APS Healthcare, Inc.
Helping People Lead Healthier Lives
smInformation Technology Division 8403 Colesville Rd.
Silver Spring, MD 20910
837 Professional EDI
Specifications &
Companion Guide
The purpose of this guide is to focus
on segments in the edi that APS
requires to be sent in a specific
manner.
---
July 2005
CONTENTS
Companion Guide
Claim Level 2310B Rendering Provider Information Loop………3
Service Line 2420A Rendering Provider Information Loop………7
Specifications
Specifications for mapping enveloping of 837P… ………..12
Specifications for mapping body of 837P……….………..15
Disclosure Statement
This document has been designed to assist both technical and business areas of our trading partners who wish to submit HIPAA standard transactions. It contains
specifications of the transaction, contact information, and other information we believe may be helpful to our trading partners in working with us toward compliance with HIPAA transaction and code set requirements.
All instructions in this document were written using information known at the time of publication and may change. The most up-to-date version of the Companion Guide is available on the APS Healthcare, Inc. Web site (http://www.apshealtchare.com). Please be sure that any printed version you use is the same as the latest version available at the APS Healthcare Web site. The X12 file responses you receive during testing are not a guarantee of payment.
Loop: 2310B — RENDERING PROVIDER NAME
Notes: 1. Information in Loop ID-2310 applies to the entire claim unless
overridden on a service line by the presence of Loop ID-2420 with the
same value in NM101.
SPECIAL APS NOTE
===========================================================
APS requires this loop to be present in any 837p claim as long as
this provider is the same for each service line. If the provider for
a given service line is different than the one listed here, then the
2420A loop for that service line should be filled out listing the different
Provider.
IF THE RENDERING PROVIDER AT THE SERVICE LINE IS THE SAME AS THAT
LISTED AT THE CLAIM LINE LEVEL RENDERING PROVIDER, THE PROVIDER
INFORMATION IS NOT TO BE FILLED OUT. APS WILL GET THE PERTINENT
RENDERING PROVIDER INFO FROM THE CLAIM LINE LEVEL.
===========================================================
Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.
Required when the Rendering Provider NM1 information is different
than that carried in either the Billing Provider NM1 or the Pay-to
Provider NM1 in the 2010AA/AB loops respectively.
Used for all types of rendering providers including laboratories. The
Rendering Provider is the person or company (laboratory or other
facility) who rendered the care. In the case where a substitute provider
(locum tenans) was used, that person should be entered here.
Example: NM1*82*1*BEATTY*GARY*C**SR*XX*12345678~
STANDARD
Purpose: To supply the full name of an individual or organizational entity
Set Notes: 1. Loop 2310 contains information about the rendering, referring,
or attending provider.
Syntax:
1. If either NM108 or NM109 is present, then the other is required.
2. If NM111 is present, then NM110 is required.
ELEMENT SUMMARY
===============================================================
USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES
===============================================================
REQUIRED NM101 Entity Identifier Code M ID 2/3
Code identifying an organizational entity, a physical location,
property or an individual
The entity identifier in NM101 applies to all segments in this Loop
ID-2310.
CODE DEFINITION
82 Rendering Provider
REQUIRED NM102 Entity Type Qualifier M ID 1/1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE DEFINITION
1 Person
2 Non-Person Entity
REQUIRED NM103 Name Last or Organization Name O AN 1/35
Individual last name or organizational name
INDUSTRY: Rendering Provider Last or Organization Name
ALIAS: Rendering Provider Last Name
INDUSTRY: Rendering Provider First Name
Required if NM102=1 (person).
===============================================================
USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES
===============================================================
SITUATIONAL NM105 Name Middle O AN 1/25
Individual middle name or initial
INDUSTRY: Rendering Provider Middle Name
Required if NM102=1 and the middle name/initial of the person is
known.
NOT USED NM106 Name Prefix O AN 1/10
SITUATIONAL NM107 Name Suffix O AN 1/10
Suffix to individual name
INDUSTRY: Rendering Provider Name Suffix
ALIAS: Rendering Provider Generation
Required if known.
REQUIRED NM108 Identification Code Qualifier X ID 1/2
Code designating the system/method of code structure used for Identification
Code
FA0-57.0 crosswalk is only used in Medicare COB payer-to-payer
claims.
