ANSI FORMAT Interchange Control Header: ISA*00* Item 4R Ansi:Password 6R Ansi:Submitter Entered in the [FORM OPTIONS] Item of the report. 8R Ansi:ReceiverID 9R {TODAY} - Pulled from the computer's main system. 10R {Time:HHMM} - Pulled from the computer's main system. 13R {ClaimBatch} - Pulled From the print insurance Screen. Functional Group Header: GS*HC Item 2R Ansi:Submitter 3R Ansi:ReceiverID 4R {Today} 5R {Time:HHMM} 6R {ClaimBatch} 8R Version hard coded in “004010X098A1” Transaction Set Header ST*837 Item 2R {ClaimBatch} BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00* Item 3R {ClaimBatch} 4R {TODAY} 5R {Time:HHMM} TRANSMISSION TYPE IDENTIFICATION Ref Version hard coded in “004010X098A1” Loop Id 1000A Submitter Name NM1*41*2* Item 3R Practice:Name 9R Ansi:Submitter ** if the Practice:Name is more than 35 chars ask** PER*IC* ( billing service is used then the following is needed) Item 2R Practice:S_Contact - Entered in the Practice File, Billing Service screen Pulling Contact Person. 4R Practice:S_Phone - Entered in the Practice File, Billing Service screen Pulling the phone number. 6R Practice:S_Ext – Entered in the Practice File, Billing Service screen Pulling the Phone extention. (else if the practice is the one filing) 2R Practice:Contact – Entered in the Practice File, Pulling Billing Contact. 4R Practice:Phone – Entered from the Practice File, Pulling Phone 6R Practice:Ext – Entered from the the Practice File, Pulling Phone Extention Loop ID 1000B Receiver Name NM1*40*2* Item 3R Ansi:Receiver - Entered in the [FORM OPTIONS] Item of the report. (name of the clearing house or insurance company. 9R Ansi:ReceiverID ** if the Ansi:Receiver is more than 35 chars ask** Loop ID 2000A Billing/Pay-to Provider HL*1**20*1 PRV*BI*ZZ* Item 3S Practice:taxonomy - Entered in the Practice File on the Electronic Claims Screen Under Taxonomy Code (You can get this code from the AB02_146.Doc Available at AltaPoint.) Loop ID 2010AA Billing Provider Name (With a billing Service) NM1*85*2 Item 3R Practice:Bill_Serv - Entered in the Practice File on the Billing Service Screen. Under Billing Service. 9R Pracice:S_TIN - Entered in the Practice File on the Billing Service Screen. Under Tax ID. N3 2R Practice:S_Address1 - Entered in the Practice File on the Billing Service Screen. Under Address 1. 3R Practice:S_Address2 - Entered in the Practice File on the Billing Service Screen. Under Address 2. N4 2R Practice:S_City 3R Practice:S_State 4R Practice:S_Zip - Entered in the Practice File on the Billing Service Screen. Under City, State, and Zip. REF*1C* If this is going to be for Medicare there is a line that needs to be included. Right now there is a * from the line that says .... 2S Practice:Medicare - Entered in the Practice File in the Electronic Claims Screen. Under Medicare. Loop ID 2010AB Pay-To Provider Name (With a billing Service) NM1*87*2 Item 3S Practice:Name - Entered in the Practice File Under Pracice Name 9S Practice:EID - Entered in the Practice File Under Employer ID N3 2R Practice:Address1 - Entered in the Practice File Under Address 1 3R Practice:Address2 - Entered in the Practice File Under Address 2 N4 2R Practice:City 3R Practice:State 4R Practice:Zip - Entered in the Practice File Under City, State, Zip “PRV*BI*” 2S Practice:Taxonomy - Entered in the Practice File on the Electronic Claims Screen Under Taxonomy Code You can get this code from AltaPoint. Loop ID 2010AA Billing Provider Name (No billing Service) “NM*85*2” Item 3R Practice:Name - Entered in the Practice File Under Pracice Name 9R Practice:EID - Entered in the Practice File Under Employer ID N3 2R Practice:Address1 - Entered in the Practice File Under Address 1 3R Practice:Address2 - Entered in the Practice File Under Address 2 N4 2R Practice:City 3R Practice:State 4R Practice:Zip - Entered in the Practice File Under City, State, Zip If this is going