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
