Beacon Health Strategies

Transcription

1 Beacon Health trategies 837P Health Care Claim Companion Guide and 837I Health Care Claim Companion Guide For use with AC X12N 837 Health Care Professional and Institutional Transactions et Implementation Guides and Addenda (Version HIPAA 5010) December 12, 2013 Version 3.3

2 Document Version History Version Date Published Notes 1.0 July testing-production version 1.1 Aug ubstituted version X222A1 in place of X222 ubstituted version X223A2 in place of X223A1 1.2 Nov ubstituted Qualifier 5010 LU for 4010 Qualifier G5 for ite data. 2.0 April 01, 2012 NEW 5010 Production version added text for eton and Amida Care 2.1 June 14, 2012 added text for Center Light 3.0 Jan 10, 2013 Added text for (eniorwholehealthma, eniorwholehealthny, HumanaCareourceKY) - Add/Updated text for APG,POA, and Value Codes - Added text for TX MedicaidNo and KY ImpactPlusProviderNo 3.1 August 15, 2013 Added text for: Health Net NJ, Managed Health Net NJ, Empire, Inc. NJ 3.2 August 28, 2013 Corrected tates for: Health Net changed to CA, Managed Health Net changed to CA, Empire, Inc. changed to NY 3.3 December 12, 2013 Updated Medicaid Number information and added additional 3-digit plan codes. Beacon Health trategies, LLC Page 2 of 31

3 Table of Contents Table of Contents... 3 Introduction... 4 What is HIPAA?... 4 Purpose... 4 Intended Audience... 4 Contact Information... 5 Transaction ubmission Procedures... 6 ubmission Methods... 6 etup/certification Procedures... 6 Testing... 7 Technical equirements... 7 eports... 8 Considerations... 9 Transactions upported (inbound)... 9 Delimiters upported... 9 ize/maximum Limitations... 9 Key Points NPI ubmission... 9 pecific Data equirements Interchange Control and Functional Group pecifications Professional Claims (837P) Data equirements Institutional Claims (837I) Data equirements Beacon Health trategies, LLC Page 3 of 31

4 Introduction What is HIPAA? The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandates the establishment of national standards for electronic transmission of health data and ensuring privacy protection. The Administrative implification provisions of HIPAA, Title II require the Department of Health and Human ervices to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care. Beacon Health trategies, as a covered entity and health insurance payer will be accepting X Professional (837P) and Institutional (837I) Health Care Claims as mandated by the administration simplification provisions of HIPAA. Purpose This document has been prepared as a Beacon Health trategies (Beacon) specific companion document to that implementation guide and to clarify when conditional data elements and segments must be used for Beacon reporting, and identify those codes and data elements that do not apply to Beacon. This companion guide document supplements, but does not contradict any requirements in the 837 version 5010 implementation guide. This companion is to be used in conjunction with the X12 implementation guide. The implementation guides for all HIPAA transactions are available from Washington Publishing Company and are available electronically to download at This document will be subject to revisions as new versions of the X Professional and Institutional Health Care Claim Transaction et Implementation Guides are released. Intended Audience The intended audience for this document is the technical area which is responsible for submitting electronic claims transactions to Beacon Health trategies. In addition, this information should be communicated and coordinated with the provider's billing office in order to ensure the required billing information is provided to their billing agent/submitter. Beacon Health trategies, LLC Page 4 of 31

5 Contact Information The purpose of this section is to provide contact information for any questions regarding HIPAA, 837 transactions, EDI, EDI Gateway, documentation and testing. For General HIPAA questions relating to Beacon, you can get answers in one of the following ways: 1. From the Beacon website at Click on Providers, Click on Providers Tools, Enter Plan Name Abbreviation, i.e. BMC croll down to Administrative esources and News ; then Click on it, then Click on HIPAA. 2. By contacting any of the following staff listed here by responsibility. Type of Contact Contact Telephone Number Address General TC Anup Vidyarthy (781) [email protected] ecurity Anup Vidyarthy (781) [email protected] Privacy Donna Zeh (781) [email protected] Local codes Beth Quinn (781) [email protected] Companion EDI Operations (781) [email protected] Documents Trading Partner EDI Operations (781) [email protected] etup EDI Gateway EDI Operations (781) [email protected] 837 Transactions and Testing EDI Operations (781) [email protected] Beacon Health trategies, LLC Page 5 of 31

