837P

HIPAA Transaction Sets and Code Sets (HTSCS) 837 Professional Companion Guide Specifications
Version 4.7 June 23, 2008
HTSCS 837 Professional Companion Guide Specifications
Table of Contents
1. 2. 3. 4. 5. INTRODUCTION ................................................................................................1 SCOPE...............................................................................................................2 837 PROFESSIONAL HEALTH CARE CLAIM TRANSACTION MAP .........................3 TRANSPORTATION BROKER VALUES ...............................................................56 DOCUMENT CHANGE HISTORY ........................................................................57
837P Companion Guide June 23, 2008
Version 4.7
. The electronic version of this document is controlled. All paper copies are uncontrolled. Copyright 2004 South Carolina Department of Health and Human Services. All rights reserved.
1.
INTRODUCTION
Companion Guides are designed to be used in conjunction with the HIPAA-required ANSI X12 Implementation Guide and Addenda. The Companion Guide specifications define current functions and other information specific to South Carolina Medicaid Title XIX (SC Medicaid). The South Carolina Department of Health and Human Services (SCDHHS) solution for the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that providers utilize this companion guide for the indicated transactions. This Companion Guide supports the requirements of the 4010A1 version of the ANSI X12 Implementation Guide and the changes indicated by any addenda for this transaction. Copies of the ANSI X12 Implementation Guide can be obtained by downloading the files from the following Web site: http://www.wpc-edi.com/hipaa/HIPAA_40.asp
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2.
SCOPE
The United States Congress included provisions to address the need for standards for electronic transactions and other administrative simplification issues in the HIPAA, Public Law 104-191, which was enacted on August 21, 1996. Through Subtitle F of Title II of that law, Congress added to Title XI of the Social Security Act a new Part C, entitled, Administrative Simplification. On August 17, 2000, final regulations were published in the Federal Register for, Standards for Electronic Transactions, which became effective on October 16, 2000. The final rule requires compliance be met within 2 years of the rule effective date, making compliance necessary by October 16, 2002, unless covered entities have filed for an extension to the deadline. In 2001, in the Administrative Simplification Compliance Act, Congress authorized a one-year extension to October 16, 2003, for those covered and required to comply in 2002. SCDHHS has filed such an extension. Electronic submission of claims will follow these guidelines: Claims currently filed on CMS-1500 or equivalent current electronic format will be filed on the 837 Professional format. Claims currently filed on ADA or equivalent current electronic format will be filed on the 837 Dental format except for oral surgeons who will use the 837 Professional format. Claims currently filed on UB-04 or equivalent current electronic format will be filed on the 837 Institutional format.
This Companion Guide includes the scope and transaction maps for the ASC X12N 837 004010X098A1 Health Care Claim Professional transaction set. The purpose of the guide is to provide support for the submission of the HIPAA-compliant 837 Professional claim and ensure proper processing of claims submitted to SC Medicaid. Fields from the current SC Medicaid Professional format have been cross-referenced to the applicable data element in the 837 Professional transaction. South Carolina Medicaid billing requirements also should be followed to ensure proper processing of claims. Specific SC Medicaid billing instructions can be found in provider manuals and monthly Medicaid bulletins.
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3.
837 PROFESSIONAL HEALTH CARE CLAIM TRANSACTION MAP
*Unless otherwise noted, please follow the rules of the ANSI X12 Implementation Guide (including Addendum) for 004010X098A1. **The Loop column consists of the loop number followed by a /, whether required (R) or situational (S), then a dash followed by the page number reference in the Implementation Guide
Loop** SEG ID ISA/R-B.3 Element ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 ISA09 ISA10 ISA11 ISA12 ISA13 Element Requirement R R R R R R R R R R R R R Industry Name Authorization Information Qualifier Authorization Information Security Information Qualifier Security Information Interchange ID Qualifier Interchange Sender ID Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards Identifier Interchange Control Version Number Interchange Control Number South Carolina Medicaid Specifications* Use Value 00 No Authorization Information Present (No Meaningful Information in I02) Enter 10 Blanks Use Value 00 No Security Information Present (No Meaningful Information in I04) Enter 10 Blanks Use Value ZZ Mutually Defined Use the SC Medicaid Assigned Submitter Number Left Justified - 15 Characters Use Value ZZ Mutually Defined Use Value SCMEDICAID 15 Characters Format is YYMMDD Format is HHMM Use Value U U.S. Community EDI of ASC X12, TDCC, and UCS Use Value 00410 Assigned by Sender Must be Identical to Interchange Trailer IEA02 Left Justified
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The electronic version of this document is controlled. All paper copies are uncontrolled. Copyright 2004 South Carolina Department of Health and Human Services. All rights reserved.
Loop**
SEG ID
Element ISA14
Element Requirement R
Industry Name Acknowledgement Request
South Carolina Medicaid Specifications* Value 0 No Acknowledgement Requested Value 1 Acknowledgement Requested
ISA15
Usage Indicator
Value P Production Data Value T Test Data
ISA16 GS/R-B.8 GS01 GS02 GS03 GS04 GS05 GS06 GS07 GS08 ST/R-62 ST01 ST02
R R R R R R R R R R R
Component Element Separator Functional Identifier Code Application Senders Code Application Receivers Code Creation Date Creation Time Group Control Number Responsible Agency Code Version/Release/Industry Identifier Code Transaction Set Identifier Code Transaction Set Control Number
Assigned by Submitter Use Value HC Health Care Claim Use the SC Medicaid Assigned Submitter ID Use Value SCMEDICAID Format is CCYYMMDD Format is HHMM Assigned by Sender Must be Identical to Functional Trailer GS02 Use Value X Accredited Standards Committee X12 Use Value 004010098A1 Use Value 837 Assigned by Submitter The value in ST02 must be identical to SE02.
BHT/R-63
BHT01 BHT02 BHT03 BHT04 BHT05
R R R R R
Hierarchical Structure Code Transaction Set Purpose Code Originator Application Transaction Identifier Transaction Set Creation Date Transaction Set Creation Time
Use Value 0019 Use Value 00 - Original Use Value 837 Format is CCYYMMDD Format is HHMM
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SEG ID
Element BHT06
Industry Name Claim or Encounter Identifier
South Carolina Medicaid Specifications* Value CH Chargeable Value RP Reporting (use this value for Encounters)
REF/R-66
REF01 REF02 REF03 REF04
R R N N
Reference Identification Qualifier Transaction Type Code Description Reference Identifier SUBMITTER NAME
Use Value 87 Functional Category Use value 004010X098A1
1000A/R67 NM1/R-67 NM101 NM102 R R
Entity Identifier Code Entity Type Qualifier
Use Value 41 Submitter Value 1 Person Value 2 Non-Person Entity
NM103 NM104 NM105 NM106 NM107 NM108 NM109
R S S N N R R
Submitter Last or Organization Name Submitter First Name Submitter Middle Name Name Prefix Name Suffix Identification Code Qualifier Submitter Identifier Use Value 46 Electronic Transmitter Identification Number (ETIN) Use your SC Medicaid Trading Partner ID. FOR TRANSPORTATION BROKERS ONLY: Use Value TT Required if NM102=1 (person). Required if NM102=1 and the middle name/initial of the person is known.
NM110
Entity Relationship Code
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SEG ID
Element NM111
Element Requirement N R R R R S S S S N
Industry Name Entity Identifier Code Contact Function Code Submitter Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference RECEIVER NAME
South Carolina Medicaid Specifications*
PER/R-70
PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08 PER09
1000B/R74 NM1/R-74 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 R R R N N N N R R N
Entity Identifier Code Entity Type Qualifier Receiver Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Receiver Primary Identifier Entity Relationship Code
Use Value 40 - Receiver Use Value 2 Non-Person Entity Use value SC Medicaid.
Use Value 46 Electronic Transmitter Identification Number Use value SC Medicaid.
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SEG ID
Element NM111
Element Requirement N
Industry Name Entity Identifier Code BILLING/PAY-TO PROVIDER
2000A/R77 HL/R-78 HL01 R
Hierarchical ID Number
HL01 must begin with 1" and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed inHL01.
HL02 HL03 HL04 PRV/S-79 PRV01 PRV02 PRV03
N R R R R S
Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code Provider Code Reference Identification Qualifier Provider Taxonomy Code Use value 20. Use Value 1 - Additional Subordinate HL Data Segment in This Hierarchical Structure. Use value BI. Use Value ZZ
These codes, as maintained by the National Uniform Claim Committee, can be obtained from www.wpcedi.com/hipaa. Submit the Provider Taxonomy that was used for the SC Medicaid Provider Enrollment. Use taxonomy in this loop when provider is non-group, such as Rural Health Clinic, Home Health, FQHC, Lab, Mental Health Clinic or DME provider. In these cases, the 2310B loop will not be used.
