HIPAA 837 Professional Claim

HIPAA 837 Professional Claim Mapping Guides For HAP Midwest Health Plan Partners

HIPAA 837 Professional Claim transaction set is used to exchange institutional health care claim information from providers of health care services. HIPAA 837 Professional Claim can be submitted either directly or via intermediary billing services and/or claims clearinghouses.

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.

HIPAA 837 Professional Claim Mapping Tips

  • Member ID is 10 digits Beneficiary ID for MEDICAID and ABW members (0012345678), 9 digits for HAP Midwest Health Plan Medicare Advantage members (000991234), 9 digits for Wayne County Health Choice Members (120012345) and alpha-numeric ID for Macomb Care Connect (B0502001)
  • 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
  • NM1 – Billing Provider Name – Use the National Provider Identification (NPI) Should be Group NPI (Line 33a HCFA)
  • N3 – Billing Provider Address – Maximum length of 24 characters
  • N3- Pay – To Address – Address (N301- Address Information) – 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 (NM103- NM104 – Last name, First name) – Must match what MWHP has in their database. Can verify on MWHP website
  • NTE – Note/Special Instruction (NTE02 – Description) – When used for Prenatal visits format should be the letters OB followed by colon by dates (mmddyy) of visits separated by semicolons exampleOB:MMDDYY;MMDDYY

PRENATAL VISITS: When billing with the Antepartum Care Procedure Codes 59425 or 59426 procedure Code and Pre-Natal visits must be reported use NTE segment in Loop 2300 the Reference code should be ADD and the description format should be the letters OB followed by colon by pre-natal dates (mmddyy) of visits separated by semicolons no other separators in the date is excepted. example- OB:MMDDYY;MMDDYY;MMDDYY

  • NM1 – Rendering Provider Name (NM108 – Identification Code Qualifier) – Required by HAP Midwest Health Plan even if same as billing. Use “XX” for National Provider Identification (NPI) Should be an Individual NPI (line 24J HCFA)
  • NM1 – SERVICE FACILITY LOCATION NAME (NM103 – Laboratory or Facility Name) – As of 6/2013, required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).

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