to be for Medicare there is a line that needs to be included. Right now there is a * from the line that says .... [“REF*1C*”+ Practice:Medicare+”~”,,,8,Left,Font 1]; “PRV*BI*” 2S Practice:Taxonomy - Entered in the Practice File on the Electronic Claims Screen Under Taxonomy Code You can get this code from Available at AltaPoint. Loop ID 2000B Subscriber Hierarchical Level HL*Ansi:Loop1*1*22*1 or 0 SBR*P* Item 9R Bill:Ins1_Type - Pulled from the Billing Option screen Primary Insurance Under Insurance Type. Permanent location is in the Patient file Billing screen Primary Insurance Under Insurance Type. Loop ID 2010BA Subscriber Name “NM1*IL*1” Item 3R Guarantor1:LastName Based on the Primary Insured identified in Bill Options Prim. Ins. 4R Guarantor1:FirstName Responsible Party. Permanent location is in the Patient file Billing 5R Guarantor1:Middle screen Primary Insurance Under Insurance Type. 9R Bill:Ins1_ID - Pulled from the Billing Option screen Primary Insurance Under ID No. Permanent location is in the Patient file Billing screen Primary Insurance Under ID No. N3 2S Guarantor1:Address1 3S Guarantor1:Address2 N4 2S Guarantor1:City Based on the Primary Insured identified in Bill Options Primary Ins. 3S Guarantor1:State Responsible Party. Permanent location is in the Patient file Billing 4S Guarantor1:Zip screen Primary Insurance Under Insurance Type. DMG*D8* 2S Guarantor1:Birthdate 3S Guarantor1:Sex Loop ID 2010BB Payer Name “NM1*PR*2*” Item 3R Primary:Company 9R Primary:EMC_ID1 or 9R Primary:GroupID or 9R InsuranceID:Prov_ID Based on the Primary Insurancedentified in Bill Options N3 Primary Insurance Company. Permanent location is in the Patient 2S Primary:Address1 file Billing screen Primary Insurance Under Insurance Company. 3S Primary:Address2 N4 2S Primary:City 3S Primary:State 4S Primary:Zip Loop ID 2010BC Responsble Party Name “NM1*QD*1*” (not used right now) Situational; Needed if the responsible party is neither the subscriber nor the patient. Item 4S Client:LastName 5S Client:FirstName 6S Client:Middle Based on the Patient file Guarantor on the front page. N3 2SR Client:Address1 3SR Client:Address2 N4 2SR Client:City 3SR Client:State 4SR Client:Zip Loop ID 2000C Patient Hierarchical Level “HL*Ansi:loop1*Ansi:Loop2*23*0” The following is included only if the Responsible Pary for the Patient is someone else. PAT Item 1SR Bil:ins1_GRel – Pulled from the Billing Option screen Primary Insurance Under Relationship to Insured. Permanent location is in the Patient file Billing screen Primary Insurance. Under Insured Relationship. 6SR Pateint:Deceased – Pulled from the Patient File Screen 2 Under Deceased. Loop ID 2010CA Patient Name “NM1*QC*1*” The following is included only if the Responsible Pary for the Patient is someone else. Item 3R Patient:LastName 4R Patient:FirstName Pulled from the Patient File Screen 1 5R Patient:Middle 9R Bill:Ins1_ID - Pulled from the Billing Option Primary Insurance Screen Under Insurance Company. Permanent location is in the Patient file Billing screen Primary Insurance Under Primary Insurance. N3 Item 2R Patient:Address1 3R Pateint:Address2 N4 2R Patient:City 3R Patient:State Pulled from the Patient File Screen 1 4R Patient:Zip DMG*D8* 3R Patient:Birthdate 4R Patient:Sex The follwing is included only if the Pateint is The Responsible Party. PAT Item 6R Pateint:Deceased - Pulled from the Patient File Screen 2 Under Deceased. LoopID – 2300 Claim information CLM Item 1R Patient:Code - Pulled from the billing header under Bill Number 2R {Charges} - Pulled from the billing header (calculated field) 6R InsuranceID:Sig_Cert - Pulled from the File Provider and Employee Insurance ID's screen “Signiture Required on Claims” Column. 