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1 837 Professional Health Care Claim Overview 1 Claims Processing 1 Acknowledgements 1 Ancillary Billing 1 Anesthesia Bi...

Chapter 2: 837 Professional Health Care Claim

837 Professional Health Care Claim Overview

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Claims Processing Acknowledgements Ancillary Billing Anesthesia Billing Coordination of Benefits (COB) Processing Code Sets Corrections and Reversals Data Retention of Denied Claims Data Format/Content Code Set Versions Dates Decimals Monetary and Unit Amount Values Phone Numbers Time Frames for Processing Medicare Claims Processing

1 1 1 2 2 2 2 3 3 3 3 3 3 3 4 4

Identification Codes and Numbers Provider Identifiers National Provider Identifiers (NPI) Billing Provider Rendering Provider Referring Provider Subscriber Identifiers Claim Identifiers Claim Filing Indicator Code

4 4 4 4 4 5 5 5 5

Edits and Reports Reporting Modifying Erred Claims

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837 Professional: Data Element Table

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837 Professional Transaction Sample Business Scenario Data String Example 837 Professional File Map

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Appendix: BCBSNC Business Edits for the 837 Health Care Claim Document Change Log

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Chapter 2: 837 Professional Health Care Claim

Chapter 2: 837 – Professional Health Care Claim Overview This chapter of the BCBSNC Companion Guide identifies processing or adjudication particular to BCBSNC in its implementation of the 837 Professional Health Care Claim Transaction for version 5010. The chapter contains three sections: •

a general section with information applicable to the processing of claims and business edits performed by BCBSNC

a table outlining specific requests for data format or content within the transaction, or describing BCBSNC handling of specific data types

a sample scenario that is illustrated as both a data string and mapped transaction

While all ASC X12N compliant transactions are accepted by BCBSNC, the HIPAA Technical Reports (TR3s) allow for some discretion in applying the regulations to existing business practices. Understanding BCBSNC business procedures will expedite claims processing for trading partners as they exchange EDI transactions with BCBSNC.

Claims Processing Acknowledgements Senders receive two forms of acknowledgement transactions: the TA1 Transaction to acknowledge the Interchange Control Envelope (ISA/IEA) of a transmission, and 999 Transaction to acknowledge the Functional Group (GS/GE) and Transaction Set (ST/SE). At the claim level of a transaction, the only acknowledgement of receipt is the return of the NOP or the Claims Audit Report. See the Reporting Section below for more information.

Ancillary Billing The Blue Cross and Blue Shield Association (BSBCA) defines ancillary claims as those claims from independent laboratories specialty pharmacies, or for durable medical equipment (DME). The Blue Cross and Blue Shield Association has changed the filing instructions for Ancillary claims.. Starting in November of 2012, determination of where the claim should be filed is based on where the services were requested or where the equipment was delivered, instead of being based on where the Billing Provider is contracted or where the Membership resides. Therefore if you are an Independent Lab, Specialty Pharmacy or DME Provider, please be aware you may have claims reject if you do not follow the new filing rules: • •

Independent Lab & Specialty Pharmacy – If the Referring Provider is from the state of North Carolina, then file the claim to BCBSNC DME Providers – If the equipment was delivered to a location within the State of North Carolina, then file the claim to BCBSNC

BCBSNC will now require Referring Provider information for Independent Lab and Specialty Pharmacy ancillary claims. A Service Facility Location is required to process a DME claim when the equipment was

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Chapter 2: 837 Professional Health Care Claim

delivered to somewhere other than a location considered the Member’s Home. Out-of-state (non North Carolina) Independent Lab, Specialty Pharmacy or DME providers may enroll and submit electronic claims to Blue Cross Blue Shield of North Carolina. To do so they must submit the Electronic Connectivity Request (ECR) form. Search for “ECR form” and instructions at www.bcbsnc.com.

Anesthesia Billing BCBSNC accepts nationally recognized code sets for anesthesia services and does not require the surgical CPT code on a claim for anesthesia services. BCBSNC Network Management distributes a document entitled Billing Guidelines for Anesthesia Services to all anesthesiologists within our network. For information about billing issues specific to anesthesiology services, contact your BCBSNC Network Management field office representative. Contact numbers are available online at http://www.bcbsnc.com/content/providers/contacts.htm or in your BCBSNC Network Management copy of The Blue Book: Provider Manual, which is also available online at http://www.bcbsnc.com/content/providers/blue-book.htm . For Medicare Advantage claims, see the Blue Medicare Provider Manual – also at www.bcbsnc.com.

Coordination of Benefits (COB) Processing To ensure the proper processing of claims requiring coordination of benefits, BCBSNC recommends that providers validate the patient’s Membership Identification Number and supplementary or primary carrier information for every claim. Important Notice: Primary and secondary coverage for the same claim will not be processed simultaneously. Claims that contain BCBSNC Policy Numbers for both primary and secondary coverage must be broken out into two claims. File the primary coverage claim first and submit the secondary coverage claim after the primary coverage claim has been processed. Submitters can be assured that the primary coverage claim has been processed upon receipt of the Explanation of Payment (EOP). A secondary coverage claim that is submitted prior to the processing of its preceding primary coverage claim will be denied, based on the need for primary insurance information.

Code Sets BCBSNC will follow CMS guidelines and be prepared to accept ICD-10 codes on the CMS compliance date. We will continue to accept ICD-9 codes until such time. Only standard HCPCS-CPT codes, valid at the time of the date(s) of service, should be used. BCBSNC does not require the use of National Drug Codes (NDC) by non-retail pharmacies. J-code submissions are acceptable.

Corrections and Reversals The 837 TR3 defines what values submitters must use to signal to payers that the inbound 837 contains a reversal or correction to a claim that has previously been submitted for processing. For both Professional and Institutional 837 claims, 2300 CLM05-3 (Claim Frequency Code) must contain a value from the National UB Data Element Specification Type List Type of Bill Position 3. Values supported for corrections and reversals are: 5 = “Late Charges Only” Claim 7 = Replacement of Prior Claim 8 = Void/Cancel of Prior Claim

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Data Retention of Denied Claims Data from claims that are denied is retained for a minimum of three years before archiving. This data is available electronically for eighteen months before archiving. After eighteen months, inquiries should be restricted to telephone inquiries only.