PRV04 PRV05 837P Companion Guide June 23, 2008
N N
State or Province Code Provider Specialty Information
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SEG ID
Element PRV06
Element Requirement N
Industry Name Provider Organization Code Foreign Currency Information BILLING PROVIDER NAME
CUR/S-81 2010AA/R84 NM1/R-84 NM101 R
SC Medicaid will not use this segment.
Entity Identifier Code
Use value 85 for Billing Provider. Use this code to indicate billing provider, billing submitter, and encounter reporting entity.
NM102
Entity Type Qualifier
Value 1 Person Value 2 Non-Person Entity
NM103
Billing Provider Last or Organization Name
This element is the equivalent of: CMS-1500 Field Number (F#) 33
NM104 NM105 NM106 NM107 NM108
S S N S R
Billing Provider First Name Billing Provider Middle Name Name Prefix Billing Provider Name Suffix Identification Code Qualifier
Required if NM102=1 (person). Required if NM102=1 and the middle name/initial of the person is known.
Required if known. Use value XX for NPI if typical provider. Else use value 24 for the Employers ID Number or 34 for the Social Security Number NPI for Billing Provider if typical provider. Else submit your Employers ID Number or Social Security Number
NM109
Billing Provider Identifier
NM110 NM111 N3/R-88 837P Companion Guide June 23, 2008 N301
N N R
Entity Relationship Code Entity Identifier Code Billing Provider Address Line
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SEG ID
Element N302
Element Requirement S R R R S N N R
Industry Name Billing Provider Address Line Billing Provider City Name Billing Provider State or Province Code Billing Provider Postal Zone or ZIP Code Billing Provider Country Code Location Qualifier Location Identifier Reference Identification Qualifier
N4/R-89
N401 N402 N403 N404 N405 N406
Submit Full 9 Digit Zip Code
REF/S-91
REF01
If XX National Provider Identifier (NPI) was submitted in NM108, enter SY for Social Security Number or EI for Employers ID Number in the first iteration of this segment. Use value 1D SC Medicaid provider number for atypical providers ONLY.
REF02
Billing Provider Additional Identifier
If the NPI was submitted in NM109, then either the Social Security Number or Employers ID. Use value 1D SC Medicaid provider number for atypical providers ONLY. .
REF03 REF04 REF/S-94 PER/S-96 2010AB/S99
N N
Description Reference Identifier Credit/Debit Card Billing Information Billing Provider Contact Information PAY-TO PROVIDER NAME SC Medicaid will not use this segment. SC Medicaid will not use this segment. SC Medicaid will not use this loop.
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Loop** 2000B/R108
SEG ID
Element
Element Requirement
Industry Name SUBSCRIBER HIERARCHICAL LEVEL
HL/R-109
HL01 HL02 HL03 HL04
R R R R
Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
Assigned by Submitter Assigned by Submitter Use Value 22 - Subscriber Assigned by Submitter Value 0 - No Subordinate HL Segment in This Hierarchical Structure. Value 1 - Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR/R-110
SBR01
Payer Responsibility Sequence Number Code
Value P Primary Value S Secondary Value T Tertiary (payer of last resort)
SBR02 SBR03 SBR04 SBR05 SBR06 SBR07 SBR08 SBR09 PAT/S-114 2010BA/R117 PAT01
S S S S N N N S N
Individual Relationship Code Insured Group or Policy Number Insured Group Name Insurance Type Code Coordination of Benefits Code Yes/No Condition or Response Code Employment Status Code Claim Filing Indicator Code Individual Relationship Code SUBSCRIBER NAME
Use Value 18 - Self
Use Value MC - Medicaid SC Medicaid will not user this Segment
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SEG ID NM1/R-118
Element NM101 NM102 NM103
Element Requirement R R R
Industry Name Entity Identifier Code Entity Type Qualifier Subscriber Last Name
South Carolina Medicaid Specifications* Use Value IL Insured/Subscriber Use Value 1 - Person This element is the equivalent of: CMS-1500 F# 2
NM104
Subscriber First Name
This element is the equivalent of: CMS-1500 F# 2 This data element is required when NM102 equals one (1).
NM105
Subscriber Middle Name
This data element is required when NM102 = 1 and the Middle Name or Initial of the person is known.
NM106 NM107
N S
Name Prefix Subscriber Name Suffix This data element is required when the NM102 equals one (1) and the name suffix is known. Examples: I, II, III, IV, Jr, Sr. Use value MI Member Identification Number. Use the recipients 10 Digit SC Medicaid Identification Number. This data element is required when NM102 equals one (1). This element is the equivalent of: CMS-1500 F# 1A
NM108 NM109
S S
Identification Code Qualifier Subscriber Primary Identifier
NM110 NM111
N N
Entity Relationship Code Entity Identifier Code
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SEG ID N3/S-121
Element N301
Industry Name Subscriber Address Line
South Carolina Medicaid Specifications* This segment is required when the Patient is the same person as the Subscriber. (Required when Loop ID 2000B, SBR02- 18 (self)).
N302 N4/S-122 N401
S R
Subscriber Address Line Subscriber City Name This segment is required when the Patient is the same person as the Subscriber. (Required when Loop ID 2000B, SBR02- 18 (self)).
N402 N403 N404 N405 N406 DMG/S-124 DMG01
R R S N N R
Subscriber State Code Subscriber Postal Zone or ZIP Code Subscriber Country Code Location Qualifier Location Identifier Date Time Period Format Qualifier This segment is required when the Patient is the same person as theSubscriber. (Required when Loop ID 2000B, SBR02- 18 (self)). Use Value D8
DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 REF/S-126 REF01
R R N N N N N N R
Subscriber Birth Date Subscriber Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity Reference Identification Qualifier
Format is CCYYMMDD
SC Medicaid will not Use this Segment
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SEG ID REF/S-128
Element REF01
Industry Name Property and Casualty Claim Number PAYER NAME
South Carolina Medicaid Specifications* SC Medicaid will not use this segment.
2010BB/R130 NM1/R-130 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 N3/S-134 N301 N302 N4/S-135 N401 N402 N403 N404 N405 N406 REF/S-137 837P Companion Guide June 23, 2008 R R R N N N N R R N N R S R R R S N N
Entity Identifier Code Entity Type Qualifier Payer Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code Payer Address Line Payer Address Line Payer City Name Payer State Code Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier Payer Additional Identifier
Use Value PR Payer Use Value 2 Non-Person Entity Use value SC Medicaid.
Use value PI Payer Identification. Use value SCXIX.
Use value 1801 Main St.
Use value Columbia. Use value SC. Use value 29201.
SC Medicaid will not use this segment.
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Loop** 2010BC/S139 2010BD/S146 2000C/S152 2010CA/R157 2300/R170
SEG ID
Element
Element Requirement
Industry Name RESPONSIBLE PARTY NAME CREDIT/DEBIT CARD HOLDER NAME PATIENT HIERARCHICAL LEVEL PATIENT NAME CLAIM INFORMATION
South Carolina Medicaid Specifications* SC Medicaid will not use this loop. SC Medicaid will not use this loop. SC Medicaid will not use this loop. SC Medicaid will not use this loop.
CLM/R-171
CLM01
Patient Account Number
The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitters system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the patient account number or the claim number in the billing providers system. The MAXIMUM NUMBER OF CHARACTERS to be supported for this field is 20. A Provider may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any responding system is 20. Characters beyond 20 are not required to be stored nor returned by any receiving system.
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SEG ID
Element CLM02
Industry Name Total Claim Charge Amount
South Carolina Medicaid Specifications* This element is the equivalent of: CMS-1500 F# 28. Due to limitations in the SCMMIS, this entry should have no more than 5 positions to the left of the decimal and two positions to the right 9(5)V99.
CLM03 CLM04 CLM05-1
N N R
Claim Filling Indicator Code Non-Institutional Claim Type Code Facility Type Code This element is the equivalent of: CMS-1500 F# 24B
CLM05-2 CLM05-3
N R
Facility Code Qualifier Claim Frequency Code NOTE: for codes 7 and 8, the Claim Control Number (CCN) of the original claim must be provided in a REF segment in this loop in the Claim Original Reference Number element.
CLM06 CLM07 CLM08 CLM09 CLM10 CLM11-1
R S R R S R
Provider or Supplier Signature on File Provider Accept Assignment Code Benefits Assignment Certification Indicator Release Of Information Code Patient Signature Source Code Related Causes Code This element is the equivalent of: CMS-1500 F# 10
CLM11-2 CLM11-3 CLM11-4 CLM11-5
S S S S
Related Causes Code Related Causes Code Auto Accident State or Province Code Country Code
SC Medicaid will not use this element. SC Medicaid will not use this element.
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SEG ID
Element CLM12
Element Requirement S
Industry Name Special Program Indicator
South Carolina Medicaid Specifications* Required if the services were rendered under one of the following circumstances, programs or projects. 01 Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP) 02 Physically Handicapped Childrens Program 03 Special Federal Funding 05 Disability 07 Induced Abortion - Danger to Life 08 - Induced Abortion - Rape or Incest 09 - Second Opinion or Surgery