6 Transaction ubmission Procedures ubmission Methods Providers/Trading partners will be able to submit 837 claim transactions utilizing any of the following methods: 1. Using Beacon s online secure EDI Gateway. To use this EDI gateway, you will need an Internet `connection, a browser that supports 128-bit encryption, such as Internet Explorer 5.5 or higher. etup/certification Process 1. Providers/trading partners interested in submitting electronic claim transactions must complete the following forms supplied by Beacon: a. EDI Transactions/Billing Intermediary Authorization Form (Appendix A) b. Trading Partner/EDI Gateway etup Form (Appendix B) 2. These forms can be downloaded from Beacon s website at or can be requested by contacting EDI Operations at Beacon. 3. The EDI Transactions/Billing Intermediary Authorization Form has to be completed by every provider who will be conducting EDI transactions with Beacon. This form is also utilized to authorize a billing intermediary if the provider utilizes one. 4. The Trading Partner/EDI Gateway etup Form has to be completed by the technical person of the health care provider or the billing intermediary if applicable. This form is utilized to gather some trading partner technical information and to setup a ubmitter ID on Beacon s EDI Gateway. 5. Complete both the forms then Please send FAX to at BEACON HEALTH TATEGIE 200 tate treet Boston MA Upon receipt of the EDI Transactions/Billing Intermediary Authorization Form and the Trading Partner/EDI Gateway etup Form, you will receive an ed acknowledgement letter from Beacon stating that EDI Operations has establish a test submitter ID and a folder (mailbox) on the BH EDI Gateway. 7. A submitter ID is assigned to each trading partner, provider or billing intermediary. You will utilize the submitter ID to create a login ID and password on the EDI Gateway. To access your folder (mailbox) to upload or download files, you have to login using the login ID. If there are multiple people who do the upload and download, you can create a login ID for each person utilizing the same submitter ID. This way there is a history of who uploaded or downloaded specific files. If a person with a login ID is no longer with the organization, the trading partner should notify EDI Operations at Beacon so we can deactivate that login ID. 8. Upon completion of successful testing, you will be notified of the same and you will be assigned a new submitter ID for the production system which should be used in all files submitted for production claims processing. The test ubmitter ID should be used in all files submitted for testing. Beacon Health trategies, LLC Page 6 of 31

7 Testing Beacon requires testing for all providers/trading partners/submitters submitting the 837P and 837I transactions. Please follow the appropriate format specifications listed in the specific data requirements and submission directions. Test files have to be submitted utilizing the secure protocols and submission methodology selected. Once a test ubmitter ID is setup for a trading partner, the submitter can start sending claims transactions for testing. In order to test, it is imperative that a technical contact at the provider/submitter organization be established. This contact should have the ability to monitor, change and submit the 837P and 837I transaction files to Beacon. This contact should be familiar with 837P and 837I transaction as well as possess a solid understanding of the technology used to create these files. During the testing process, Beacon will examine submitted transactions for required formats and elements and will get responses during the testing process. A Beacon EDI Operations staff will contact you via telephone with results of the most recent test, generally within a week of submission. This testing stage will continue until testing satisfaction is achieved in both sides. Beacon s testing procedures will validate the test file in its entirety. The entire file will either pass or fail validation. Beacon does not allow partial file submissions. If the file fails validation, a failure report will be provided explaining the failure messages. Upon the completion of successful testing, you will be notified of the same and you will be assigned a new submitter ID for the production system which should be used in all files submitted for production claims processing. The test ubmitter ID should be used in all files submitted for testing. Technical equirements During testing of the 837P and 837I transactions, Beacon recommends that test claim files should contain a minimum of 25 claims and not exceed 100 claims in any one batch. File contents should simulate claims from normal business. Creating small files for testing provides for easier trouble shooting and recreation of the test file. Once your files have passed testing, you may send files of larger sizes. pecial note 5010 Testing All established providers/trading partners/ubmitters should use their previously assigned Test ubmitterid for 5010 testing. Beacon Health trategies, LLC Page 7 of 31