Data Format/Content BCBSNC accepts all compliant data elements on the 837Professional Claim. The following points outline consistent data format and content issues that should be followed for submission. Code Set Versions BCBSNC will be ready to process the ICD-10 codes on October 1, 2014 and will not accept ICD-10 codes before the October 1, 2014 implementation date. There will be no grace period or dual use period for ICD-9 codes after October 1, 2014. The following rules will be used: • • •

If the dates of service are greater than September 30, 2014, use ICD-10; If the dates of service are less than October 1, 2014, use ICD-9; If the dates of service span October 1, 2014, split the claim so that one claim covers the time before October 1, 2014 and the other claim covers the time from October 1, 2014 and later.

Dates The following statements apply to any dates within an 837 transaction: •

All dates should be formatted according to Year 2000 compliance, CCYYMMDD, except for ISA segments where the date format is YYMMDD.

The only values acceptable for “CC” (century) within birthdates are 18, 19, or 20.

Dates that include hours should use the following format: CCYYMMDDHHMM.

Use military format, or numbers from 0 to 23, to indicate hours. For example, an admission date of 201006262115 defines the date and time of June 26, 2010 at 9:15 p.m.

No spaces or character delimiters should be used in presenting dates or times.

Dates that are logically invalid (e.g. 20011301) are rejected.

Dates must be valid within the context of the transaction. For example, a patient’s birth date cannot be after a patient’s service date.

Decimals All percentages should be presented in decimal format. For example, a 12.5% value should be presented as .125. Dollar amounts should be presented with decimals to indicate portions of a dollar; however, no more than two positions should follow the decimal point. Dollar amounts containing more than two positions after the decimal point are rejected. Monetary and Unit Amount Values BCBSNC accepts all compliant data elements on the 837 Professional Claim; however, monetary or unit amount values that are in negative numbers are denied. Phone Numbers Phone numbers should be presented as contiguous number strings, without dashes or parenthesis markers. For example, the phone number (336) 555-1212 should be presented as 3365551212. Area codes should always be included.

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Time Frames for Processing Batch claims are moved through the adjudication process at cycles throughout the day. The last cycle of processing for the day occurs at 8 p.m. for Professional Health Care Claims. Batches must have passed through an initial validation process to reach the adjudication process cycle. Senders should allow time for validation and submit transmissions by 7:30 p.m. to make the last processing cycle of the day.

Medicare Claims Processing For Medicare Supplemental subrogation, file directly first with Medicare, prior to filing secondary claims with BCBSNC. Primary payments should be completed before secondary claim filing. Medicare Advantage specific X12 processing information is contained throughout this document.

Identification Codes and Numbers Provider Identifiers National Provider Identifiers (NPI) HIPAA regulation mandates that providers use their NPI for electronic claims submission. The NPI is used at the record level of HIPAA transactions; for 837 claims, it is placed in the 2010AA Loop level. See the 837 Professional Data Element Table for specific instructions about where to place the NPI within the 837 Professional file. The table also clarifies what other elements must be submitted when the NPI is used. With the exception of Medicare Advantage providers, mid-level providers, such as physician assistants or advanced practice nurse practitioners, do not contract with BCBSNC, and BCBSNC does not collect/store their NPI. When they perform services for a BCBSNC subscriber/patient, the service will need to be reported in the Rendering Provider Loop (2310B or 2420A) under the supervising provider's NPI. Please see the Rendering Provider section for more information. Mid-Level Practitioners serving Medicare Advantage members can file claims and be paid under their individual NPI as dictated by their provider agreement with Blue Medicare. Billing Provider The Billing Provider Primary Identifier should be the group/organization ID of the billing entity, filed only at 2010AA. This will be a Type 2 (Group) NPI unless the Billing provider is a sole proprietor and processes all claims and remittances with a Type 1 (Individual) NPI. Rendering Provider BCBSNC requires Rendering Provider identifiers (NM109 of Loop 2310B or 2420A) to complete processing. Important Notice: If your office staff includes physician assistants or advanced practice nurse practitioners, you may have applied for and received National Provider Identifiers NPI for them. However, do not use physician assistant or advanced practice nurse practitioners' NPI when reporting services in claim submissions to BCBSNC, unless these practitioners are serving Medicare Advantage members. Continue to report services provided by physician assistants and advanced practice nurse practitioners employed in your office under the NPI assigned provider number of the supervising physician providing the oversight. Practitioners serving Medicare Advantage members can file claims and be paid under their individual NPI as dictated by their provider agreement with Blue Medicare.

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Chapter 2: 837 Professional Health Care Claim

BCBSNC does not directly reimburse physician assistants or advanced practice nurse practitioners for services provided in a physician’s office. Filing claims using physician assistant or registered nurse NPI can delay claims processing which can also delay payment to your practice.

Referring Provider BCBSNC requires Referring Provider information for independent laboratory and specialty pharmacy ancillary claims.