CLM13 CLM14 CLM15 CLM16 CLM17 CLM18 CLM19 CLM20 DTP/S-182 DTP/S-186 DTP/S-188 DTP/S-190 837P Companion Guide June 23, 2008 DTP01 DTP01 DTP01 DTP01
N N N S N N N S R R R R
Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code Participation Agreement Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code Delay Reason Code Initial Treatment Date Date Last Seen Date of Onset of Current Illness Acute Manifestation Date Required when claim is submitted late (past contracted date of filing limitations). SC Medicaid will not use this Date SC Medicaid will not use this Date SC Medicaid will not use this Date SC Medicaid will not use this Date
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SEG ID DTP/S-192 DTP/S-194
Element DTP01 DTP01
Element Requirement R R
Industry Name Similar Illness or Symptom Date Date Time Qualifier
South Carolina Medicaid Specifications* SC Medicaid will not use this Date Required if CLM11-1, CLM11-2, or CLM11-3 = AA, AB, AP or OA. Use Value 439 - Accident
DTP02
Date Time Period Format Qualifier
Value D8 Date Or Value DT Date/Time
DTP03
Accident Date
Format is CCYYMMDD Or Format is CCYYMMDDHHMM
DTP/S-196 DTP/S-197 DTP/S-200 DTP/S-201 DTP/S-203 DTP/S-205 DTP/S-206 DTP/S-208
DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01
R R R R R R R R
Last Menstrual Period Date Last X-ray Date Hearing/Vision Prescription Date Disability From Date Disability End Date Last Worked Date Date Authorized to Return to Work Date Time Qualifier
SC Medicaid will not use this Date SC Medicaid will not use this Date SC Medicaid will not use this Date SC Medicaid will not use this Date SC Medicaid will not use this Date SC Medicaid will not use this Date SC Medicaid will not use this Date Required on all ambulance claims/encounters when the patient was known to be admitted to the hospital. Also required on inpatient medical visits claims/encounters. Use Value 436 - Admission
DTP02 DTP03
R R
Date Time Period Format Qualifier Related Hospitalization Admission Date
Use Value D8 Date Format is CCYYMMDD
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SEG ID DTP/S-210
Element DTP01
Industry Name Date Time Qualifier
South Carolina Medicaid Specifications* Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. Use Value 096 Discharge Date
DTP02 DTP03 DTP/S-212 PWK/S-214 CN1/S-217 DTP01 PWK01 CN101
R R R R R
Date Time Period Format Qualifier Related Hospitalization Discharge Date Assumed or Relinquished Care Date Attachment Report Type Code Contract Type Code
Use Value D8 Date Format is CCYYMMDD SC Medicaid will not use this Date SC Medicaid will not use this Segment Required if the provider is contractually obligated to provide contract information on this claim.
CN102 CN103 CN104 CN105 CN106 AMT/S-219 AMT/S-220 AMT01 AMT02 AMT03 AMT/S-221 REF/S-222 REF/S-224 REF/S-226 AMT01 REF01 REF01 REF01
S S S S S
Contract Amount Contract Percentage Contract Code Terms Discount Percent Contract Version Identifier Credit Card Maximum Amount SC Medicaid will not use this segment.
R R N R R R R
Amount Qualifier Code Patient Amount Paid Credit/Debit Flag Code Total Purchased Service Amount Service Authorization Exception Code Medicare Section 4081 Indicator Mammography Certification Number SC Medicaid will not use this Segment SC Medicaid will not use this Segment
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SEG ID REF/S-227
Element REF01
Industry Name Reference Identification Qualifier
South Carolina Medicaid Specifications* SCMMIS will read an authorization number at this loop only and will ignore one at the service line level. Enter the number whether it pertains to the claim or the service line. G1 Prior authorization number 9F will be used for referral number. PCCM RSP will use this qualifier. This qualifier will replace number formerly put in 2310A REF segment This element is the equivalent of: CMS-1500 F# 23
REF02 REF03 REF04 REF/S-229 REF01 REF02 REF03 REF04 REF/S-231 REF01
R N N R R N N R
Prior Authorization or Referral Number Description Reference Identifier Reference Identification Qualifier Claim Original Reference Number Description Reference Identifier Reference Identification Qualifier
Use F8 Original Reference Number when CLM05-3 equals 6, 7, or 8. Use the CCN of the original claim.
Required on Medicare and Medicaid claims for any laboratory performing tests covered by the CLIA Act. Use Value X4 - Clinical Laboratory Improvement Amendment Number
REF02 REF03 REF04 REF/S-233 REF01
R N N R
Clinical Laboratory Improvement Amendment Number Description Reference Identifier Repriced Claim Reference Number SC Medicaid will not use this Segment
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Loop**
SEG ID REF/S-235 REF/S-236 REF/S-238
Element REF01 REF01 REF01
Element Requirement R R R
Industry Name Adjusted Repriced Claim Reference Number Investigational Device Exemption Identifier Reference Identification Qualifier
Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim/encounter, 837recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Use Value D9 - Claim Number
REF02 REF03 REF04 REF/S-240 REF/S-241 REF01 REF01
R N N R R
Clearinghouse Trace Number Description Reference Identifier Ambulatory Patient Group Number Reference Identification Qualifier Used at discretion of submitter. Use Value EA Medical Record Number SC Medicaid will not use this Segment
REF02
Medical Record Number
This element is the equivalent of: CMS-1500 F# 26
REF03 REF04 REF/S-242 K3/S-244 NTE/S-246 REF01 K301 NTE01
N N R R R
Description Reference Identifier Demonstration Project Identifier Fixed Format Information Note Reference Code SC Medicaid will not use this Segment SC Medicaid will not use this Segment FOR TRANSPORTATION BROKERS ONLY: Use Value ADD Additional Information
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Loop**
SEG ID
Element NTE02
Industry Name Description
South Carolina Medicaid Specifications* FOR TRANSPORTATION BROKERS ONLY: Positions 1 2: Rendering Provider County Positions 3 4: Number of Persons Sharing Ride Position 5: Origin Code See Section 4 for Values Position 6: Destination Code See Section 4 for Values Positions 7 8: Region Code
CR1/S-248
CR101 CR102 CR103 CR104 CR105 CR106 CR107 CR108 CR109 CR110
S S R R R R N N S S R
Unit or Basis of Measurement Code Patient Weight Ambulance Transport Code Ambulance Transport Reason Code Unit or Basis of Measurement Code Transport Distance Address Information Address Information Round Trip Purpose Description Stretcher Purpose Description Treatment Series Number
Required on all claims involving ambulance services.
CR2/S-251
CR201
Required on all claims involving spinal manipulation. Such claims could originate with chiropractors, physical therapists, DOs, and many other types of health care providers.
CR202
Treatment Count
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SEG ID
Element CR203 CR204 CR205 CR206 CR207 CR208 CR209 CR210 CR211 CR212
Element Requirement S S R R R R R S S R R R R S S S S R R R S
Industry Name Subluxation Level Code Subluxation Level Code Unit or Basis of Measurement Code Treatment Period Count Monthly Treatment Count Patient Condition Code Complication Indicator Patient Condition Description Patient Condition Description X-ray Availability Indicator Code Category Certification Condition Indicator Condition Code Condition Code Condition Code Condition Code Condition Code Code Category Certification Condition Indicator Condition Code Condition Code
CRC/S-257
CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07
Required on ambulance claims/encounters, i.e. when CR1 segment is used.
CRC/S-260
CRC01 CRC02 CRC03 CRC04
Required on vision claims/encounters involving replacement lenses or frames.
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SEG ID
Element CRC05 CRC06 CRC07
Element Requirement S S S R R
Industry Name Condition Code Condition Code Condition Code Homebound Indicator Code Category
CRC/S-263 CRC/SAddenda Page 37
CRC01 CRC01
SC Medicaid will not use this Segment Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims/encounters. Use Value ZZ Mutually Defined EPSDT Screening referral information.
CRC02 CRC03 CRC04 CRC05 CRC06 CRC07 HI/S-265 HI01-1 HI01-2
R R N N N N R R
Certification Condition Indicator EPSDT Referral Condition Indicator Condition Indicator Condition Indicator Condition Indicator Diagnosis Type Code Diagnosis Code Use ValueBK Principal Diagnosis This element is the equivalent of: CMS-1500 F# 21
HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
N N N N N
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
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Loop**
SEG ID
Element HI02-1
Industry Name Diagnosis Type Code
South Carolina Medicaid Specifications* Use Value BF Diagnosis Code ICD-9 Codes
HI02-2
Diagnosis Code
This element is the equivalent of: CMS-1500 F# 21
HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 837P Companion Guide June 23, 2008
N N N N N R R N N N N N R R N N N N N
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
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SEG ID
Element HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI08-1 HI08-2
Element Requirement R R N N N N N R R N N N N N R R N N N N N R R
Industry Name Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Diagnosis Type Code Diagnosis Code
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SEG ID
Element HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI09 HI10 HI11 HI12
Element Requirement N N N N N N N N N R
