Thursday, 3 July 2014

837 EDI Professional Claim Example and Mapping


edi software

837 Professional Claim Scenario

The included example shows a standard 837 Professional claim file. It includes data from the provider of Service indicating the member’s demographic information, diagnosis, services rendered and charges. This data will be used by the Insurance Company to determine what benefits should be rendered.
Here are the attributes of the example:
- The submitter of the claim is AGILE BILLING SOLUTIONS
- The receiver of the claim is BCBS DISNEY
- The billing provider is JOHN WATSON
- The patient “Mickey Mouse” is the subscriber
- The payer is BCBS DISNEY
- Mickey Mouse had felt like he had Diarrhea (ICD-9 787.91) and went to visit the doctor and the doctor diagnosed him with the stomach flu (e.g. Gastroenteritis) ICD-9 Codes 787.91 (primary), 009.0 (primary), 009.1, 558
- Mickey’s initial office visit was on January 24th, 2012 – Where Mickey spent 15 minutes with Dr. Watson face-to-face and the diagnosis code for Diarrhea was established – Procedure Code 99213 (HCPCS) – cost $50
After the office Visit Mickey went to the lab for a Stool Culture lab test procedure Code 87046 – cost $15 The lab services were performed at the BEST LAB COMPANY

837 Deciphering Raw Data BHT – 2000A

Beginning of Hierarchical Transaction:  BHT*0019*00*004545*20120124*135420*CH

BHT01    Hierarchical Structure Code : Information Source, Subscriber, Dependent
BHT02    Transaction Set Purpose Code : Original
BHT03    Reference Identification : 004545
BHT04    Date : 1/24/2012
BHT05    Time : 1:54:20 PM
BHT06    Transaction Type Code : Chargeable

LOOP 1000A Submitter Name

Submitter Information:  NM1*41*2*AGILE BILLING SOLUTIONS*****46*1981

NM101    Entity Identifier Code : Submitter
NM102    Entity Type Qualifier : Non-Person Entity
NM103    Name Last or Organization Name : AGILE BILLING SOLUTIONS
NM108    Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)
NM109    Identification Code : 1981
 Submitter Contact Information: PER*IC*ANN GILLIS*TE*8185601000
 PER01     Contact Type: Information Contact “IC”
 PER02     Contact Name: ANN GILLIS
 PER03     Communication Qualifier: Telephone “TE”
 PER04     Telephone Number: 8185601000

LOOP 1000B Receiver Name

Receiver Information: NM1*40*2*BCBS DISNEY*****46*47198

NM101    Entity Identifier Code : Receiver “40″
NM102    Entity Type Qualifier : Non-Person Entity  “2″
NM103    Name Last or Organization Name : BCBS DISNEY
NM108    Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)  “46″
NM109    Identification Code : 47198

LOOP 2000A BILLING PROVIDER

Billing Provider Hierarchical Level: HL*1**20*1

HL01     Hierarchical ID: 1
HL02     Parent Hierarchical ID: No Parent
HL03     Hierarchy Level Name: “20″ = Information Source
HL04     Number of Hierarchical Children: 1 more additional subordinate HL
 Provider Specialty Information: PRV*BI*PXC*207Q00000X
 PRV01     Type of Provider: Billing “BI”
 PRV02     Code Qualifier: Health Care Provider Taxonomy Code “PXC”
 PRV03     Provider Taxonomy Code: 207Q00000X

837 Deciphering Raw Data 201AA – 2000B
LOOP 2010AA BILLING PROVIDER NAME

Billing Provider Information: NM1*85*1*WATSON*JOHN*H***XX*1134125736

 NM101    Entity Identifier Code : Billing Provider “85″
 NM102    Entity Type Qualifier : Person “1″
 NM103    Name Last or Organization Name : WATSON
 NM104    First Name: WATSON
 NM103    Middle Name or Initial: WATSON
 NM108    Identification Code Qualifier : National Provider Identifier “XX”
 NM109    NPI: 1134125736
  Billing Provider Address :N3*221 Baker Street
  N301     Street Address: 221 Baker Street
  Billing Provider City, State, ZIP Code: N4*ANAHEIM*CA*92802
  N401     City: ANAHEIM
  N402     State: CA
  N403     Zip: 92802
  Billing Provider Tax Identification: REF*EI*123456789  
  REF01    Reference Qualifier: Employer’s Identification Number “EI”
  REF02    EIN: 123456789

LOOP 2000B SUBSCRIBER HIERARCHICAL
Subscriber Hierarchical Level: HL*2*1*22*0

  HL01     Hierarchical ID: 2
  HL02     Parent Hierarchical ID: 1 (Information Source/Billing Provider)
  HL03     Hierarchy Level Name: “22″ = Subscriber
  HL04     Number of Hierarchical Children: 0 (Subscriber is the patient)

Subscriber Information: SBR*P*18*******CI

  SBR01    Payer Responsibility Sequence Number Code: Primary  “P”
  SBR02    Individual Relationship Code: Self  “18″
  SBR09    Code identifying type of claim: Commercial Insurance Co. “CI”

LOOP 2010BA SUBSCRIBER NAME
Subscriber Information: NM1*IL*1*MOUSE*MICKEY****MI*60345914A