CODE DEFINITION
24 Employer’s Identification Number
34 Social Security Number
XX Health Care Financing Administration National
Provider Identifier
===============================================================
USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES
===============================================================
REQUIRED NM109 Identification Code X AN 2/80
Code identifying a party or other code
INDUSTRY: Rendering Provider Identifier
ALIAS: Rendering Provider Primary Identifier
FA0-58.0 crosswalk is only used in Medicare COB payer-to-payer
claims.
Loop: 2420A — RENDERING PROVIDER NAME
Repeat: 1
Usage: SITUATIONAL
Repeat: 1
SPECIAL APS NOTE
===============================================================
IF THE RENDERING PROVIDER AT THE SERVICE LINE IS THE SAME AS THAT
LISTED AT THE CLAIM LINE LEVEL RENDERING PROVIDER, THE PROVIDER
INFORMATION IS NOT TO BE FILLED OUT AT THE SERVICE LINE LEVEL.
APS WILL GET THE PERTINENT RENDERING PROVIDER INFO FROM THE
CLAIM LINE LEVEL.
===============================================================
1. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.
2. Required if the Rendering Provider NM1 information is different than
that carried in the 2310B (claim) loop, or if the Rendering provider
information is carried at the Billing/Pay-to Provider loop level
(2010AA/AB) and this particular service line has a different Rendering
Provider that what is given in the 2010AA/AB loop. The identifying
payer-specific numbers are those that belong to the destination payer
identified in loop 2010BB.
3. Used for all types of rendering providers including laboratories. The
Rendering Provider is the person or company (laboratory or other
facility) who rendered the care. In the case where a substitute Provider
(locum tenans) was used, that person should be entered here.
Example: NM1*82*1*SMITH*JUNE*L***XX*87654321~
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 500
Loop: 2420 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose:
1. Loop 2420 contains information about the rendering, referring, or attending
provider on a service line level. These segments override the information in
the claim - level segments if the entity identifier codes in each NM1
segment are the same.
Syntax:
1. If either NM108 or NM109 is present, then the other is required.
2. If NM111 is present, then NM110 is required.
ELEMENT SUMMARY
===============================================================
USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES
===============================================================
REQUIRED NM101 Entity Identifier Code M ID 2/3
Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this
iteration of Loop ID-2420.
CODE DEFINITION
82 Rendering Provider
REQUIRED NM102 Entity Type Qualifier M ID 1/1
Code qualifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE DEFINITION
1 Person
2 Non-Person Entity
REQUIRED NM103 Name Last or Organization Name O AN 1/35
Individual last name or organizational name
INDUSTRY: Rendering Provider Last or Organization Name
ALIAS: Rendering Provider Last Name
SITUATIONAL NM104 Name First O AN 1/25
Individual first name
Required if NM102=1 (person).
===============================================================
USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES
===============================================================
SITUATIONAL NM105 Name Middle O AN 1/25
Individual middle name or initial
INDUSTRY: Rendering Provider Middle Name
Required if NM102=1 and the middle name/initial of the person is
known.
NOT USED NM106 Name Prefix O AN 1/10
SITUATIONAL NM107 Name Suffix O AN 1/10
Suffix to individual name
INDUSTRY: Rendering Provider Name Suffix
ALIAS: Rendering Provider Generation
Required if known.
REQUIRED NM108 Identification Code Qualifier X ID 1/2
Code designating the system/method of code structure used for Identification
Code
CODE DEFINITION
24 Employer’s Identification Number
34 Social Security Number
Social Security Number cannot be used for
Medicare claims.
XX Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.
Code identifying a party or other code
INDUSTRY: Rendering Provider Identifier
ALIAS: Rendering Provider Primary Identifier
===============================================================
USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES
===============================================================
Information from the HIPAA implementation guide for the
ASC X12N 837 (004010X098) May 2000
ASC X12N · INSURANCE SUBCOMMITTEE 004010X098 · 837
IMPLEMENTATION GUIDE HEALTH CARE CLAIM: PROFESSIONAL
MAY 2000 1
© 2000 WPC
Copyright for the members of ASC X12N by Washington Publishing
Company.