Industry Name Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Heath Care Code Information Heath Care Code Information Heath Care Code Information Heath Care Code Information Claim Pricing/Repricing Information HOME HEALTH CARE PLAN
HCP/S-271 2305/S276 CR7/S-276
HCP
SC Medicaid will not use this segment. Required on home health claims/encounters that involve billing/reporting home health visits.
CR701 CR702 CR703
R R R S S S S S S S
Discipline Type Code Total Visits Rendered Count Certification Period Projected Visit Count Quantity Qualifier Number of Visits Frequency Period Frequency Count Duration of Visits Units Duration of Visits, Number of Units Ship/Delivery or Calendar Pattern Date Use Value VS - Visits
HSD/S-278
HSD01 HSD02 HSD03 HSD04 HSD05 HSD06 HSD07
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SEG ID
Element HSD08
Industry Name Delivery Pattern Time Code REFERRING PROVIDER NAME
2310A/S282 NM1/S-283 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 PRV/S-285 PRV01 PRV02 PRV03 PRV04 PRV05 PRV06 REF/S-287 REF01 REF02 R R R S S N S S S N N R R R N N N R R
SC Medicaid will not use this loop.
Entity Identifier Code Entity Type Qualifier Referring Provider Last Name Referring Provider First Name Referring Provider Middle Name Name Prefix Referring Provider Name Suffix Identification Code Qualifier Referring Provider Identifier Entity Relationship Code Entity Identifier Code Provider Code Reference Identification Qualifier Provider Code State or Province Code Provider Specialty Information Provider Organization Code Reference Identification Qualifier Referring Provider Secondary Identifier Referral or authorization numbers previously sent in this field will now use loop 2300 REF02 with REF01 value 9F
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Loop**
SEG ID
Element REF03 REF04
Element Requirement N N
Industry Name Description Reference Identifier RENDERING PROVIDER NAME
2310B/S290
Required when the Rendering Provider NM1 information is different than that carried in either the Billing Provider NM1 or the Pay-to Provider NM1 in the 2010AA loop. Do not use this loop when provider is nongroup, such as Rural Health Clinic, Home Health, FQHC, Lab, Mental Health Clinic or DME provider. In these cases, the 2310B loop will not be used.
Use value 82. Value 1 Person Value 2 Non-Person Entity
NM1/S-291
NM101 NM102
R R
NM103 NM104 NM105 NM106 NM107 NM108
R S S N S R
Rendering Provider Last or Organization Name Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix Identification Code Qualifier Required if known Use value XX for NPI if provider is typical. Else use value 24 for the Employers ID Number or 34 for the Social Security Number Required if NM102=1 (person). Required if NM102=1 and the middle name/initial of the person is known
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Loop**
SEG ID
Element NM109
Industry Name Rendering Provider Identifier
South Carolina Medicaid Specifications* Use NPI for Rendering Provider if typical. Else submit your Employers ID Number or Social Security Number
NM110 NM111 PRV/S-293 PRV01 PRV02 PRV03
N N R R R
Entity Relationship Code Entity Identifier Code Provider Code Reference Identification Qualifier Provider Taxonomy Code Use value PE - Performing Use value ZZ. These codes, as maintained by the National Uniform Claim Committee, can be obtained from www.wpc-edi.com/hipaa. Submit the Provider Taxonomy that was used for the SC Medicaid Provider Enrollment. Do not use this loop when provider is non-group, such as Rural Health Clinic, Home Health, FQHC, Lab, Mental Health Clinic or DME provider. In these cases, the 2310B loop will not be used. The the taxonomy will be in 2000A.
PRV04 PRV05 PRV06 REF/S-296 REF01 REF02 REF03 REF04 2310C/S298
N N N R R N N
State or Province Code Provider Specialty Information Provider Organization Code Reference Identification Qualifier Rendering Provider Secondary Identifier Description Reference Identifier PURCHASED SERVICE PROVIDER NAME SC Medicaid will not use this loop. Use value 1D for atypical providers ONLY. Use the rendering providers SC Medicaid provider number for atypical providers ONLY.
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Loop** 2310D/S303
SEG ID
Element
Element Requirement
Industry Name SERVICE FACILITY LOCATION
South Carolina Medicaid Specifications* This loop is required when the location of health care service is different than that carried in the 2010AA (Billing Provider) loop Value 77 Service Location Use when other codes in this element do not apply. Value FA Facility Value LI - Independent Lab Value TL - Testing Laboratory
NM1/S-304
NM101
Entity Identifier Code
NM102 NM103 NM104 NM105 NM106 NM107 NM108
R R N N N N R
Entity Type Qualifier Service Facility Provider Last or Organization Name Service Facility Provider First Name Service Facility Provider Middle Name Name Prefix Service Facility Provider Name Suffix Identification Code Qualifier
Use Value 2 Non-Person Entity Required except when service was rendered in the patients home.
Use value XX for NPI if typical. Else use value 24 for the Employers ID Number or 34 for the Social Security Number Use NPI for Service Facility Provider is typical. Else submit you Employers ID Number or Social Security Number
NM109
Service Facility Provider Identifier
NM110
Entity Relationship Code
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Loop**
SEG ID
Element NM111
Element Requirement N R S R R R S N N R R
Industry Name Entity Identifier Code Address Information Line 1 Address Information Line 2 City Name State or Province Code Postal Code Country Code Location Qualifier Location Qualifier Reference Identification Qualifier Service Facility Provider Secondary Identifier
N3/R-307
N301 N302
N4/R-308
N401 N402 N403 N404 N405 N406
Submit 9 Digit Zip Code
REF/S-310
REF01 REF02
Use value 1D for atypical providers ONLY. Use the Service Facility providers SC Medicaid provider number for atypical providers ONLY.
REF03 REF04 2310E/S312
N N
Description Reference Identifier SUPERVISING PROVIDER NAME SC Medicaid will not use this loop.
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Loop** 2320/S318
SEG ID
Element
Element Requirement
Industry Name OTHER SUBSCRIBER INFORMATION
South Carolina Medicaid Specifications* Required if other payers are known to potentially be involved in paying on this claim. Include Medicare payments.
SBR/S-319
SBR01 SBR02 SBR03
R R R
Payer Responsibility Sequence Number Code Individual Relationship Code Insured Group or Policy Number This will be ignored if in the 2330A loop NM101 = IL and NM108 = MI and NM109 is not blank
SBR04 SBR05 SBR06 SBR07 SBR08 SBR09 CAS/S-326 CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09
S R N N N S R R R S S S S S S
Other Insured Group Name Insurance Type Code Coordination of Benefits Code Yes/No Condition or Response Code Employment Status Code Claim Filing Indicator Code Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount
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Loop**
SEG ID
Element CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
Element Requirement S S S S S S S S S S R R N R R N R R N R R N R
Industry Name Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Amount Qualifier Code Payer Paid Amount Credit/Debit Flag Code Amount Qualifier Code Approved Amount Credit/Debit Flag Code Amount Qualifier Code Allowed Amount Credit/Debit Flag Code Amount Qualifier Code Other Payer Patient Responsibility Amount Credit/Debit Flag Code Amount Qualifier Code
AMT/S-332
AMT01 AMT02 AMT03
AMT/S-333
AMT01 AMT02 AMT03
AMT/S-334
AMT01 AMT02 AMT03
AMT/S-335
AMT01 AMT02 AMT03
AMT/S-336 837P Companion Guide June 23, 2008
AMT01
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Loop**
SEG ID
Element AMT02 AMT03
Element Requirement R N R R N R R N R R N R R N R R N R R R N N N
Industry Name Other Payer Covered Amount Credit/Debit Flag Code Amount Qualifier Code Other Payer Discount Amount Credit/Debit Flag Code Amount Qualifier Code Other Payer Per Day Limit Amount Credit/Debit Flag Code Amount Qualifier Code Other Payer Patient Paid Amount Credit/Debit Flag Code Amount Qualifier Code Other Payer Tax Amount Credit/Debit Flag Code Amount Qualifier Code Other Payer Pre-Tax Claim Total Amount Credit/Debit Flag Code Date Time Period Format Qualifier Other Insured Birth Date Other Insured Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code
AMT/S-337
AMT01 AMT02 AMT03
AMT/S-338
AMT01 AMT02 AMT03
AMT/S-339
AMT01 AMT02 AMT03
AMT/S-340
AMT01 AMT02 AMT03
AMT/S-341
AMT01 AMT02 AMT03
DMG/S-342
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06
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Loop**
SEG ID
Element DMG07 DMG08 DMG09
Element Requirement N N N N N R S N R S S S S S S S S S
Industry Name Country Code Basis of Verification Code Quantity Claim Filing Indicator Code Claim Submission Reason Code Benefits Assignment Certification Indicator Patient Signature Source Code Provider Agreement Code Release of Information Code Reimbursement Rate HCPCS Payable Amount Remark Code Remark Code Remark Code Remark Code Remark Code End Stage Renal Disease Payment Amount Non-payable Professional Component Billed Amount OTHER SUBSCRIBER NAME
OI/R-344
OI01 OI02 OI03 OI04 OI05 OI06
MOA/S-347
MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07 MOA08 MOA09
2330A/R350 NM1/R-351 NM101 NM102 R R
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Loop**
SEG ID
Element NM103 NM104 NM105 NM106 NM107 NM108 NM109
Element Requirement R S S N S R R
Industry Name Other Insured Last Name Other Insured First Name Other Insured Middle Name Name Prefix Other Insured Name Suffix Identification Code Qualifier Other Insured Identifier