   NM101    Entity Identifier Code : Subscriber  “IL”
   NM102    Entity Type Qualifier : Person “1″
   NM103    Subscriber Last Name: Mouse
   NM104    Subscriber First Name: Mickey
   NM108    Identification Code Qualifier : Member Identification Number “MI”
   NM109    Member Identification Number: 60345914A
    Subscriber Address: N3*1565 DISNEYLAND DRIVE
    N301     Street Address: 1565 DISNEYLAND DRIVE
    Subscriber City, State, ZIP Code: N4*ANAHEIM*CA*92802
    N401     City: ANAHEIM
    N402     State: CA
    N403     Zip: 92802
   Subscriber Demographic Information: DMG*D8*19281118*M
    DMG01    Date Time Period Format Qualifier: Date Expressed in Format CCYYMMDD “D8″
    DMG02    Subscriber Birth Date: 19281118
    DMG03    Subscriber Gender Code: ‘M’ for Male
    Subscriber Secondary Identification: REF*SY*055090001
    REF01    Reference Qualifier: Social Security Number “SY”
    REF02    SSN: 055090001

837 Deciphering Raw Data 2010BB – 2400

    LOOP ID – 2010BB PAYER NAME

    Payer Name: NM1*PR*2*BCBS DISNEY*****PI*8584537845
    NM101    Entity Identifier Code : Payer “PR”
    NM102    Entity Type Qualifier : Non-Person Entity  “2″
    NM103    Name Last or Organization Name : BCBS DISNEY
    NM108    Identification Code Qualifier :  National Plan ID “PI”
    NM109    Identification Code : 8584537845

   LOOP 2300 CLAIM INFORMATION

   Claim Information: CLM*ABC7001*65***11:B:1*Y*A*Y*Y
    CLM01    Claim ID: ABC7001
    CLM02    Claim Amount: 65
    CLM05-1  Place of Service Code: ’11′ Office
    CLM05-2  Facility Code Qualifier: ‘B’ Place of Service Codes for Professional or Dental Services
    CLM05-3  Claim Frequency Code: ’1′ The only bill to be received for a course of treatment
    CLM06    Provider or Supplier Signature On File Indicator: ‘Y’ Yes
    CLM07    Plan Participation Code: ‘A’ Assigned – Provider accepts agreement with payer
    CLM08    Benefit Indicator: ‘Y’ Subscriber authorized payer to remit payment directly to the provider
    CLM09    Release of Information Indicator: ‘Y’ Provider has a Statement Permitting Release of Medical Billing Data Related to a Claim
     ICD9Diagnosis Codes: HI*BK:78791*BF:0091*BF:558*BF:0090
     HI01-1  ‘BK’ for (DX1) Primary Diagnosis    HI01-2: 78791
     HI02-1  ‘BF’ for (DX2) Supporting Diagnosis HI02-2: 0091
     HI03-1  ‘BF’ for (DX3) Supporting Diagnosis HI03-2: 558
     HI04-1  ‘BF’ for (DX4) Supporting Diagnosis HI04-2: 0090

  LOOP 2400 SERVICE LINE

  Service Line Number 1: LX*1

  Professional Service Line Item Details: SV1*HC:99213*50*UN*1***1

  SV101-01 Procedure Code Qualifier: ‘HC’ HCPCS
  SV101-02 Procedure Code: 99213
  SV102    Procedure Amount:  $50
  SV103    Unit of Measure Code: ‘UN’ Units
  SV104    Service Unit Count: 1
  SV107-01 1st Diagnosis Code Pointer: 1
   Date or Time or Period: DTP*472*D8*20120124
      Date/Time Qualifier : ’472′ Service
      Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
      Date Time Period : 20120124
  Service Line Number 2: LX*2 
   Professional Service Line Item Details: SV1*HC:87046*15*UN*1***1:2:3:4
  SV101-01 Procedure Code Qualifier: ‘HC’ HCPCS
  SV101-02 Procedure Code: 87046
  SV102    Procedure Amount:  $15
  SV103    Unit of Measure Code: ‘UN’ Units
  SV104    Service Unit Count: 1
  SV107-01 1st Diagnosis Code Pointer: 1
  SV107-02 2nd Diagnosis Code Pointer: 2
  SV107-03 3rd Diagnosis Code Pointer: 3
  SV107-04 4th Diagnosis Code Pointer: 4
   Date or Time or Period: DTP*472*D8*20120124
      Date/Time Qualifier : ’472′ Service
      Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
      Date Time Period : 20120124

837 Deciphering Raw Data 2420C

LOOP 2420C SERVICE FACILITY LOCATION NAME

       Billing Provider Information: NM1*77*2*BEST LAB COMPANY*****XX*1124157821
       NM101    Entity Identifier Code : Service Location “77″
       NM102    Entity Type Qualifier : Non-Person Entity “2″
       NM103    Organization Name : BEST LAB COMPANY
       NM108    Identification Code Qualifier : National Provider Identifier “XX”
       NM109    NPI: 1134125736
        Service Facility Address: N3*505 Main Street
        N301     Street Address: 505 Main Street
        Billing Provider City, State, ZIP Code: N4*ANAHEIM*CA*92802
        N401     City: ANAHEIM
        N402     State: CA
        N403     Zip: 92802
Post a Comment