7R Bill:Accept - Pulled from the Bill Option Primary insurance Under the Accept Assignment box wether checked or not. 8R Patient:Sig_Assign - Pulled from the Patient File Billing Screen “Signature on File – Assignment of Benefits” wether checked or not. 9/10R Patient:Sig_Info – Pulled from the Patient File Billing Screen “Signature on File – Release of Information” wether checked or not. 12S Bill:Acc_Type - Pulled from the Bill Options Accident/Disability Screen Under Accident Type 12S Bill:Acc_State - Pulled from the Bill Options Accident/Disability Screen Under Accident State. ***** End of the Claim Section (CLM DTP*454*D8* 3S Patient:First_date - Pulled from the Patient File Page 2 Under First Seen DTP*304*D8* 3S Patient:Ref_Date - Pulled from the Patient File Page 2 Under Referral Date DTP*304*D8* 3S Patient:Last_Date - Pulled from the Pateint File Page 2 Under Last Seen If Bill:Symptom = P DTP*484*D8* 3S Bill:Sympt_Date – Pulled from Bill Options Insurance Claim Screen If Bill:Symptom is not P DTP*431*D8* 3S Bill:Sympt_Date – Pulled from Bill Options Insurance Claim Screen DTP*438*D8* 3S Bill:Similar – Pullled from Bill Options Insurance Claim Screen DTP*439*D8* 3S Bill:Acc_Date – Pulled from Bill Options Accident/Disablility Screen DTP*455*D8* 3S Bill:Last_XRay - Pullled from Bill Options Insurance Claim Screen DTP*471*D8 3S Bill:Last_Rx - Pullled from Bill Options Insurance Claim Screen DTP*360*D8 3S Bill:Work1 - Pulled from Bill Options Accident/Disablility Screen DTP*361*D8 3S Bill:Work2 - Pulled from Bill Options Accident/Disablility Screen DTP*297*D8 3S Bill:Work_Last - Pulled from Bill Options Accident/Disablility Screen DTP*296*D8 3S Bill:WorkReturn - Pulled from Bill Options Accident/Disablility Screen DTP*435*D8 3S Bill:Hosp1 - Pulled from Bill Options Accident/Disablility Screen DTP*096*D8 3S Bill:Hosp2 - Pulled from Bill Options Accident/Disablility Screen REF*G1* 2S Bill:Ins1_Prior - Pulled from Bill Options Primary Insurance Screen – Prior Authorization REF*F8* 2S Bill:IVOICE – Pulled from the transaction screen - Invoice REF*X4* 2S Employee:CLIA – File/ Prividers and Employees / Electronic Billing - CLIA NTE*ADD* 2S Bill:Notes - Pulled from Bill Options - Notes. HI*BK# 2S Bill:Diag1 - Pulled from line item detail - diagnosis 1 *BF# 3S Bill:Diag2 - Pulled from line item detail - diagnosis 2 4S Bill:Diag3 - Pulled from line item detail - diagnosis 3 *BF# 5S Bill:Diag4 - Pulled from line item detail - diagnosis 4 Loop ID – 2310A Referring Provider Name NM1*DN*1 Item 3S Referral:LastName - Referenced from Patient File Page 2 Pulled from Address file – Last Name 4S Referral:FirstName - Referenced from Patient File Page 2 Pulled from Address file – First Name. PRV*RF* Item 2SR Referral:Specialty - Referenced from Pateint File Page 2 Pulled from Address File - Insurance ID Specialty. REF*1G* Item 2SR Referral:Ref_UPIN - Referenced from Pateint File Page 2 Pulled from Address File Insurance ID – Default UPin LoopID 2310B - Rendering Provider NM1*82*1* Item 3S Employee:LastName - Pulled from File/ Providers and Employees Page 1 – Last Name 4S Employee:FirstName - Pulled from File/Providers and Employees Page 1 – First Name 5S Employee:Middle - Pulled from File/Providers and Employees Page 1 - Middle 9S XX*Employee:EMC_ID or - Pulled from File/Providers and Employees Electronic Billing – Electrionic Provider ID. 9S 24*Employee:Tax_ID or - Pulled from File/Providers and Employees Page 2 – Tax ID 9S 34*Employee:SS - Pulled from File/Providers and Employees Page 2 - SS PRV*PE*ZZ* 3SR Employee:Specialty – Pulled from File/ Providers and Employees Electronic Billing – Specialty. It is the Taxonomy Number for Document REF*1C 2S Employee:Medicare - Pulled from File/ Providers and Employees Electronic Billing – Medicare. - OR - REF*G2* 2S InsuranceID:Prov_ID – Pulled from File/Providers and Employee Insurance ID OR - REF*1G* 2S Employee:UPIN - Pulled from File/ Providers and Employees Electronic Billing – UPIN USIN number. - OR - REF*OB* 2S Employee:License - Pulled from File/Providers and