Ignore value in element SBR03 in loop 2320 if NM101 = IL and NM108 = MI and this element is not blank in this loop
NM110 NM111 N3/S-354 N301 N302 N4/S-355 N401 N402 N403 N404 N405 N406 REF/S-357 REF01 REF02 REF03 REF04
N N R S S R R S N N R R N N
Entity Relationship Code Entity Identifier Code Other Subscriber Address Line Other Subscriber Address Line Other Insured City Name Other Insured State Code Other Insured Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier Reference Identification Qualifier Other Insured Additional Identifier Description Reference Identifier
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Loop** 2330B/R359
SEG ID
Element
Element Requirement
Industry Name OTHER PAYER NAME
South Carolina Medicaid Specifications* Submitters are required to send all known information on other payers in this Loop ID2330.
NM1/R-360
NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109
R R R N N N N R R
Entity Identifier Code Entity Type Qualifier Other Payer Last or Organization Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Other Payer Primary Identifier Use value PI. This number must be identical to SVD01 (Loop ID-2430) for COB. Use the carrier codes assigned by SC Medicaid to identify other insurance carriers.
NM110 NM111 PER/S-364 PER01 PER02 PER03 PER04 PER05 PER06 PER07
N N R R R R S S S
Entity Relationship Code Entity Identifier Code Contact Function Code Other Payer Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Other Payer Communication Number Communication Number Qualifier
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Loop**
SEG ID
Element PER08 PER09
Element Requirement S N R R R R R N N R R N N R R N N
Industry Name Communication Number Contact Inquiry Reference Date Time Qualifier Date Time Period Format Qualifier Adjudication or Payment Date Reference Identification Qualifier Other Payer Secondary Identifier Description Reference Identifier Reference Identification Qualifier Other Payer Prior Authorization or Referral Number Description Reference Identifier Reference Identification Qualifier Other Payer Claim Adjustment Indicator Description Reference Identifier OTHER PAYER PATIENT INFORMATION OTHER PAYER REFERRING PROVIDER OTHER PAYER RENDERING PROVIDER
DTP/S-366
DTP01 DTP02 DTP03
Transportation broker will use this field for encounter claims to show date claim was paid
REF/S-368
REF/S-370
REF/S-371
2330C/S374 2330D/S378 2330E/S382 837P Companion Guide June 23, 2008
SC Medicaid will not use this loop. SC Medicaid will not use this loop. SC Medicaid will not use this loop.
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Loop** 2330F/S386 2330G/S390 2330H/S394 2400/R398
SEG ID
Element
Element Requirement
Industry Name OTHER PAYER PURCHASED SERVICE PROVIDER
South Carolina Medicaid Specifications* SC Medicaid will not use this loop.
OTHER PAYER SERVICE FACILITY LOCATION SC Medicaid will not use this loop. OTHER PAYER SUPERVISING PROVIDER SERVICE LINE LX/R-399 SV1/R-401 LX01 SV101-1 SV101-2 R R R Assigned Number Product or Service ID Qualifier Procedure Code This element is the equivalent of: CMS-1500 F# 24D SV101-3 S Procedure Modifier 1 This element is the equivalent of: CMS-1500 F# 24D SV101-4 SV101-5 SV101-6 SV101-7 SV102 S S S N R Procedure Modifier 2 Procedure Modifier 3 Procedure Modifier 4 Description Line Item Charge Amount This element is the equivalent of: CMS-1500 F# 24F For encounter transmissions, zero (0) may be a valid amount. SV103 SV104 R R Unit or Basis of Measurement Code Service Unit Count This element is the equivalent of: CMS-1500 F# 24G SC Medicaid will not use this loop.
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Loop**
SEG ID
Element SV105
Industry Name Place of Service Code
South Carolina Medicaid Specifications* This element is the equivalent of: CMS-1500 F# 24B
SV106 SV107-1 SV107-2 SV107-3 SV107-4 SV108 SV109 SV110 SV111 SV112 SV113 SV114 SV115 SV116 SV117 SV118 SV119 SV120 SV121
N R S S S N S N S S N N S N N N N N N
Service Type Code Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer Monetary Amount Emergency Indicator Multiple Procedure Code EPSDT Indicator Family Planning Indicator Review Code National or Local Assigned Review Value Co-pay Status Code Health Care Professional Shortage Area Code Reference Identification Postal Code Monetary Amount Level of Care Code Provider Agreement Code Required if Medicaid services are the result of a screening referral.
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Loop**
SEG ID SV4/S-408
Element SV401 SV402 SV403 SV404 SV405 SV406 SV407 SV408 SV409 SV410 SV411 SV412 SV413 SV414 SV415 SV416 SV417 SV418
Element Requirement R N N N N N N N N N N N N N N N N N
Industry Name Prescription Number COMPOSITE MEDICAL PROCEDURE IDENTIFIER Reference Identification Yes/No Condition or Response Code Dispense as Written Code Level of Service Code Prescription Origin Code Description Yes/No Condition or Response Code Yes/No Condition or Response Code Unit Dose Code Basis of Cost Determination Code Basis of Days Supply Determination Code Dosage Form Code Copay Status Code Patient Location Code Level of Care Code Prior Authorization Type Code DURABLE MEDICAL EQUIPMENT SERVICE
South Carolina Medicaid Specifications* Required if dispense of the drug has been done with an assigned Rx number.
SV501/S-58A
SV501
Required when reporting rental and purchase price information for durable medical equipment. Value HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
SV501-1
Product/Service ID Qualifier
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Loop**
SEG ID
Element SV501-2 SV501-3 SV501-4 SV501-5 SV501-6 SV501-7 SV502 SV503 SV504 SV505 SV506
Element Requirement R N N N N N R R S S S
Industry Name Product/Service ID Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier Description Unit or Basis for Measurement Code Quantity Monetary Amount Monetary Amount Frequency Code
South Carolina Medicaid Specifications* This value must be the same as that reported in SV101-2.
Value DA - Days
Value 1 Weekly Value 4 Monthly Value 6 - Daily
SV507 PWK/S-410 CR1/S-413 PWK01 CR101
N R S
Prognosis Code Attachment Report Type Code Unit or Basis of Measurement Code SC Medicaid will not use this Segment Required on all ambulance claims if the information is different than in the CR1 at the claim level (Loop ID-2300).
CR102 CR103 CR104 CR105 CR106 837P Companion Guide June 23, 2008
S R R R R
Patient Weight Ambulance Transport Code Ambulance Transport Reason Code Unit or Basis of Measurement Code Transport Distance
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Loop**
SEG ID
Element CR107 CR108 CR109 CR110
Element Requirement N N S S N
Industry Name Address Information Address Information Round Trip Purpose Description Stretcher Purpose Description Treatment Series Number
CR2/S-416
CR201
Required on all claims involving spinal manipulation if information is different from Loop-ID 2300 CR2 information. Such claims could originate with chiropractors, physical therapists, DOs, and many other types of health care providers.
CR202 CR203 CR204 CR205 CR206 CR207 CR208 CR209 CR210 CR211 CR212 CR3/S-421 CR5/S-424 CR301 CR501 CR502
N N N N N N N N S S S R R R
Treatment Count Subluxation Level Code Subluxation Level Code Unit or Basis of Measurement Code Treatment Period Count Monthly Treatment Count Patient Condition Code Complication Indicator Patient Condition Description Patient Condition Description X-ray Availability Indicator DME Certification Certification Type Code Treatment Period Count SC Medicaid will not use this Segment Required on all initial, renewal, and revision home oxygen therapy claims
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Loop**
SEG ID
Element CR503 CR504 CR505 CR506 CR507 CR508 CR509 CR510 CR511 CR512 CR513 CR514 CR515 CR516 CR517 CR518
Element Requirement N N N N N N N S S R S S S N N N R R R R R
Industry Name Oxygen Equipment Type Code Oxygen Equipment Type Code Description Quantity Quantity Quantity Description Arterial Blood Gas Quantity Oxygen Saturation Quantity Oxygen Test Condition Code Oxygen Test Findings Code Oxygen Test Findings Code Oxygen Test Findings Code Quantity Oxygen Delivery System Code Oxygen Equipment Type Code Ambulance Certification Hospice Employee Indicator DMERC Condition Indicator Date Time Qualifier Date Time Period Format Qualifier
CRC/S-427 CRC/S-431 CRC/S-433 DTP/R-435
CRC01 CRC01 CRC01 DTP01 DTP02
SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment Use Value 472 Service Value D8 Date Or Value RD8 Date Range
Version 4.7
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Loop**
SEG ID
Element DTP03
Industry Name Service Date
South Carolina Medicaid Specifications* This element is the equivalent of: CMS-1500 F# 24A Format is CCYYMMDD Or Format is CCYYMMDD-CCYYMMDD
DTP/S-437 DTP/S-440 DTP/S-442 DTP/S-445 DTP/S-447 DTP/S-449 DTP/S-451 DTP/S-452 DTP/S-454 DTP/S-456 DTP/S-458 DTP/S-460 MEA/S-465 CN1/S-466
DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 DTP01 MEA01 CN101
R R R R R R R R R R R R R R
Certification Revision Date Begin Therapy Date Last Certification Date Last Seen Date Test Performed Date Oxygen Saturation Test Date Shipped Date Onset Date Last X-Ray Date Acute Manifestation Date Initial Treatment Date Similar Illness or Symptom Date Test Results Contract Type Code
SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment Information contained at this level overwrites CN1 information at the claim level for this specific service line.
CN102 CN103
S S
Contract Amount Contract Percentage
Version 4.7
45
Loop**
SEG ID
Element CN104 CN105 CN106