Subscriber Identifiers Submitters must use the entire alphanumeric or numeric identification code, as it appears on the subscriber’s card in the 2010BA element. Nearly all BCBSNC members have a three (3) character alpha prefix, followed by eleven (11) alphanumeric characters. Some exceptions are Federal employees, who have only one (1) alpha prefix and eight (8) numeric characters to their member ID. The alpha prefix must be included when providing the subscriber identifier in the transaction. The most common reason for claims failure to process is an erroneous Subscriber Identifier. To ensure accuracy, trading partners are advised to use the Health Eligibility Inquiry (270) and use the membership ID returned in the 271 Response. BCBSNC members have unique member identifiers. For BCBSNC member claims, send all patient information, including ID and demographics, in the 2010BA Loop. For FEP and BlueCard (IPP) members who may not have unique identifiers, please send the subscriber ID and other Subscriber information in 2010BA plus Patient Name and demographics in 2010CA.to ensure timely processing. For detailed information about Subscriber Identification Cards and their corresponding BCBSNC plans, see Section 3 of the BCBSNC Network Management The Blue Book Provider Manual at www.bcbsnc.com . If you do not have a copy of the manual, see your BCBSNC Network Management representative or call the BCBSNC BlueLine Customer Support at 1-800-214-4844. For Blue Medicare Advantage products, use the Blue Provider Manual for Medicare Advantage, available at www.bcbsnc.com

Claim Identifiers BCBSNC issues a claim identification number upon receipt of any submitted claim. The ASC X12 Technical Reports (Type 3) may refer to this number as the Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN). It is provided to senders in the Claims Audit Report and in the CLP segment of an 835 transaction. When submitting for a claim adjustment, this number should be submitted in the Original Reference Number (ICN/DCN) segment, 2300 Loop, REF02. BCBSNC returns the submitter’s Patient Account Number (2300,CLM01) on the proprietary Claims Audit Report and the 835 Claim Payment/Advice (CLP01).

Claim Filing Indicator Code The Claim Filing Indicator Code identifies the type of claim being filed. BCBSNC requires that the first instance of this code (2000B, SBR09) within the 2000B looping structure be either a value of BL (Blue Cross/Blue Shield) or ZZ (Mutually Defined – for subscribers covered under the State Employee Health Plan).

Edits and Reports Incoming claims are reviewed first for HIPAA compliance and then for BCBSNC business rules requirements. The BCBSNC business edits include security validation at the ST/SE level and the verification of proprietary business requirements. The business rules that define these requirements are BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

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Chapter 2: 837 Professional Health Care Claim

identified in the 837 Professional Data Element Table below, and are also available as a comprehensive list in the 837 Professional Claims – BCBSNC Business Edits Table contained in this chapter. Both HIPAA TR3 implementation guide errors and BCBSNC business edit errors are returned on the BCBSNC Claims Audit Report. This report is available to direct senders from your electronic mailbox, or to indirect 1 submitters from your clearinghouse or vendor, or online via Blue e, in the 837 Claims Error Listing transaction.

Reporting The following table indicates which transaction or report to review for problem data found within the 837 Professional Claim Transaction. Transaction Structure Level

Type of Error or Problem

Transaction or Report Returned

ISA/IEA Interchange Control

Invalid Message or Information Invalid Identifier/s Inactive Message Improper Batch Structure

TA1 (Negative)

GS/GE Functional Group ST/SE Segment Detail Segments

HIPAA Implementation Guide Violations

999 * (Negative)

Unauthorized submission

BCBSNC Claims Audit Report (a proprietary confirmation and error report)

Detail Segments

BCBSNC Business Edits (see 837 Professional Claim BCBSNC Business Edits for details)

BCBSNC Claims Audit Report (a proprietary confirmation and error report)

Security Validation Messages

837Claims Error Listing, available in Blue e only Claims Status Detail Error Explanation (a proprietary report for Medicare Advantage and Medicare Supplemental Claims only.)

Error Reporting for 837 Health Care Claims

Important Notice: BCBSNC does not return an unsolicited 277 Response for any 837 Claim.

Modifying Erred Claims Important Notice Submitters must make corrections to erred 837 claims on their own systems and resubmit claims via batch 837 transmission. Blue e is available to review erred claims (see the HIPAA 837 Claims Error Listing), but not for correction or resubmission of X12 format claims. Only CMS1500 or UB04 claims can be entered or

1

The 837 Claims Denial Listing, available on Blue e, is an additional report that provides information about denied claims. Note that this report does not include errors about Medicare product claims.

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Chapter 2: 837 Professional Health Care Claim

corrected in Blue e.

837 Professional: Data Element Table The 837 Professional Data Element Table identifies only those elements within the X12 5010 Technical Report implementation guide that require comment within the context of BCBSNC business processes. The 837 Professional Data Element Table references the guide by loop name, segment name and identifier, element name and identifier. The Data Element Table also references the BCBSNC Business Edit Code Number if there is an edit applicable to the data element in question. The BCBSNC Business Edit Code Numbers appear on the Claims Audit Report, along with a narrative explanation of the edit. For a list of the error messages and their respective code numbers, see 837 Professional Claim Business Edits. The BCBSNC business rule comments provided in this table do not identify if elements are required or situational according to the 837 Professional Implementation Guide. It is assumed that the user knows the designated usage for the element in question. Not all elements listed in the table below are required, but if they are used, the table reflects the values BCBSNC expects to see. 837 Professional Health Care Claim Loop ID Segm ent Type

BHT

Segment Designator

Element ID

Data Element

SBR

P027

BCBSNC processes a value of 31 only for Medicaid submitted claims.

P022

Use the valid NPI that has been registered with BCBSNC.

P015

For the first instance of SBR09 within this Hierarchical Level (HL), use a value of BL (Blue Cross/Blue Shield) , except for subscribers covered by State Health Employee Plan, use a value of “ZZ” (Mutually Defined) ..

Billing Provider Name NM109 Identification Code

2000B

BCBSNC Business Rules

Beginning of Hierarchical Transaction BHT06 Transaction Type Code

2010AA NM1

BCBSNC Business Edit or Security Validation Edit Code Number 2

Subscriber Information SBR09 Claim Filing indicator Code

2010BA LOOP Subscriber Name Applicable to all of 2010BA

BCBSNC members have unique member IDs. For our members, send all patient information, including full ID and demographics, in the 2010BA Loop. For FEP and BlueCard (IPP) members, please send the subscriber ID and other Subscriber information in 2010BA plus Patient Name and demographics in 2010CA.to ensure timely processing.

2010BA NM1

Subscriber Name NM103 – Name (Last, First, Middle) NM105

2

P301

BCBSNC processes all alpha characters, dashes, apostrophes, spaces, or periods. No other special characters are processed.