Permission is hereby granted to any organization to copy and distribute this
material internally as long as this copyright statement is
SPECIFICATIONS FOR THE 837P
ENVELOPING FOR 837P
Loop Segment Element
Mapping
Instructions Notes
Hdr ISA 1 Hardcode '00'
2 Hardcode ten spaces
3 Hardcode '00'
4 Hardcode ten spaces
5 Hardcode 'ZZ'
6
Map your trading partner id
Trading Partner Sender id value
7 Hardcode 'ZZ'
8 Hardcode '54160' APS's id
9
6 digit current date in YYMMDD format 10 4 digit current time in HHMM format
11 Hardcode 'U'
12 Hardcode '00401'
13
Hardcode '000000001' and increment by 1 each time a new ISA is written
14 Hardcode '0'
15
Hardcode 'T' if this is a test file, 'P' if this is
production Test or production indicator
16 Hardcode ':'
2 Map GS id for trading partner
3 Hardcode '54160'
4 Hardcode 8 digit date in CCYYMMDD format
5
4 digit current time in HHMM format
6
Hardcode '1' for each new ISA and increment by 1 everytime a new GS to GE is started within
the same ISA GS control #
7 Hardcode 'X'
8 Hardcode '004010X098A1' This indicates that the edi is an 837 professional
Hdr ST 1 Hardcode '837'
2
Hardcode '0001' and increment by 1 for each new ST in the same GS
to GE
Hdr BHT 1 Hardcode '0019'
2 Hardcode '00'
3
This should have the date and time and a 4 digit number. The 4 digit number should be incremented each time a new ST to SE is created. The format should look like this
CCYYMMDDHHMM9999 4 8 digit date CCYYMMDD 5 4 digit hour HHMM
6 Hardcode 'CH'
Hdr REF 1 Hardcode '87'
2
If this is test, hardcode '004010X98DA1'. If this is production, hardcode
'004010X98A1' This indicates that the edi is an 837 professional
1000A NM1 1 Hardcode '41' Submitter information
3 Map name of the sender of this 837 4 do not map 5 do not map 6 do not map 7 do not map 8 Hardcode '46' 9 ID of sender
1000A PER 1 Hardcode 'IC'
2
Name of clearinghouse or provider sending this
837
3 Hardcode 'TE'
4 Telephone # of sender
1000B NM1 1 Hardcode '40' Receiver information
2 Hardcode '2'
3 Hardcode 'APS Health Care'
4 do not map 5 do not map 6 do not map 7 do not map 8 Hardcode '46' 9 Hardcode '54160' 2000A HL 1 Hardcode '1' 2 do not map 3 Hardcode '20' 4 Hardcode '1'
For directions on mapping the body of the edi, see ‘BODY OF 837P'
Trailer SE 1
Number of segments contained within and including the ST and SE
segments segment count
2 ST 02 ST 02 and SE 02 must be the same value
Trailer GE 1
# of transaction sets contained within this GS to GE
2 ISA 13
ISA 13 must be ths same value as IEA 02
BODY OF 837P
Notes
Loop Segment Element Mapping Instructions
When inputting the billing provider, be sure to include the correct EIN for that
entity. 2010AA NM1 1 Hardcode '85'
2 Hardcode '2'
Billing (Pay To) provider
name 3 Map over Billing Provider Name
4 do not map
5 do not map
6 do not map
7 do not map
8 Hardcode '24'
EIN of Billing (Pay To)
provider 9 Map over EIN for NM1 03
Street address of billing
provider 2010AA N3 1 Map over street address of Billing Provider
City of billing provider 2010AA N4 1 Map over city of BP
State of billing provider 2 Map over state of BP
Zip code of billing provider 3 Map over zip of BP
2000B HL 1 Hardcode '2'
2 Hardcode '1'
3 Hardcode '22'
4
If patient is subscriber, hardcode '0'. Else ha '1' to denote that the patient is a dependent subscriber and that there will be a 2000C loo
It is important to disclose to APS if APS is not the
patient's primary insurance 2000B SBR 1
If APS is the primary insurance for this patie hardcode 'P', if APS is the secondary insura this patient, hardcode 'S'
2
Hardcode '18' only if the patient is the subsc Otherwise, do not map
This indicates what kind of
insurance is being used 9 Claim filing indicator code. See 837p implemguide for list of codes
2010BA NM1 1 Hardcode 'IL'
2 Hardcode '1'
Subscriber's last name only. Any suffix such as 'Jr' or 'III' goes in NM1 07 and not here
at the end of the last name 3 Map subscriber's last name
Subscriber's first name 4 Map subscriber's first name
5 Map subscriber's middle initial if known
Prefix is not used. An
example of a prefix would be