Element Requirement S S S R R R
Industry Name Contract Code Terms Discount Percent Contract Version Identifier Repriced Line Item Reference Number Adjusted Repriced Line Item Reference Number Reference Identification Qualifier
REF/S-468 REF/S-469 REF/S-470
REF01 REF01 REF01
SC Medicaid will not use this Segment SC Medicaid will not use this Segment Required if service line involved a prior authorization number or referral number that is different than the number reported at the claim level (Loop-ID 2300). Value 9F Referral Number Value G1 Prior Authorization Number
REF02 REF03 REF04 REF/S-472 REF01
R N N R
Prior Authorization or Referral Number Description Reference Identifier Reference Identification Qualifier Required if it is necessary to send a line control or inventory number. Providers are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the provide automatically posts their remittance advice. Submitting a unique line item control number gives providers the capability to automatically post by service line. The line item control number should be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837. Use Value 6R Provider Control Number
Version 4.7
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Loop**
SEG ID
Element REF02 REF03 REF04
Element Requirement R N N R R
Industry Name Line Item Control Number Description Reference Identifier Mammography Certification Number Reference Identification Qualifier
REF/S-474 REF/S-475
REF01 REF01
SC Medicaid will not use this Segment Required for all CLIA certified facilities performing CLIA covered laboratory services and if number is different from CLIA number reported at claim level (Loop ID-2300). Use Value X4 - Clinical Laboratory Improvement Amendment Number
REF02 REF03 REF04 REF/S-477 REF/S-478 REF/S-479 REF/S-480 REF/S-483 AMT/S-484 AMT/S-485 AMT/S-486 K3/S-487 NTE/S-488 REF01 REF01 REF01 REF01 REF01 AMT01 AMT01 AMT01 K301 NTE01
R N N R R R R R R S R R R
Clinical Lab Improvement Amendment Number Description Reference Identifier Referring CLIA Number Immunization Batch Number Ambulatory Patient Group Number Oxygen Flow Rate Universal Product Number Sales Tax Amount Approved Amount Postage Claimed Amount Fixed Format Information Note Reference Code SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment SC Medicaid will not use this Segment FOR TRANSPORTATION BROKERS ONLY: Use Value ADD Additional Information
Version 4.7
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Loop**
SEG ID
Element NTE02
Industry Name Line Note Text
South Carolina Medicaid Specifications* FOR TRANSPORTATION BROKERS ONLY: Positions 1 2: Rendering Provider County Positions 3 4: Number of Persons Sharing Ride Position 5: Origin Code See Section 4 for Values Position 6: Destination Code See Section 4 for Values Positions 7 8: Region Code
PS1/S-489 HSD/S-492
PS101 HSD01 HSD02
R S S
Purchased Service Provider Identifier Quantity Qualifier Number of Visits
SC Medicaid will not use this Segment Use Value VS - Visits Home Health Enter the number of visits if different from the number entered in CR702.
HSD03 HSD04 HSD05 HSD06 HSD07 HSD08 HCP/S-496 2410/S71A HCP01
S S S S S S R
Frequency Period Frequency Count Duration of Visits Units Duration of Visits, Number of Units Ship/Delivery or Calendar Pattern Code Delivery Pattern Time Code Pricing Methodology DRUG IDENTIFICATION SC Medicaid will not use this Segment SC Medicaid will only accept the first occurrence of this loop and ignore any additional occurrences.
Version 4.7
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Loop**
SEG ID LIN/S-71
Element LIN01 LIN02 LIN03 LIN04 LIN05 LIN06 LIN07 LIN08 LIN09 LIN10 LIN11 LIN12 LIN13 LIN14 LIN15
Element Requirement N R R N N N N N N N N N N N N
Industry Name Assigned Identification Product/Service ID Qualifier National Drug Code Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID
South Carolina Medicaid Specifications* Not Used (according to the Implementation Guide Addenda) Use value N4
Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda)
Version 4.7
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Loop**
SEG ID
Element LIN16 LIN17 LIN18 LIN19 LIN20 LIN21 LIN22 LIN23 LIN24 LIN25 LIN26 LIN27 LIN28 LIN29
Element Requirement N N N N N N N N N N N N N N
Industry Name Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID
South Carolina Medicaid Specifications* Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda)
Version 4.7
50
Loop**
SEG ID
Element LIN30 LIN31
Element Requirement N N N
Industry Name Product/Service ID Qualifier Product/Service ID Class of Trade Code
South Carolina Medicaid Specifications* Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) SC Medicaid does not validate the elements in this segment. Either omit this segment or you must enter all of the required elements if any are entered. If submitted please follow the usage as noted on each element. Not Used (according to the Implementation Guide Addenda)
CTP/S-74
CTP01
CTP02 CTP03 CTP04 CTP05-01 CTP05-02 CTP05-03 CTP05-04 CTP05-05 CTP05-06 CTP05-07
N R R R N N N N N N
Price Identifier Code Drug Unit Price National Drug Unit Count Unit or Basis of Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Enter 0.00, value not currently used by SC Medicaid
Version 4.7
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Loop**
SEG ID
Element CTP05-08 CTP05-09 CTP05-10 CTP05-11 CTP05-12 CTP05-13 CTP05-14 CTP05-15 CTP06 CTP07 CTP08 CTP09 CTP10 CTP11
Element Requirement N N N N N N N N N N N N N N
Industry Name Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Price Multiplier Qualifier Multiplier Monetary Amount Basis of Unit Price Code Condition Value Multiple Price Quantity
South Carolina Medicaid Specifications* Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda) Not Used (according to the Implementation Guide Addenda)
Version 4.7
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Loop** 2420A/S501
SEG ID
Element
Element Requirement
Industry Name RENDERING PROVIDER NAME
South Carolina Medicaid Specifications* Required if the Rendering Provider NM1 information is different than that carried in the 2310B (claim) loop, or if the Rendering provider information is carried at the Billing/Pay-to Provider loop level 2010AA and this particular service line has a different Rendering Provider that what is given in the 2010AA loop. The identifying payer-specific numbers are those that belong to the destination payer identified in loop 2010BB. Use value 82 - Rendering Value 1 Person Value 2 Non-Person Entity
NM1/S-502
NM101 NM102
R R
NM103 NM104 NM105 NM106 NM107 NM108
R S S N S R
Rendering Provider Last or Organization Name Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix Identification Code Qualifier Required if known Use value XX for NPI if typical provider. Else use value 24 for the Employers ID Number or 34 for the Social Security Number Use NPI for Rendering Provider if typical provider. Else submit you Employers ID Number or Social Security Number Required if NM102=1 (person). Required if NM102=1 and the middle name/initial of the person is known.
NM109
Rendering Provider Identifier
NM110 NM111 PRV/S-504 PRV01
N N R
Entity Relationship Code Entity Identifier Code Provider Code Use value PE - Performing
Version 4.7
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Loop**
SEG ID
Element PRV02 PRV03
Element Requirement R R
Industry Name Reference Identification Qualifier Provider Taxonomy Code
South Carolina Medicaid Specifications* Use value ZZ. These codes, as maintained by the National Uniform Claim Committee, can be obtained from www.wpc-edi.com/hipaa. Submit the Provider Taxonomy that best fits provider type and specialty for the billing provider and that was used for the SC Medicaid Provider Enrollment.
PRV04 PRV05 PRV06 REF/S-507 REF01 REF02 REF03 REF04 2420B/S509 2420C/S514 2420D/S523 2420E/S529 2420F/S541
N N N R R N N
State or Province Code Provider Specialty Information Provider Organization Code Reference Identification Qualifier Rendering Provider Secondary Identifier Description Reference Identifier PURCHASED SERVICE PROVIDER NAME SERVICE FACILITY LOCATION SUPERVISING PROVIDER NAME ORDERING PROVIDER NAME REFERRING PROVIDER NAME SC Medicaid will not use this loop. SC Medicaid will not use this loop. SC Medicaid will not use this loop. SC Medicaid will not use this loop. SC Medicaid will not use this loop. Use value 1D Medicaid Provider Number. for atypical providers ONLY. Use the rendering providers SC Medicaid provider number for atypical providers ONLY.
Version 4.7
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Loop** 2420G/S549 2430/S554 2440/S567 9999/R572
SEG ID
Element
Element Requirement
Industry Name OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER LINE ADJUDICATION INFORMATION FORM IDENTIFICATION CODE TRANSACTION SET TRAILER
South Carolina Medicaid Specifications* SC Medicaid will not use this loop. SC Medicaid will not use this loop. SC Medicaid will not use this loop.
SE/R-572
SE01 SE02
R R R R R R
Transaction Segment Count Transaction Set Control Number Number of Transaction Sets Included Group Control Number Number of Included Functional Groups Interchange Control Number
Enter Number of Segments Included in Transaction Set, including the ST and SE. Assigned by Sender Must be Identical to Transaction Set Header ST02 Enter Number of Transaction Sets Included Assigned by Sender Must be Identical to Functional Header GE02 Enter Number of Functional Groups Included Assigned by Sender Must be Identical to Interchange Header ISA13
GS/R-B.10
GS01 GS02
IEA/R-B.7
IEA01 IEA02
Version 4.7
55
4. TRANSPORTATION BROKER VALUES