BCBSNC Edit Codes are not returned for Medicare Supplemental or Medicare Advantage products.

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Chapter 2: 837 Professional Health Care Claim

837 Professional Health Care Claim Loop ID Segm ent Type

Segment Designator

Element ID

NM109

N3 & N4

Data Element

ID Code

BCBSNC Business Edit or Security Validation Edit Code Number 2 P006

BCBSNC Business Rules

BCBSNC uses up to 19 characters. The Member ID Number should appear as it does on the Membership Card. If the first two positions of the Member ID Number are alpha, then the third position must be alpha also.

P018

Member id not valid for DOS.

P027

Medicare Advantage or the Medicare Supplement Subscriber ID must be valid.

P029

Alpha prefix is required.

P030

Member ID must be valid

P346

This edit reflects filing requirements listed in the Ancillary Billing section. The edit reads: If state address is not NC, file claim with the local plan for ancillary claims.

Patient Address (City, State, Zip) N402

State

DMG Demographic Information

2010BB NM1

REF

DMG03

Gender Code

BCBSNC uses only the M and F values.

NM103

Last Name or Organization Name

Use BCBSNC.

Payer Name

Billing Provider Secondary Identifier

REF02 2010CA NM1

Reference Identification

P026

Patient Name Applicable to all of 2010CA

2010CA NM1

For Medicaid subrogated claims only, the Billing Provider Secondary ID Qualifier must equal G2 and/or Billing Provider Secondary ID must be valid. For FEP and BlueCard (IPP) members, please send the subscriber ID and other Subscriber information in 2010BA plus Patient Name and demographics in 2010CA.to ensure timely processing.

Patient Name NM101 NM103

N3 & N4

P337

BCBSNC processes all alpha characters, dashes, apostrophes, spaces, or periods. No other special characters are processed.

P346

This edit reflects filing requirements listed in the Ancillary Billing section. The edit reads: If state address is not NC, file claim with the local plan for ancillary claims.

CLM05:1 Facility Code Value

P335

CLM05:3 Claim Frequency Type Code

P340

A value of “99” (Other Unlisted Facility) is denied, unless the claim is for a Medicare Supplemental or Medicare Advantage product. To indicate a corrected claim, select one

Patient Address (City, State, Zip) N402

2300

CLM

Last Name or Organization

State

Claim Information

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Chapter 2: 837 Professional Health Care Claim

837 Professional Health Care Claim Loop ID Segm ent Type

Segment Designator

Element ID

Data Element

BCBSNC Business Edit or Security Validation Edit Code Number 2

BCBSNC Business Rules

of the following values from the National Uniform Billing Data Element Specification Types: ● 5 = Late charges only claim ● 7 = Replacement of Prior Claim ● 8 = Void/Cancel of Prior Claim Claims requiring correction should be sent in with a value of “8” to void the claim; the subsequent revised claim should be sent in with a value of “7”. A value of “6” is not accepted.

DTP

P033

NOTE: Claim Frequency Type Code of ‘0’ is not accepted.

P305

If present, Date of current Illness, Accident, or LMP:

Date (Onset of Current Illness/Symptom to Date – LMP) DTP03

Date Time Period

P306

DTP

DTP

cannot exceed the current date

cannot be less than the patient’s date of birth.

Date Time Period

P336

Date Time Period

P308

Date must be a valid date

P310

When a Facility Code value of 21, 31, 51, or 61 is used on a charge line (CLM05-1 of 2300), Hospitalization Dates cannot be greater than current date or less than the patient’s birth date.

P309

Date must be a valid date

P310

When a Facility Code value of 21, 31, 51, or 61 is used on a charge line (CLM05-1 of 2300), Hospitalization Dates cannot be greater than current date or less than the patient’s birth date.

Hospitalization Discharge Date must be equal to or greater than the Admission Date.

Disability End Date cannot be prior to Disability Begin Date.

Date - Admission DTP03

2300

must be valid

Date (Disability Begin and Disability End) DTP03

DTP

Date - Discharge DTP03

Date Time Period

REF Payer Claim Control Number

02

Reference Identifier

I-034

When submitting a corrected claim (i.e. CLM05-3 = 7), use the same claim number and format of the original claim control number.

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Chapter 2: 837 Professional Health Care Claim

837 Professional Health Care Claim Loop ID Segm ent Type

2300

HI

Segment Designator

Element ID

NM1

BCBSNC Business Edit or Security Validation Edit Code Number 2

BCBSNC Business Rules

P031

Claim can contain only one version of industry code; submit separate claim if using different versions of Industry Code.

P341

E-code cannot be the primary diagnosis code. (This edit will be removed 10/2014.)

P346

Please file claim with the Local Plan as defined for ancillary claims.

P347

Referring Provider information required to process Ancillary claim.

Health Care Diagnosis Code HI01:2

2310A

Data Element

Industry Code

Referring Provider Name NM103, NM104, NM109

Referring Provider Address and Name

P349

2310B

NM1

Referring Provider is not a Valid NC Provider. Please file claim with the Local Plan per BCBS Ancillary rule.

Rendering Provider Name NM109

Rendering Provider Name

P342

Rendering Provider ID should ONLY be sent when it is a different number from the Billing Provider NM109 in 2010AA. See the Rendering Provider section of this document for additional details on using this segment.

2310C

NM1

Service Facility Name NM103 & Service Facility Name NM109

N3 & N4

CAS

Service Facility Address

P346

If state address is not NC, file claim with the local plan for ancillary claims.

Monetary Amount

P344

The sum of all line level payments and patient responsibility line level adjustments, must match the claim level payment and patient responsibility adjustments.

