837 Institutional Claim scenario and mapping guidelines
837 Institutional Claim example presented in today’s post shows a standard 837 Institutional claim. As we spoke in our previous post, the 837 Healthcare Claim transaction has three different implementation guides specifically developed for Professional, Institutional and Dental claims. The specifications are geared to meet the individual requirements of the three different types of claim forms. 837 Institutional Claim manual allows for Value Codes, Occurrence Codes and Occurrence Spans. These fields are specific to the UB04 claim form only.
In today’s 837 Institutional Claim example there are two claims in this scenario (Two CLM 2300 Loop Levels). Here are the attributes of the 837 Institutional Claim 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 Claim Raw Data
ST*837*3706*005010X223A2
BHT*0019*00*004545*20120124*135420*CH
NM1*41*2*UCLA MEDICAL CENTER*****46*1982
PER*IC*ANN GILLIS*TE*8185601000
NM1*40*2*BCBS DISNEY*****46*47198
HL*1**20*1
PRV*BI*PXC*282N00000X
NM1*85*2*UCLA MEDICAL CENTER*****XX*1215193883
N3*757 WESTWOOD PLAZA
N4*LOS ANGELES*CA*900257437
REF*EI*123456789
HL*2*1*22*0
SBR*P*18*******CI
NM1*IL*1*MOUSE*MICKEY****MI*60345914A
N3*1565 DISNEYLAND DRIVE*SUITE 101
N4*ANAHEIM*CA*92802
DMG*D8*19281118*M
REF*SY*055090001
NM1*PR*2*BCBS DISNEY*****PI*8584537845
CLM*ABC9001*225***22:A:1*Y*C*Y*Y
DTP*434*RD8*20120124-20120124
CL1*3*7*1
HI*BK:8842
HI*PR:8842
HI*BN:E8199
NM1*71*1*WATSON*JOHN*H***XX*1134125736
LX*1
SV2*0450*HC:98765*150*UN*1
DTP*472*D8*20120124
LX*2
SV2*0360*HC:26591*75*UN*1
DTP*472*D8*20120124
HL*3*1*22*0
NM1*IL*1*DUCK*DONALD****MI*60345914B
N3*1565 DISNEYLAND DRIVE*SUITE 102
N4*ANAHEIM*CA*92802
DMG*D8*19340619*M
REF*SY*066080002
NM1*PR*2*BCBS DISNEY*****PI*8584537845
CLM*ABC9002*225***22:A:1*Y*C*Y*Y
DTP*434*RD8*20120124-20120124
CL1*3*7*1
HI*BK:8842
HI*PR:8842
HI*BN:E8199
NM1*71*1*WATSON*JOHN*H***XX*1134125736
LX*1
SV2*0450*HC:98765*150*UN*1
DTP*472*D8*20120124
LX*2
SV2*0360*HC:26591*75*UN*1
DTP*472*D8*20120124
SE*53*3706
837 Institutional Claim 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 Claim 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 Claim 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 Claim 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 Claim 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.
The above mentioned example, including mapping guides, can serve for deeper understanding of healthcare claims EDI processing. If you are somehow connected to HIPAA EDI and electronic data interchange in the healthcare industry, EDI Academy trainings may serve you to get useful knowledge. Visit our site to learn the schedule of the courses interesting for you.