AMT REF K3 NTE CR1 CR2 CR3 CR4 CR5 CR6 CR8 CRC HI QTY HCP LOOP ID - 2300 Health Claim Date or Time or Period Claim Codes Orthodontic Information Tooth Summary Paperwork Contract Information Disability Information Peer Review Organization or Utilization Review Monetary Amount Reference Identification File Information Note/Special Instruction Ambulance Certification Chiropractic Certification Durable Medical Equipment Certification Enteral or Parenteral Therapy Certification Oxygen Therapy Certification Home Health Care Certification Pacemaker Certification Conditions Indicator Health Care Information Codes Quantity Health Care Pricing O O O O O O O O O O O O O O O O O O O O O O O O 1 150 1 1 35 10 1 1 1 40 30 10 20 1 1 1 3 1 1 1 100 25 10 1 242 243 CR7 HSD LOOP ID - 2305 Home Health Treatment Plan Certification Health Care Services Delivery O O 1 12 250 255 260 265 270 271 275 NM1 PRV N2 N3 N4 REF PER LOOP ID - 2310 Individual or Organizational Name Provider Information Additional Name Information Address Information Geographic Location Reference Identification Administrative Communications Contact O O O O O O O 1 1 2 2 1 20 2 290 295 300 305 310 315 320 SBR CAS AMT DMG OI MIA MOA LOOP ID - 2320 Subscriber Information Claims Adjustment Monetary Amount Demographic Information Other Health Insurance Information Medicare Inpatient Adjudication Medicare Outpatient Adjudication O O O O O O O 1 99 15 1 1 1 1 325 330 332 340 345 NM1 N2 N3 N4 PER LOOP ID - 2330 Individual or Organizational Name Additional Name Information Address Information Geographic Location Administrative Communications Contact O O O O O 1 2 2 1 2 100 6 9 10 10 59
ASC X12N INSURANCE SUBCOMMITTEE IMPLEMENTATION GUIDE 004010X098 837 60 350 355 DTP REF Date or Time or Period Reference Identification O O 9 3 365 370 375 380 382 385 400 405 410 415 420 425 430 435 440 445 450 455 460 462 465 470 475 480 485 488 490 491 492 LX SV1 SV2 SV3 TOO SV4 SV5 SV6 SV7 HI PWK CR1 CR2 CR3 CR4 CR5 CRC DTP QTY MEA CN1 REF AMT K3 NTE PS1 IMM HSD HCP LOOP ID - 2400 Assigned Number Professional Service Institutional Service Dental Service Tooth Identification Drug Service Durab
STANDARDS EVOLVE · Working papers · Three times a year · Draft standards · ANSI standards · Version & release 001000 ANSI - 1983 002000 ANSI - 1986 002040 Draft X12 May 89 003000 ANSI - 1992 003020 Draft X12 Oct 91 003021 Draft X12 Feb 92 004000 ANSI - 1997 004010 Draft X12 Oct 97 CHANGES · Simplify data. · Eliminate transactions.
VOLVO Application of ANSI X12 1 P a g e Application of ANSI X12 General ANSI X12 or ASC X12 (Accredited Standards Committee) develops and maintains EDI standards. X12 was the sequential designator assigned by
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- Digit digit test X3 X3 X3 X3 - Digit symbol test X3 X3 X3 X3 - Controlled Oral Word Association (COWA) X12 X12 X12 - Telephone Interview for Cognitive Status (TICS) X14 X14 X14 Contact information X X XX X X X X X X X X X X X X X X X X X X X X X X X12 X12 X12 Demographics - age X - educatio
Code Sources—ANSI ASC X12 allows industry-specific codes. These codes are not main-tained by the ANSI ASC X12 committee, but by industry organizations. A list of where to obtain these industry codes can be found in the ASC X12 Standards manual. Interactive Control Structure—These are syntax rules at the application level that have been
ANSI X12 V3050 997 Functional Acknowledgment INFORMATIVE GUIDE. February 9, 2000 . Insurance Information & Enforcement System (IIES) New Directions in Enforcing Compulsory Insurance Laws. . Draft Standard for Trial Use Approved by ASC X12 Through May 1989 . 00300 . Standard Issued as ANSI X12.5-1992 . 00301 .
A Transaction Set is a single business document such as a Purchase Order, Invoice, or Shipment Notice. There are hundreds of Transaction Sets available in the ANSI ASC X12 standards. Each set of transaction data is identified by a three digit code number. ANSI ASC X12 Standards Overview
Maintenance of X12 ANS is governed by ANSI’s periodic maintenance option. Upon initiation of a project to develop or revise an X12 ANS, X12 staff will prepare and submit a PINS form, or its equivalent, to ANSI for announcement in ANSI’s Standards Act
American Revolution This question is based on the accompanying document (1-6). The question is designed to test your ability to work with historical documents. Some of the documents have been edited for the purposes of the question. As you analyze the documents, take into account the source of each document and any point of view that may be presented in the document. HISTORICAL CONTEXT: passed .