Monetary Amount

P331

• •

Claim Level Adjustment CAS02

AMT

The Service Facility name and location are required to process a DME claim for the Place of Service provided. (See also N3 and N4)

Service Facility Address (City, State, and Zip) N3 N402

2320

P348

COB Payer Paid Amount AMT02

P345

Negative Payer Amounts are denied. If filing a secondary or Medicare claim, fill the actual amount paid by the other carrier. Do NOT include deductive, coinsurance, copayments, or other adjustments in the Payer Paid Amount field. The Paid Amount at the claim level

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Chapter 2: 837 Professional Health Care Claim

837 Professional Health Care Claim Loop ID Segm ent Type

Segment Designator

Element ID

Data Element

BCBSNC Business Edit or Security Validation Edit Code Number 2

BCBSNC Business Rules

(2320 AMT02) must match the sum of the Paid Amount(s) at the line level (SVD02). AMT

Remaining Patient Liability AMT02

2330A

2400

NM1

LX

SV1

Monetary Amount

P344

NM102

Entity Type Qualifier

P004

LX01

Assigned Number

The sum of all line level payments and patient responsibility line level adjustments, must match the claim level payment and patient responsibility adjustments.

Other Subscriber Name Use a value of 1 (Person)

Service Line BCBSNC uses LX01 as a line item control number. Use actual values instead of placeholders for this element in order to receive matching line numbers in the 835 Transaction: 2110 SVC06 and the 2110 REF Service Identification segments responses.

Professional Service SV101:2 Product/Service ID

P005

Newborn charges should not be filed on the mother’s claim, but on a separate claim, under the baby’s name.

SV101:3, Procedure Modifier 4, 5, and 6

P317

The Procedure Modifier must be consistent with the Procedure Code presented in SV101:2. (For example, modifier values of 80, 81, or 82 [Assistant at Surgery] would be consistent with surgical codes 10000 to 69999 and anesthesia codes 00100-01999.)

SV104

Quantity P322 P323

Units should be greater than one (1) when a modifier of “50” is entered.

Days or units should be greater than zero (0).

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Chapter 2: 837 Professional Health Care Claim

837 Professional Health Care Claim Loop ID Segm ent Type

DTP

Segment Designator

Element ID

Data Element

BCBSNC Business Edit or Security Validation Edit Code Number 2

BCBSNC Business Rules

Date – Service Date DTP03

Date Time Period

P313

‘From Date’ and ‘To Date’ must be consistent with Hospitalization Dates.

The “From Date” must be prior to the “To Date”.

Service date must not be greater than current date.

Earliest Date of Service for all charge lines must not be prior to Patient’s Birth date.

Claim cannot be corrected more than 1 year from Claim’s Earliest Date of Service.

P314

P315 P330 P316

P035

2420A

NM1

Rendering Provider Identification NM109

Rendering Provider ID

P342

Rendering Provider ID should be sent in this loop ONLY if the number is different from the Rendering Provider NM109 in the 2300 loop, OR no rendering provider NM109 was sent in the 2300 loop and the Rendering Provider ID is different than the Billing Provider ID sent in 2010AA. See the Rendering Provider section of this document for additional details on using this segment.

2430

SVD

Line Adjudication Information SVD02

Monetary Amount

P028 P344

Negative Service Line Paid Amount must be a valid value. The sum of all line level payments and patient responsibility line level adjustments, must match the claim level payment and patient responsibility adjustments.

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Chapter 2: 837 Professional Health Care Claim

837 Professional Transaction Sample The following sample presents three formats for the data contained within an 837 Professional claim: •

a high-level business scenario typical within BCBSNC claims processing

a data string, illustrating the actual record transmission

a file map that allows users to see all submitted data elements and their relationship to the entire transaction

Business Scenario The Patient is the same person as the Subscriber. The Payer is Blue Cross and Blue Shield of North Carolina. The encounter has been transmitted through a clearinghouse. The Submitter is the clearinghouse. Data Element

Value

Subscriber/Patient: Subscriber Address: Sex: DOB: Employer: Group #: Payer ID Number: Member Identification Number Destination Payer: Payer Address AHLIC #: Submitter: Billing Provider: Address: TIN: Billing Provider ID Contact Person & Phone Number Patient Account Number: DOS POS Services Rendered Charges Total charges

Mary B Dough PO Box 12312, Durham, NC 27701 F August 7, 1967 Acme, Co. ABC123101 987654321 24670389600 Blue Cross Blue Shield of North Carolina (BCBSNC) 5901 Chapel Hill Road, Durham, NC 27707 987654321 ABC Clearinghouse Elizabeth Smith, MD 123 Mudd Lane, Durham, NC, 27715 123456789 0123456789 Wilma Flintstone 919 555-1111 Ptacct2235057 8/1/2010 Office Office visit st 1 office visit - $100.50 $100.50

Data String Example The following transmission sample illustrates the file format used for an EDI transaction, which includes delimiters and data segment symbols. Note that the sample contains only one ST/SE set within the Functional Group (GS) and only one claim within the ST/SE set. Normally there would be multiple claims within an ST/SE set. For more information about batch sizes, see the Batch Volume section of this chapter. This sample contains a line break after each tilde to provide an easy illustration of where a new data segment begins. For more information about BCBSNC file format requests, see Record Format/Lengths in the Connectivity section of the Introduction to the BCBSNC Companion Guide to EDI Transactions. For more information about the file formats and application control structures, see “Appendix B: ASC X12 Nomenclature” in the ASC X12N 5010 837.

