EDI 837

Health Net EDI 837 Professional and Institutional Submissions Mapping Guides

Health Net requires at least one ST and one SE record per Submitter ID within a submission. This means that Health Net requires one ST and one SE for each unique occurrence of the 1000A NM109 Submitter ID field.

Health Net does not want any additional ST/SE records than this. X12 file formats are hierarchical in nature. To send additional levels of ST/SE records on a submission increases the run time to process files in our Translator and EDI Frontend applications. Some submitters are sending a unique instance of ST/SE records for every claim/encounter within the submission. Health Net Translator is able to process a unique instance ST/SE combination.

Provider Id – Professional

  1. A NPI, Tax ID or Social Security Number, and State License ID must be sent in the Billing Provider Loop. The Billing Provider state and zip code is required when the address is in the United States.
  2. The NPI and CA State License ID must be provided in the 2310 claim loop for the Referring Provider of the claim/encounter.
  3. The NPI and CA State License ID must be provided in the 2310 claim loop for the Rendering Provider of service for the claim/encounter.
  4. Service Facility is required if different than the Billing Provider. The NPI and State License ID must be provided on the claim in the 2310 claim loop for the Service Facility, if present.

Co-Pay, Co-insurance, Deductible, Ambulance Transport and National Drug Code (PAD) – Professional

  1. Patient co-pay paid or responsibility amount is required on all professional encounters.
  2. Patient coinsurance, copayment and deductible is required on all professional encounters in Loop 2430 in the x12 837 CAS*PR segment when patient responsibility is greater than 0.
  3. Ambulance Transport is required on all professional encounters when billing for ambulance or non-emergency transportation. (CLM05-01 is ’41’ or ’42’).
  4. The National Drug Code (NDC) is required on all Physicians Administered Drugs (PAD). A PAD is any covered drug provided or administered to a patient which is billed by a provider other than a pharmacy. Includes any method of administration and is not limited to injectable drugs.

Provider Id scenarios – Institutional

  1. A NPI and Tax ID must be sent in the Billing Provider Loop. The Billing Provider state and zip code is required when the address is in the United States.
  2. The NPI and CA State License ID must be provided in the 2310 claim loop for the Attending provider of the claim/encounter.
  3. Service Facility is required if different than the Billing Provider. The NPI and State License ID must be provided on the claim in the 2310 claim loop for the Service Facility, if present.
  4. The NPI and CA State License ID must be provided in the 2310 claim loop for the Referring Provider of the claim/encounter.
  5. The NPI and CA State License ID must be provided in the 2310 claim loop for the Rendering Provider of service for the claim/encounter.

Admission Date, Co-Pay, Admitting Diagnosis, Patient Reason for Visit Code and National Drug Code (PAD) – Institutional

  1. The patient responsibility amount (co-pay) is required on all institutional encounters.
  2. Patient coinsurance, copayment and deductible is required on all professional encounters in Loop 2430 in the x12 837 CAS*PR segment when Patient Responsibility is greater than 0.
  3. Admission Date and Admitting Diagnosis Code is required on all inpatient visits. Patient Reason for Visit is required on all outpatient visits.
  4. The National Drug Code (NDC) is required on all Physicians Administered Drugs (PAD). A PAD is any covered drug provided or administered to a patient which is billed by a provider other than a pharmacy. Includes any method of administration and is not limited to injectable drugs.

To learn more about Helath Care EDI Transactions mapping and become a certified  EDI Professional please visit our course schedule page.

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