Thursday, 3 July 2014

837 Institutional EDI UB04 Claim Example

Beacon EDI Is a Clearinghouse

837 Institutional Claim Scenario

The included example shows a standard 837 Institutional claim. There are two claims in this scenario (Two CLM 2300 Loop Levels)
Here are the attributes of the example:
- The submitter of these claims is UCLA MEDICAL CENTER
- The receiver of the claim is BCBS DISNEY
- The billing provider is UCLA MEDICAL CENTER
- The first patient “Mickey Mouse” is the subscriber
- The payer is BCBS DISNEY
- Mickey Mouse visited the emergency room because he had an open wound (ICD-9 8842) when he was driving around with Donald Duck (E8199 Person injured in unspecified motor-vehicle accident) and went to visit the hospital.
- Mickey’s visit was on January 24th, 2012
- Where Mickey was admitted to the Hospital ER Procedure Code 99201 (HCPCS) $150 and treated by Dr. Watson with a Laceration Repair Procedure Code 26591 (HCPCS) – cost $75
- The second patient “Donald Duck” is the subscriber and was treated by Dr. Watson with the same procedure and diagnosis codes.
- Donald and Mickey had the same insurance except Donald had a different member ID with BCBS Disney.

837 Institutional 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*UCLA MEDICAL CENTER*****46*1982
NM101    Entity Identifier Code : Submitter
NM102    Entity Type Qualifier : Non-Person Entity
NM103    Name Last or Organization Name : UCLA MEDICAL CENTER
NM108    Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)
NM109    Identification Code : 1982
 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* 203BA0200N
 PRV01     Type of Provider: Billing “BI”
 PRV02     Code Qualifier: Health Care Provider Taxonomy Code “PXC”
 PRV03     Provider Taxonomy Code: 203BA0200N
837 Institutional Deciphering Raw Data 201AA – 2000B

LOOP 2010AA BILLING PROVIDER NAME

 Billing Provider Information: NM1*85*2*UCLA MEDICAL CENTER*****XX*1215193883
 NM101    Entity Identifier Code : Billing Provider “85″
 NM102    Entity Type Qualifier : Person “2″ Organization
 NM103    Name Last or Organization Name : UCLA MEDICAL CENTER
 NM108    Identification Code Qualifier : National Provider Identifier “XX”
 NM109    NPI: 1215193883
  Billing Provider Address:757 WESTWOOD PLAZA
  N301     Street Address: 757 WESTWOOD PLAZA
  Billing Provider City, State, ZIP Code: N4*LOS ANGELES*CA*900257437
  N401     City: LOS ANGELES
  N402     State: CA
  N403     Zip: 900257437
  Billing Provider Tax Identification: REF*EI*123456789
  REF01    Reference Qualifier: Employer’s Identification Number “EI”
  REF02    EIN: 123456789
LOOP 2000B SUBSCRIBER HIERARCHICAL (Claim 1)
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*SUITE 101
    N301     Street Address: 1565 DISNEYLAND DRIVE
    N302    Street Address Line 2:SUITE 101
    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 Institutional Deciphering Raw Data 2010BB – 2400 (Claim 1)

   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*ABC9001*225***22:A:1*Y*C*Y*Y
CLM01    Claim ID: ABC9001
CLM02    Claim Amount: 225
CLM05-1 Place of Service Code: ’22′ Outpatient Hospital
CLM05-2 Facility Code Qualifier: ‘A’ Uniform Billing Claim Form Bill Type
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    Assignment or Plan Participation Code: ‘C’ Not Assigned
CLM08    Benefit Indicator: ‘Y’ Yes – Subscriber authorized the payer to remit payment directly to the provider
CLM09    Release of Information Indicator: ‘Y’ Yes – Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
     ICD9Diagnosis Codes:
     HI*BK:8842
     HI01-1 ‘BK’ for Primary Diagnosis    HI01-2: 8842 (Open Wound)
     HI*PR:8842
     HI01-1 ‘BK’ for Patient’s Reason For Visit HI01-2: 8842 (Open Wound)
HI*BN:E8199
HI01-1 ‘BN’ for External Cause Of Injury HI01-2: (E8199 Person injured in unspecified motor-vehicle accident)
  LOOP 2400 SERVICE LINE
  Service Line Number 1: LX*1
     LOOP 2310A ATTENDING PROVIDER NAME
     Attending Provider Name: NM1*71*1*WATSON*JOHN*H***XX*1134125736
     NM101    Entity Identifier Code : Attending Provider “71″
     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
  Institutional Service Line Item Details: SV2*0450*HC:99201*150*UN*1
SV201      Service Line Revenue Code: 0450
SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS
SV202-02 Procedure Code: 99201 (Hospital Visit)
SV203      Procedure Amount:  $150
SV204      Unit of Measure Code: ‘UN’ Units
SV205     Service Unit Count: 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
  Institutional Service Line Item Details: SV2*0360*HC:26591*75*UN*1
SV201    Service Line Revenue Code: 0360
SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS
SV202-02 Procedure Code: 26591 (Laceration Repair)
SV203    Procedure Amount:  $75
SV204    Unit of Measure Code: ‘UN’ Units
SV205    Service Unit Count: 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