Origin Codes Where Ride Originated NTE02 Position 5 Destination Codes- Destination of Ride NTE02 Position 6
VALUE 1 2 3 4 5 6 7 8 9 0 A B C D E
DESCRIPTION Inpatient Hospital Outpatient Hospital Office Home Site of Accident Place of Employment Domiciliary/Nursing Home/ICF Extended Care Facility/SNF Boarding Home Other Independent Laboratory Medical Clinic Psychiatric Clinic Independent X-Ray Rural Health Clinic
ORIGIN/DESTINATION O/D O/D O/D O/D O/D O/D O/D O/D O/D O/D O/D O/D O/D O/D O/D
Version 4.7
56
5. DOCUMENT CHANGE HISTORY

Project Information Project Name: 837 Professional Companion Guide
Hard copies of this document are for information only and are not subject to document control.
Version 1.0 1.1
Approval Date 06/25/03 09/03/03
Changed By
Reason Original Document
Jim Hazelrigs
Page 2, 3rd bullet from the bottom changed to read: For a recipients unknown Social Security Number (SSN), use 123456789 as the submitted value to SC Medicaid.
1.2
09/30/03
Jim Hazelrigs
Following text is removed from page 2, SCOPE paragraph A trading partner may not have all data collected in their system to plug every required field on the transaction. In these cases, the following values are suggested: For unknown fields defined as AN (alphanumeric) in the ANSI X12 Implementation Guide, use UNKNOWN as the submitted value to SC Medicaid. For date fields defined as CCYYMMDD in the ANSI X12 Implementation Guide that are not known, use 99991231 as the submitted value to SC Medicaid. For a recipients unknown Social Security Number (SSN), use 123456789 as the submitted value to SC Medicaid.
NOTE: The submission of these values does not guarantee a payment. All claims are subject to the SC Medicaid edits. 1.3 12/03/03 Jim Hazelrigs For REF02 segment Use value 004010X097DA1 in test mode and 004010X97A1 in production. It now reads use value 004010X97A1 Page 3 For REF02 segment the value is changed It now reads: Use value 004010X98A1
2.0
12/18/03
Jim Hazel rigs
Version 4.7
57
Version 1.5
Approval Date 01/16/04
Changed By Jim Hazel rigs
Reason p.13 referring to the CLM02 entry - Total Claim Charge Amount added the text Due to limitations in the SCMMIS, this entry should have no more than 7 positions to the left of the decimal and two positions to the right 9(7)V99. P 18 referring to the REF01 (REF/S-227) entry - Reference Identification Qualifier SCMMIS will read an authorization number at this loop only and will ignore one at the service line level. Enter the number whether it pertains to the claim or the service line.
1.6
03/03/04
Jim Hazelrigs
p.13 referring to the CLM02 entry - Total Claim Charge Amount Added the text Due to limitations in the SCMMIS, this entry should have no more than 5 positions to the left of the decimal and two positions to the right 9(5)V99.
NA
03/17/04
Tina Roberts
Per Management, updated footers, title page and document for version number. This document is referenced internally as version 2.6, but is published as version 1.6. p. 13, the notation for SC Medicaid for the Claim Frequency Code was changed to read: Only valid values for SC Medicaid are 1, 7, and 8. For codes 7 and 8, the Claim Control Number (CCN) of the original claim must be provided in a REF segment in this loop in the Claim Original Reference Number element.
1.7
04/02/04
Jim Hazelrigs
1.8
4/27/04
Jim Hazelrigs
p.13, the notation for the Claim Frequency Code is changed to read: NOTE: for codes 7 and 8, the Claim Control Number (CCN) of the original claim must be provided in a REF segment in this loop in the Claim Original Reference Number element.
1.9
7/12/04
Colleen McCuen
p. 28, the notation for Insured Group or Policy Number is changed to read: This will be ignored if in the 2330A loop NM101 = IL and NM108 = MI and NM109 is not blank
p. 32, the notation for Other Insured Identifier is changed to read: Ignore value in element SBR03 in loop 2320 if NM101 = IL and NM108 = MI and this element is not blank in this loop 2.0 9/15/04 Jim Hazelrigs The MMIS will now process more Diagnosis Codes increased from 2 to 8 and more Modifiers increased from 1 per line to 4 per line
Version 4.7
58
Version 3.0
Approval Date 12/08/05
Changed By Colleen McCuen
Reason Various changes throughout the document to reflect changes needed for the National Provider Identifier (NPI); SC Medicaid Specifications added to the following: p.5, Element HL03 p.6, Element NM101, Element NM108, Element NM109 p.7, Element REF01, Element REF02 p.26, Element NM101, Element NM108, Element NM109, Element PRV01, Element PRV02, Element PRV03, Element REF01 p.27, Element REF02, Element NM101, Element NM108, Element 109, Element PRV01, Element PRV02 p.36, Element SV101-5, Element SV101-6 p.47, Element NM101 p,48, Element NM108, Element NM109, Element PRV01, Element PRV02, Element PRV03
3.1 4.0
4/11/06 10/01/06
Colleen McCuen Colleen McCuen
Changed p.3 from Use value 004010X98A1 to Use value 004010X098A1 Changed the following pages to accept National Drug Code data for rebates: p. 49 51 Segment LIN and all of its elements p. 51 53 Segment CTP and all of its elements
Note: These segments are not valid for usage until January 1, 2007.
4.1
12/04/06
Colleen McCuen
Added comment on 2410 loop stating SC Medicaid will only accept the first occurrence of the loop (pg. 47)
4.2
03/21/07
Colleen McCuen
Added a comment that SC Medicaid will not use the elements in segment CTP in loop 2410. But if any of the elements are entered, all required elements must be present to pass compliance and must follow the usage listed in this guide (pg. 50). Pg 1, removed at no charge in reference to Implementation Guide Availability. Pg 2, changed UB-92 to UB-04. National Provider Identifier Transition Period Instructions. General Cleanup. Added Transportation Broker Instructions and Values in Section 4. Added ISA/IEA and GS/GE information. Pg 38 added Transportation Broker instructions for DTP03, loop 2330
4.3
05/23/07
Kathy Dugan
4.4
07/26/07
Charley Cosby
Version 4.7
59
Version 4.5
Approval Date 12/01//07
Changed By Charley Cosby
Reason Effective 12/01/07. Page 19 added instructions for authorization number formerly sent in 2310A REF02. Page 28, removed instructions for Gate Keeper, added reference to loop 2300 REF01 and REF02 Changed loops 2010A, 2310B and 2420A to advise typical providers to send only NPI. Only atypical providers will continue to use SC Medicaid provider ID. 2310A is not used. Updated wording in 2000A PRV to show use when non-group. Update wording in 2310B to show use when group providers only.
4.6
05/24/2008
Charley Cosby
4.7
06/23/2008
Charley Cosby
Version 4.7
60