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

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Chapter 2: 837 Professional Health Care Claim

ISA*00* *00* *01*9012345720000 *01*9088877320000 *100822*1134*U*00200*000000007*0*T*:~ GS*HC*901234572000*908887732000*20100822*1615*7*X*005010X222~ ST*837*0007*005010X222~ BHT*0019*00*123BATCH*20100822*1615*CH~ NM1*41*2*ABC CLEARINGHOUSE*****46*123456789~ PER*IC*WILMA FLINTSTONE*TE*9195551111~ NM1*40*2*BCBSNC*****46*987654321~ HL*1**20*1~ NM1*85*1*SMITH*ELIZABETH*A**M.D.*XX*0123456789~ N3*123 MUDD LANE~ N4*DURHAM*NC*27701~ REF*EI*123456789~ HL*2*1*22*0~ SBR*P*18*ABC123101******BL~ NM1*IL*1*DOUGH*MARY*B***MI*24670389600~ N3*P O BOX 12312~ N4*DURHAM*NC*27715~ DMG*D8*19670807*F~ NM1*PR*2*BCBSNC*****PI*987654321~ CLM*PTACCT2235057*100.5***11::1*Y*A*Y*N~ REF*EA*MEDREC11111~ HI*BK:78901~ LX*1~ SV1*HC:99212*100.5*UN*1*12**1**N~ DTP*472*D8*20100801~ SE*24*0007~ GE*1*7~ IEA*1*000000007~

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

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Chapter 2: 837 Health Care Claim - Professional

837 Professional File Map Loop ID

Segment Name

Segment ID

TRANSACTION SET HEADER BEGINNING OF HIERARCHICAL TRANSACTION 1000A

1000A

1000B

2000A

Submitter Name

ST BHT NM1

Submitter EDI Contact Information

Receiver Name

PER

NM1

Billing/Pay-To Provider Hierarchical Level

HL

Elements ST01

ST02

ST03

837

0007

005010X222~

BHT01

BHT02

BHT03

BHT04

BHT05

0019

00

123batch

20100822

1615

CH~

NM101

NM102

NM103

NM104

NM105

NM106

41

2

ABC Submitter

PER01

PER02

PER03

IC

TE

NM101

Wilma Flintstone NM102

NM103

40

2

BCBSNC

HL01

HL02

HL03

1 2010AA

2010AA

2010AA 2010AA 2000B 2000B 2010BA

Billing Provider Name

Billing Provider Address

Billing/Provider City/State/Zip Code Billing Provider Tax Identification Subscriber Hierarchical Level Subscriber Information Subscriber Name

NM1

46

85

1

Smith

Elizabeth

A

N403 27701

NM109 987645432 1~

HL04 NM105

NC

NM1

NM107 NM108

1~

N402

SBR

NM106

NM104

Durham

HL

PER06

PER04

NM103

N4 REF

PER05

919555111 1~ NM104 NM105

NM102

N301

NM109

123456789 ~ PER07 PER08 PER09

NM101

123 Mudd Lane~ N401

NM107 NM108 46

20

N3

BHT06

REF01

REF02

EI

123456789

HL01

HL02

HL03

2

1

22

0~

SBR01

SBR02

SBR03

SBR04

P

18

ABC123101

NM101

NM102

NM103

NM104

NM105

IL

1

Dough

Mary

B

NM106

NM107 NM108 XX

NM109 989898989 ~

HL04 SBR05

SBR06

SBR07 SBR08

SBR09 BL~

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

© BCBSNC, 2010. Unauthorized copying or use of this document is prohibited.

NM106

NM107 NM108 MI

NM109 246703896

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Chapter 2: 837 Health Care Claim - Professional

Loop ID

Segment Name

2010BA

Subscriber Address

Segment ID

Elements 00

2010BA 2010BA 2010BB

2300

2300

Subscriber City/State/Zip Code Subscriber Demographic Information Payer Name

N3

N301

N4

POBox 12312~ N401

N402

N403

Durham

NC

27715

DMG01

DMG02

DMG03

D8

19670807

F~

NM101

NM102

NM103

PR

2

BCBSNC

CLM

CLM01

CLM02

CLM03

100.5

REF

Ptacct22350 57 REF01

DMG NM1

Claim Information

Claim Identification No. For Clearing Houses and Other Transmission Intermediaries

EA

N404

NM104

NM105

NM106

NM107 NM108

NM109

PI

CLM04

CLM05

987654321 ~ CLM06 CLM07 CLM08 CLM09

11::1

Y

SV106

A

Y

N

REF02

2300

Health Care Diagnosis Code

HI

HI01

Medrec11111 ~ HI02

BK:

78901~

2400

Service Line

LX

LX01

2400

Professional Service

SV1

SV101 HC:99212

2400

Date - Service Date

DTP

DTP01 472

D8

20100801~

TRANSACTION SET TRAILER

SE

SE01

SE02

24

0007~

1~ SV102

SV103

SV104

SV105

100.5

UN

1

12

DTP02

DTP03

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

© BCBSNC, 2010. Unauthorized copying or use of this document is prohibited.

SV107 SV108 1

SV109 N~

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Chapter 2: 837 Health Care Claim - Professional

Appendix: BCBSNC Business Edits for the 837 Health Care Claim The following proprietary error codes and messages are returned via the Claims Audit Report. The Claims Audit Report can be accessed from your electronic mailbox for direct submitters, or online, via Blue e (https://providers.bcbsnc.com/providers/login.faces ) - see the 837 Claim Denial Listing. Important Note: These error codes are not returned for Medicare Advantage or Medicare Supplemental claims. Error Code*

Explanation Message

837 Professional 3 Cross-references

P004

When Other Insured's Entity Code (NM101) = IL, Entity Qualifier must equal '1'.

2330A, Other Subscriber Name, NM102

P005

Newborn charges should not be filed on the Parent's claim. They should be filed separately under the baby's name and Member ID.

2400, Professional Service, SV101:2

P006

Member ID must be valid.

2010BA, Subscriber Name, NM109

P015

The first occurrence of Claim Filing Indicator must be BL or ZZ.

2000B, Subscriber Information, SBR09

P018

Member ID not valid for Date of Service (DOS).

2010BA, Patient Name, NM109

P022

Provider NPI not registered with BCBSNC. Please contact Network Management at 1-800-777-1643 to resolve this matter.

2010AA, Provider ID, NM109

P026

Billing Provider Secondary ID Qualifier must equal G2 and/or Billing Provider Secondary ID must be valid for Medicaid submitted claims.

2010BB, Provider ID, REF02

P027

Medicare Advantage/Medicare Supplement Member ID is invalid. Please correct and resubmit.