Dr or Mrs 6 do not map
Example of a suffix is 'Sr' or
'III' 7 Map subscriber's suffix if known
8 Hardcode 'MI'
Enter subscriber id 9 Map subscriber's id
Subscriber's street address 2010BA N3 1 Street address of subscriber
Subscriber's city 2010BA N4 1 Subscriber's city of residence
Subscriber's state 2 Subscriber's State 2-character code of resid
Subscriber's zip code 3 Subscriber's zip of residence
2010BA DMG 1 Hardcode 'D8'
Enter subscriber's birthdate. This is not required if the patient is different from the
subscriber 2 Map subscriber's birthdate CCYYMMDD
Subscriber gender-- only required if subscriber is
patient 3 If subscriber's gender is male, hardcode 'M'.Otherwise hardcode 'F'
2010BB NM1 1 Hardcode 'PR'
2 Hardcode '2'
Insurance payer name of
APS Health Care 3 Hardcode 'APS Health Care'
4 do not map
5 do not map
6 do not map
7 do not map
8 Hardcode 'PI'
Enter APS's primary id of
'54160' 9 Hardcode '54160'
This 2000C loop is only to be filled out if patient is NOT
the subscriber 2000C HL 1 Increment the number found in the precedinby 1
2 This indicates the parent hierarchical numbewhich this segment is subordinate
3 Hardcode '23'
Input the relationship of the
patient to the subscriber 2000C PAT 1
Code indicating patient's relationship to the subscriber. See the 837p Hipaa implementa guide for a list of codes that can be used
2010CA NM1 1 Hardcode 'QC'
2 Hardcode '1'
Patient's last name only. Any suffix such as 'Jr' or 'III' goes in NM1 07 and not here at
the end of the last name 3 Map patient's last name
Patient's first name 4 Map patient's first name
5 Map patient's middle initial if known
Prefix is not used. An
example of a prefix would be
Dr or Mrs 6 do not map
Enter the suffix separately from the last name. An example of a suffix is 'Sr' or
'III' 7 Map patient's suffix if known
8 do not map
9 do not map
Patient's street address 2010CA N3 1 Street address of patient
Patient's city 2010CA N4 1 Patient's city of residence
Patient's state 2 Patient's State 2-character code of residenc
Patient's zip code 3 Patient's zip of residence
2010CA DMG 1 Hardcode 'D8'
Enter patient's birthdate. 2 Map patient's birthdate CCYYMMDD
Patient gender 3
If patient's gender is male, hardcode 'M'. Oth hardcode 'F'
End of 2000C loop
Claim number 2300 CLM 1 Map patient account number
Total charge for this claim 2 Map total charge for this claim
3 do not map
4 do not map
Where the service was
performed 5-1 Facility Type Code
5-2 do not map
5-3 Hardcode '1'
This tells whether the provider signature is on file
with APS 6 If the provider's signature is on file with APSelse map 'N'
Tells whether the provider accepts Medicare
assignments 7
This provides information on whether the provider is to receive payment for this service or if the subscriber
is receiving payment 8 If the provider is to receive payment, map 'Ymap 'N'
This tells whether the patient allows medical information
to be released as necessary 9
Hardcode 'Y' if provider has patient signed s allowing appropriate release of claim medica Hardcode 'N' if provider is not allowed to rele medical info
Input how the patient
signature (if it is on file) was
acquired 10
If patient signature is on claim form, hardcod patient signature is on site at the provider si hardcode 'S' else if CLM 09 is 'N', do not ma
Only input this info if the claim is the result of an
accident 11-1
If auto accident, hardcode 'AA'. If abuse, ha 'AB. If another party responsible, hardcode ' emergency-related, hardcode 'EM'. Else ma other accident
11-2 do not map
11-3 do not map
If the claim is due to an auto accident, the 2 character
state must be entered here. 11-4
2-character state or province code if 11-1 is accident) 11-5 do not map 12 do not map 13 do not map 14 do not map 15 do not map 16 do not map 17 do not map 18 do not map 19 do not map 20 do not map 2300 HI 1-1 Hardcode 'BK'
Primary diagnosis must be
entered here 1-2 Map primary dx code
2-1 thru 8-1 Hardcode 'BF'
There can be as many as 8 more secondary diagnosis
