HIPAA 837 Institutional Claim Mapping Guides For HAP Midwest Health Plan Partners
HIPAA 837 Institutional Claim EDI transaction set is used to exchange institutional health care claim information from providers of health care services. HIPAA 837 Institutional Claim transaction can be submitted either directly or via intermediary billing services and/or claims clearinghouses.
HIPAA 837 Institutional Claim Mapping Tips
Naming Convention of EDI File
Submitter id followed by 837I followed by your internal# followed by date time with .EDI extension. Sample where Submitter id: SBM123 SBM123837IXXXX201201011157.EDI
Please note that Professional and Institutional claims may NOT be batched together within the same ISA/IEA. Each must be batched within its own ISA/IEA envelope.
ST – Transaction Set Header
HAP Midwest Health Plan accepts a maximum of 5,000 CLM segments in a single transaction (ST-SE) as recommended by the HIPAA-mandated Implementation Guide.
N3- Pay – To Address – Address
Must match! Pay to address currently on file at MWHP can verify thru MWHP website – Verify vendor info or under provider quick links “Is my payment address with you correct?”.
NM1 – Individual or Organizational Name (NM109 – Identification Code)
Use Subscriber Primary Identifier from the Member ID CARD. (This is a 10, 9 or 8 character field). Member ID is 10 digits Beneficiary ID for MEDICAID and ABW members (0012345678), 9 digits for HAP Midwest Health Plan Medicare members (000991234), 9 digits for Wayne County Health Choice Members (120012345), and alpha-numeric ID for Macomb Care Connect (B0502001).
NM1 – Individual or Organizational Name (NM103-NM104 – Last name, First name)
Must match what MWHP has in their database. Can verify on MWHP website.
DMG – Subscriber Demographic
Must match what MWHP has in their database. Can verify on MWHP website.
HI – Principal Diagnosis
Cannot be an external cause of injury code.
HI – All diagnosis
Cannot be duplicate diagnosis codes across segments or in same segment.
NM1- All Physicians (NM109 – HIPAA National Provider Identifier (NPI))
All Physician NPI’s must be valid type 1 NPI’s. Note also none of the providers may be on any State or Federal Sanction Lists for the date of service of the claim.
HAP Midwest Health Plan’s Claims Department endeavors to assure prompt and accurate claim and encounter review, processing, adjudication and payment. This is accomplished through the development of claims processing systems, pre-payment and post-payment audits, policies, and procedures that are consistently and appropriately applied.
HIPAA 837 Professional Claim Mapping Guides For HAP Midwest Health Plan Partners