2010BA, Member ID, NM109

P028

Negative Service Line Paid Amount invalid.

2430, Service Line Paid Amount, SVD02

3

This column is cross-referenced to the 837 Professional (005010X222) and Companion Guide Data Element Table. The Cross Reference provides TR3 (Technical Report, Type 3) Loop ID, Segment Name, and the segment ID/element number combined (e.g. NM102). *A disruption in the numbering of the Error Codes indicates the removal of an error that previously existed.

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

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Chapter 2: 837 Health Care Claim - Professional

Error Code*

Explanation Message

837 Professional 3 Cross-references

P029

Alpha prefix is required; please submit the member ID as it appears on the membership card.

2010BA , NM109

P030

Member ID is no longer valid. Please obtain the current ID from the membership card.

2010BA, NM109

P031

Claim must contain only one version of the Diagnosis Code ; Create two separate claims using appropriate code version and dates for each

2300, Diagnosis code qualifier, HIXX

P032

When filing Medicare primary claims to BCBSNC for adjudication, please allow at least 30 days from the date of the Medicare EOB.

2430, Line, Check, or Remittance Date, DTP03

P033

Addition of Business Rule I-033 : Claim Frequency Type Code of ‘0’ is not accepted.

2300, CLM05

P034

Invalid format for Original Claim ID. Please resubmit with valid ID.

2300, REF02, Payer Claim Control Number

P035

Claim cannot be corrected more than 1 year from Claim’s Earliest Date of Service.

2400 DTP03

BREAK IN ERROR MESSAGE NUMBERING for 837P P301

Invalid Subscriber Name as submitted. Contains special characters other than dashes, apostrophes, spaces or periods.

2010 BA, Subscriber Name, NM103

P310

If a Facility Code Value of 21, 31, 51 or 61 (CLM05-1) is used on a charge line, Hosp. Dates cannot be greater than current date or less than patient's DOB.

2300, Date- Admission or Date Discharge, DTP03

P313

From Date inconsistent with Hospitalization dates.

2400, Date – Service Date, DTP03

P314

To Date inconsistent with Hospitalization dates.

2400, Date – Service Date, DTP03

P315

To Date prior to From Date.

2400, Date – Service Date, DTP03

P316

Earliest Date of Service for all charge lines must not be prior to Patient's Birth Date.

2400, Date – Service Date, DTP03

P317

Modifier is equal to ‘80’, ‘81’, ‘82’ (assistant at surgery) and is inconsistent with a non-surgical procedure code.

2400, Professional Service, SV101:3

P319

Accident Diagnosis Codes [800-995] require Date of Onset (DTP01 =431) or Date of Current Injury (DTP01 = 439).

2300, HC Diagnosis Code, HI01:2 in reference to 2300, Date of Onset, or Accident Date, or 2300 LMP, DTP01

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

© BCBSNC, 2010. Unauthorized copying or use of this document is prohibited.

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Chapter 2: 837 Health Care Claim - Professional

Error Code*

Explanation Message

837 Professional 3 Cross-references

P322

Units must be greater than one (1) when a Modifier of ‘50’ is entered.

2400, Professional Service, SV104

P323

Days or Units must be numeric and greater than zero.

2400, Professional Service, SV104

P329

Hospitalization Discharge Date must be equal to or greater than the Admission Date.

2300, Date – Discharge, DTP03

P330

Service Date cannot be greater than current date.

2400, Date – Service, DTP03

P331

Negative Payer Amount Paid invalid.

2320, Payer Amount Paid, AMT02

P335

Facility Type Code 99 invalid for BCBSNC business.

2300, Facility Type Code, CLM05-1

P336

Disability End Date cannot be prior to Disability Begin Date.

2300, Date – Disability Begin, DTP03 and p. 203, 2300, Date- Disability End, DTP03.

P337

Invalid Patient Name as submitted – contains special characters other than dashes, apostrophes, spaces or periods.

2010CA, Patient Name, NM103 and/or NM104.

P340

Claim Frequency Type Code of "6" is not accepted.

2300 Claim Information, CLM05-3, p. 173

P341

E-code cannot be the primary diagnosis code. (This edit will be removed 10/1/2014.)

2300 Health Care Diagnosis Code, HI01-2 (when HI01-1 = ABK

P342

NPI submitted is not registered with BCBSNC.

2310B or 2430A , Rendering Provider Name, , NM109; Rendering Provider Identification Code

P344

The sum of all line level payments and patient responsibility line level adjustments, must match the claim level payment and patient responsibility adjustments.

2320,COB Payer Paid Amount, AMT02 (when AMT01=D); Line Adjudication Information, 2430, SVD02 , 2320 and 2430: CAS01=PR and AMT01=EAF,

P345

The Paid Amount at the claim level must match the sum of the Paid Amount(s) at the line level.

2320, COB Payer Paid Amount, AMT02 (when AMT01=D); Line Adjudication Information 2430, SVD02

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

© BCBSNC, 2010. Unauthorized copying or use of this document is prohibited.

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Chapter 2: 837 Health Care Claim - Professional

Error Code*

837 Professional 3 Cross-references

Explanation Message

2010BA or 2010CA, Subscriber/Patient Address, N402, and for

P346

Please file claim with the Local Plan as defined for ancillary claims.

P347

Referring Provider information required to process ancillary claims.

2310A, Referring Provider Name, NM103, NM104, NM109 (when NM101 = DN)

P348

Service Facility Location required to process DME for Place of Service provided.

2310C, Service Facility Address N301, N302,N401, N402, N403 (when NM101 = 77)

P349

Referring Provider is not a Valid NC Provider. Please file claim with the Local Plan per BCBS Ancillary rule.