This rendering provider info applies to all service lines. Therefore, no rendering provider info should be provided at the service line level. However, if the rendering provider info is different for one or more of the service lines, then separate rendering provider information is to be given for each particular service line that has a different rendering
provider than that listed here 2310B NM1 1 Hardcode '82'
2 If rendering provider name is an organizatiohardcode '2', otherwise hardcode '1'
Rendering provider last
name is entered here 3
Map last name (or organization name) of ren provider
Rendering provider first
name is entered here 4 Map first name of rendering provider (do notNM1 03 is an organization name)
5 do not map
6 do not map
7 do not map
8 Hardcode '24'
Rendering provider's EIN 9 Map rendering provider's EIN
If APS is not the primary insurance, then the Other Subscriber loop must be
filled out 2320 SBR 1 Hardcode 'P'
Enter relationship of patient
t o the other subscriber 2
Hardcode code that pertains to patient's rela to other subscriber (see 837p Imp Guide for
3 do not map
Name of other insurer 4 Map other insured group name if known
Insurance type (I.E. auto,
commercial, etc) 5 Hardcode insurance type code. If unknown, Hardcode 'OT'
6 do not map
7 do not map
8 do not map
9 Hardcode 'ZZ'
2320 AMT 1 Hardcode 'D'
Enter amount paid by other insurance (zero is an acceptable value) -- COB
Payer Paid Amt 2 Map amount paid by primary insurance
2320 AMT 1 Hardcode 'B6'
Enter the maximum that the other subscriber will pay --
2320 OI 1 do not map
2 do not map
This should be the same value found in CLM 08 and indicates whether the
benefits are assigened to the
provider or not 3 CLM 08
4 do not map
5 do not map
This should be the same as CLM 09 and indicates whether the patient allows appropriate release of medical info as relates to
this claim 6 CLM 09
2330A NM1 1 Hardcode 'IL'
2 Hardcode '1'
If APS is not the primary insurance, then the other subscriber name must be
entered 3
Map last name of other subscriber providing insurance for patient
4 Map first name of other subscriber
5 do not map
6 do not map
7 do not map
8 Hardcode 'MI'
Enter other subscriber's primary id # with the primary
payer 9 Map subscriber's id # assigned by primary p
2330A NM1 1 Hardcode 'PR'
2 Hardcode '2'
Other Payer's name 3 Map other payer org name
4 do not map
5 do not map
6 do not map
7 do not map
8 Hardcode 'PI'
Enter the Other Payer's id 9 Map other payer's primary id
End of the Other Subscriber
loop
2400 LX 1
Hardcode '1' and increment by 1 for each ad service line
2400 SV1 1-1 Hardcode 'HC'
Procedure code must be provided for each service
line 1-2 Map procedure code
If there are procedure
1-4 Map additional modifier code (if present)
1-5 Map additional modifier code (if present)
1-6 Map additional modifier code (if present)
Enter amount for this
particular service line 2 Map amount for this service
Enter unit of measure 3
If unit of measure is units, hardcode 'UM'. If minutes, hardcode 'MJ'. If uom is internation hardcode 'F2'
Quantity of units/minutes 4 Unit or minute count
5 do not map
6 do not map
7 do not map
8 do not map
If this is as a result of an emergency, please indicate
this to APS 9 Map 'Y' if this is emergency-related, else ma
2400 DTP 1 Hardcode '472'
2 If statement date is a range, hardcode 'RD8otherwise hardcode 'D8'
Enter date(s) this service
was rendered 3
If statement date is a range then map this as CCYYMMDD-CCYYMMDD with the first dat beginning of the range and the second date the end of the date range, otherwise put sing statement date as CCYYMMDD
Any rendering provider information is given in the service line if and only if it is different from the rendering provider named at the claim
level 2420A NM1 1 Hardcode '82'
2 If rendering provider name is an organizatiohardcode '2', otherwise hardcode '1'
Rendering provider last
name is entered here 3 Map last name (or organization name) of renprovider
Rendering provider first
name is entered here 4
Map first name of rendering provider (do not NM1 03 is an organization name)
5 do not map
6 do not map
7 do not map
8 Hardcode '24'