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HIPAA Transaction Sets and Code Sets (HTSCS) 837 Professional Companion Guide Specifications

Version 4.7 June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

837 PROFESSIONAL HEALTH CARE CLAIM TRANSACTION MAP

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

Industry Name Acknowledgement Request

Value P Production Data Value T Test Data

BHT01 BHT02 BHT03 BHT04 BHT05

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

Industry Name Claim or Encounter Identifier

REF01 REF02 REF03 REF04

Use Value 87 Functional Category Use value 004010X098A1

1000A/R67 NM1/R-67 NM101 NM102 R R

Entity Identifier Code Entity Type Qualifier

Use Value 41 Submitter Value 1 Person Value 2 Non-Person Entity

NM103 NM104 NM105 NM106 NM107 NM108 NM109

Entity Relationship Code

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

South Carolina Medicaid Specifications*

PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08 PER09

Use Value 46 Electronic Transmitter Identification Number Use value SC Medicaid.

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

Industry Name Entity Identifier Code BILLING/PAY-TO PROVIDER

South Carolina Medicaid Specifications*

2000A/R77 HL/R-78 HL01 R

HL02 HL03 HL04 PRV/S-79 PRV01 PRV02 PRV03

PRV04 PRV05 837P Companion Guide June 23, 2008

State or Province Code Provider Specialty Information

HTSCS 837 Professional Companion Guide Specifications

South Carolina Medicaid Specifications*

CUR/S-81 2010AA/R84 NM1/R-84 NM101 R

SC Medicaid will not use this segment.

Entity Identifier Code

Entity Type Qualifier

Value 1 Person Value 2 Non-Person Entity

Billing Provider Last or Organization Name

This element is the equivalent of: CMS-1500 Field Number (F#) 33

NM104 NM105 NM106 NM107 NM108

Billing Provider Identifier

HTSCS 837 Professional Companion Guide Specifications

South Carolina Medicaid Specifications*

N401 N402 N403 N404 N405 N406

Submit Full 9 Digit Zip Code

Billing Provider Additional Identifier

REF03 REF04 REF/S-94 PER/S-96 2010AB/S99

837P Companion Guide June 23, 2008

HTSCS 837 Professional Companion Guide Specifications

Industry Name SUBSCRIBER HIERARCHICAL LEVEL

South Carolina Medicaid Specifications*

HL01 HL02 HL03 HL04

Payer Responsibility Sequence Number Code

Value P Primary Value S Secondary Value T Tertiary (payer of last resort)

Use Value 18 - Self