2310A, Referring Provider Name, NM103, NM104, NM109 (when NM101 = DN)

2310C, Service Facility Location City, State, Zip Code, N402

Document Change Log The following change log identifies changes that have been made to the Companion Guide for 5010 837 Professional Health Care Claim transactions (originally published to the EDI Web site October 2010). Chapter Section Claims Processing

Change Description

Date of Change

Version

Addition of Corrections and Reversals section

10/22/10

1.1

Addition of Medicare Advantage and Medicare Supplemental Claims processing Information

01/2011

2

Appendix

Removal of business edits redundant with validator edits.

01/2011

2.1

Data Element Table

Clarification of conditions for sending the Rendering Provider ID (Loops 2310B and 2420A, NM109)

04/2011

2.2

Appendix

Addition of P027

05/2011

2.3

Appendix

• •

10/2011

2.4

Appendix

Addition of P029, P030, P031, P346, P347, P348, P349 Removal of P319 P341 – added a note that this edit will not be used after 10/1/2014

Changes go into affect 10/2012, unless otherwise noted

2.5

Addition of P028 – effective November 2011 Removal of references to 997 Acknowledgements, which will not be returned

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

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Chapter 2: 837 Health Care Claim - Professional

Chapter Section

Change Description

Date of Change

Version

Appendix

Minor verbiage change to P018 and P016.

08/10/12

2.6

Appendix

Minor verbiage change to P349

09/18/12

2.7

Code Set Versions; Appendix

Update Code Set Versions; Addition of Edit P032

Effective 10/1/13

2.8

Appendix

• •

Effective immediately

2.9

Appendix

Addition of P033: Claim Frequency Type Code of ‘0’ is not accepted.

Effective July 2014

3.0

Subscriber Identifiers and Data Element Table

Clarification for submission of patient and subscriber name and demographic information (2010BA and 2010CA Loops)

February 2015

3.1

Appendix and Data Element Table

Addition of P034 business edit for inclusion of the Payer Claim Control number in a corrected claim

June 2015

3.2

Data Element Table

Addition of Business Rule I-035 – Claim cannot be corrected more than 1 year from Claim’s Earliest Date of Service.

January 2015

3.3

Removal of Security Validation section; these edits are no longer returned. Revised P022; edit updated to read “Provider NPI not registered with BCBSNC. Please contact Network Management at 1-800-777-1643 to resolve this matter.”

BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.3

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21

[PDF] 837 Professional Health Care Claim - Free Download PDF (2024)

FAQs

What is the 837 professional claim format? ›

The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed.

What is the difference between EDI 837P and 837I? ›

837P is the x12 EDI standard for the Clinic/Outpatient/Professional Claims, 837I is the x12 EDI standard for the Hospital/Inpatient/Institutional Claims) and 837D for the Dental Claims. Types of Claims: 837 P – Professional claims.

What is a 837 file in healthcare? ›

What is an 837 File? An 837 file is an electronic file that contains patient claim information. This file is submitted to an insurance company or to a clearinghouse instead of printing and mailing a paper claim. The data in an 837 file is called a Transaction Set.

What is the 837 file format specification? ›

The EDI 837 specification transaction set is comprised of the format and establishes the information contents of the 837 for use within the EDI environment. This transaction set is used to transmit billing information for healthcare claims, information on the encounter, or both from providers to payers.

What is the difference between 837 institutional and professional claims? ›

The 837-P, which is the CMS 1500 Form's Electronic Replacement, is used for Professional Medical Billing. In the Professional Configuration, the letter "P" is used. The UB-04 Form is used to Bill Institutions. Institutional Medical Billing for Electronic Claims uses the 837-I Form.

What is the difference between 835 and 837 claims? ›

An 835 claim file is the format that insurance organizations send back to healthcare providers. To put it simply… In other words, an 837 is a bill and an 835 is a receipt. Sometimes 835 claims are also called Electronic Remittance Advice (ERA).

What is the difference between institutional claims and professional claims? ›

Institutional Claim: The bill comes from the facility where you received the care. Professional Billing: The bill comes from the healthcare provider who gave you the treatment.

What is 837I in medical billing? ›

The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed.

What are the loops in the 837 file? ›

Each 837 file is broken into sections of data. These sections are called loops. Each loop has a particular focus, e.g., Submitter Name, Billing Provider Name, Claim Level Information, Service Line. The data stored within loop sections are similar to that stored in Patient Registration or Fileman files.

Who sends an 837? ›

These files are the first that begin the healthcare insurance claims and remittance process. An 837 it is sent from the healthcare provider (hospital, clinic, facility, etc.) to the payor (insurance company). It's the electronic equivalent of the paper CMS-1500 or UB-04 form.

What are the five sections on a claim? ›

Answer. (1) provider information; (2) subscriber information; (3) payer information; (4) claim information; and (5) service line information. HIPAA-mandated electronic transaction for claims.

What is 837 compliant with HIPAA? ›

The EDI 837 transaction set is the format established to meet HIPAA requirements for the electronic submission of healthcare claim information. The claim information included amounts to the following, for a single care encounter between patient and provider: A description of the patient.

What is the difference between EDI and 837? ›

The purpose of EDI is to transmit information to other companies electronically instead of using paper. EDI 837 is specifically used for filing claims and for sending medical and healthcare data records to brokerage houses.

What is a 5010 claim form? ›

The 5010 HIPAA transaction standards are a new set of standards that regulate the electronic transmission of specific health care transactions. These include eligibility, claim status, referrals, claims and electronic remittance.

What is the difference between institutional and professional claims? ›

Institutional Claim: The bill comes from the facility where you received the care. Professional Billing: The bill comes from the healthcare provider who gave you the treatment.

What is the 837 institutional format? ›

WHAT ARE THE 837I AND THE FORM CMS-1450? The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed.

What is the claim form used to bill professional services? ›

Professional paper claim form (CMS-1500)

What is the ANSI ASC X12N 837 format? ›

HIPAA requires the submission of all electronic claims using the X12 837 format. The Accredited Standards Committee (ASC) X12 develops and maintains the HIPAA EDI standards. ANSI ASC X12N 837I (837 Institutional) Version 5010A2 claim format is the electronic format used to submit claims.

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