Employee -Page 2 – License. LOOPID - 2310D Service Facility Location NM1*FA*2* 3S Facility:Company - Identified under Bill Options – Insurance Claim – Facility This references the address file for that facility. N3* 2SR Facility:Address1 - Address file – Address1 3SR Facility:Address2 - Address File - Address2 N4* 2SR Facility:City - Address File - City 3SR Facility:State - Address File - State 4SR Facility:Zip - Address File – Zip LOOPID - 2310E Supervising Provider Name NM1*DQ*1* 3S Provider:LastName - Referenced from the Provider on Transaction Screen below billing number. Pulled from Employee File – Last Name 4S Provider:FirstName - Referenced from the Provider on Transaction Screen below billing number. Pulled from Employee File – First Name 5S Provider:Middle - Referenced from the Provider on Transaction Screen below billing number. Pulled from Employee File – Middle 9S Provider:EMC_ID - Referenced from the Provider on Transaction Screen below billing number. Pulled from Employee File – Electronic Billing – Electronic Provider ID. or 9S Provider:Tax_ID - Referenced from the Provider on Transaction Screen below billing number. Pulled from Employee File – Page 2 – Tax ID or 9S Provider:SS - Referenced from the Provider on Transaction Screen below billing number. Pulled from Employee File – Page 2 - SS LOOPID 2320 OTHER SUBSCRIBER INFORMATION SBR 2S Bill:Ins2_GRel - Transaction Screen – Bill Options – Secondary Insurance – Relation to Insured. 9S Bill:ins2_Type - Transaction Screen – Bill Options – Secondary Insurance – Insurance Type For all Secondary Insurance DMG*D8* S Guarantor2:Birthdate - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File Birthdate or from the Guarantor S File – Page 2 – Brithdate. S Guarantor2:Sex - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File Sex or from the Guarantor File Sex. OI*** SR Patient:SIG_ASSIGN - Pulled from the Patient File - Billing Screen Signature on File – Assignment of Benefits. SR Patient:SIG_INFO - Pulled from the Patient File - Billing Screen Signature on File – Release of Information. LOOPID 2330A OTHER SUBSCRIBER NAME NM1*IL*1* 3R Guarantor2:LastName - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File Last name or from the Guarantor File Last Name. 4R Guarantor2:FirstName - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File First or from the Guarantor File First Name. 5R Guarantor2:Middle - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File Middle or from the Guarantor File Middle. 9R Bill:Ins2_ID - Pulled from the Transaction Screen – Bill Options – Secondary Insruance – ID NO. N3* 2S Guarantor2:Address1 - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File Address1 or from the Guarantor File Address1. 3S Guarantor2:Address2 - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File Address2 or from the Guarantor File Address2. N4* 2S Guarantor2:City - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File City or from the Guarantor File City. 3S Guarantor2:State - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File State or from the Guarantor File State. 4S Guarantor2:Zip - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Responsible Party . Pulled from the Patient File Zip or from the Guarantor File Zip. LOOPID 2330B OTHER PAYER NAME NM1*PR*2* 3R Secondary:Company - Referenced from the Trasaction Screen – Bill Options – Secondary Insruance – Insurance Company. 9R Secondary:EMC_ID1 - Insurance Company File – Practice ID's – Electronic Claims Payor ID OR 9R Secondary:GroupID - Insurance Company File – Practice ID's – Your Group ID OR 9R Insurance:Prov_ID - Provider and Employee File – Insurance ID's – Provider ID LoopID 2400 - Service Line LX SV1*HC# 3R Fee:CPT_Code 3R Detail:Mod1 3R Detail:Mod2 4R Detail:Extended 6R Detail.Units 7R Detail:Med_POS 9R Detail:Diag 10R Detail:TOS DTP*472*D8* 3R Detail:Date NTE*ADD* 2S Detail:Notes