837 Institutional Deciphering Raw Data 2000B – 2300 (Claim 2)

Grayed out  and smaller font items indicate that the elements are the same as in Claim 1
LOOP 2000B SUBSCRIBER HIERARCHICAL (Claim 2)
Subscriber Hierarchical Level: HL*3*1*22*0
  HL01     Hierarchical ID: 3
  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)
 LOOP 2010BA SUBSCRIBER NAME
   Subscriber Information: NM1*IL*1*DUCK*DONALD****MI*60345914B
   NM101    Entity Identifier Code : Subscriber  “IL”
   NM102    Entity Type Qualifier : Person “1″
   NM103    Subscriber Last Name: Duck
   NM104    Subscriber First Name: Donald
   NM108    Identification Code Qualifier : Member Identification Number “MI”
   NM109    Member Identification Number: 60345914B
    Subscriber Address: N3*1565 DISNEYLAND DRIVE*SUITE 102
    N301     Street Address: 1565 DISNEYLAND DRIVE
    N302    Street Address Line 2:SUITE 102
    Subscriber City, State, ZIP Code: N4*ANAHEIM*CA*92802
    N401     City: ANAHEIM
    N402     State: CA
    N403     Zip: 92802
      Subscriber Demographic Information: DMG*D8*19340619*M
    DMG01    Date Time Period Format Qualifier: Date Expressed in Format CCYYMMDD “D8″
    DMG02    Subscriber Birth Date: 19340619
    DMG03    Subscriber Gender Code: ‘M’ for Male
    Subscriber Secondary Identification: REF*SY*066080002
    REF01    Reference Qualifier: Social Security Number “SY”
    REF02    SSN: 066080002

837 Institutional Deciphering Raw Data 2010BB -2300 – 2400 (Claim 2)

  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*ABC9002*225***22:A:1*Y*C*Y*Y

CLM01    Claim ID: ABC9002
CLM02    Claim Amount: 225
CLM05-1 Place of Service Code: ’22′ Outpatient Hospital
CLM05-2 Facility Code Qualifier: ‘A’ Uniform Billing Claim Form Bill Type
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    Assignment or Plan Participation Code: ‘C’ Not Assigned
CLM08    Benefit Indicator: ‘Y’ Yes – Subscriber authorized the payer to remit payment directly to the provider
CLM09    Release of Information Indicator: ‘Y’ Yes – Provider has a Signed Statement Permitting Release
     ICD9Diagnosis Codes:
     HI*BK:8842
     HI01-1 ‘BK’ for Primary Diagnosis    HI01-2: 8842 (Open Wound)
     HI*PR:8842
     HI01-1 ‘BK’ for Patient’s Reason For Visit HI01-2: 8842 (Open Wound)
HI*BN:E8199HI01-1 ‘BN’ for External Cause Of Injury HI01-2: (E8199 Person injured in unspecified motor-vehicle accident)
LOOP 2400 SERVICE LINE
  Service Line Number 1: LX*1
     LOOP 2310A ATTENDING PROVIDER NAME
     Attending Provider Name: NM1*71*1*WATSON*JOHN*H***XX*1134125736
     NM101    Entity Identifier Code : Attending Provider “71″
     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
  Institutional Service Line Item Details: SV2*0450*HC:99201*150*UN*1
SV201      Service Line Revenue Code: 0450
SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS
SV202-02 Procedure Code: 99201 (Hospital Visit)
SV203      Procedure Amount:  $150
SV204      Unit of Measure Code: ‘UN’ Units
SV205     Service Unit Count: 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
  Institutional Service Line Item Details: SV2*0360*HC:26591*75*UN*1
SV201    Service Line Revenue Code: 0360
SV202-01 Procedure Code Qualifier: ‘HC’ HCPCS
SV202-02 Procedure Code: 26591 (Laceration Repair)
SV203    Procedure Amount:  $75
SV204    Unit of Measure Code: ‘UN’ Units
SV205    Service Unit Count: 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
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