8 eports The following sections lists the reports that Beacon will provide and describes the process for retrieving these reports. eport/file Number eport/file Name Purpose ource Turnaround from time of ubmission 997 Functional This is a X12 file Folder/ Day of submission Acknowledgement response report Mailbox esult* esults eport file To report claim level rejections and to report on total claims accepted along with their total claim amount Folder/ Mailbox Day of submission Functional Acknowledgment eport (997) File level summary indicating accepted and rejected transaction sets within a file. Please refer the Implementation Guide for Health Care Claims. Functional Acknowledgment eport (999) Will be available in 2013 esults eport file When a file is uploaded from the EDI Gateway, the submitter is provided with a reference ID for the submission. The file name of the esults eport file will be <reference ID>_results.txt * All files that are rejected at file level will not have a results file. Note: All reports will be available to providers/trading partners via the EDI Gateway in the respective mailboxes. To access your mailbox, log in to the EDI Gateway and click on the download files link. Providers/trading partners are responsible for downloading these reports when available. Beacon Health trategies, LLC Page 8 of 31

9 Considerations Transactions upported (inbound) Currently Beacon will support and accept the following HIPAA 5010 inbound transactions: 837 Professional Health Care Claim AC X12N 837 (005010X222A1) 837 Institutional Health Care Claim AC X12N 837 (005010X223A2) Delimiters upported A delimiter is a character used to separate two data elements or sub elements, or to terminate a segment. Delimiters are specified in the interchange header segment, IA. The IA segment is a 105 byte fixed length record. The data element separator is byte number 4; the component element separator is byte number 105; and the segment terminator is the byte that immediately follows the component element separator. Once specified in the interchange header, delimiters are not to be used in a data element value elsewhere in the transaction. Beacon recommends utilizing the following default delimiters: Description Default Delimiter Data element separator * (Asterisk) ub-element separator : (Colon) egment Terminator ~ (Tilde) Note: If the data contains any of the above delimiters, different delimiters can be utilized and specified in the IA segment. ize/maximum Limitations Claims files submitted in production mode cannot exceed 5000 claims (CLM segments) in any one file as stated in the Implementation Guides. Beacon Health trategies, LLC Page 9 of 31

10 Loop Details For providers Loop 2010AA NM1 segment should contain NPI for the Billing Provider Loop 2310B (837P) NM1 segment should contain NPI for the endering Provider. Loop 2310A (837I) NM1 segment should contain NPI for the Attending Provider. Loop 2310D (837P) NM1 segment should contain NPI for the service facility location if it is different from the Billing Provider NPI. If there is more than one site with the same NPI, the claim will be processed using the first provider site. For all such cases, we recommend using provider site ID (supplied by Beacon) in the EF segment to identify the specific provider site. Loop 2310E (837I) NM1 segment should contain NPI for the service facility location if it is different from the Billing Provider NPI. If there is more than one site with the same NPI, the claim will be processed using the first provider site. For all such cases, we recommend using provider site ID (supplied by Beacon) in the EF segment to identify the specific provider site. For billing agencies Loop 2010AA NM1 segment should contain NPI for each of the provider they are billing for. Loop 2310B (837P) NM1 segment should contain NPI for the endering Provider. Loop 2310A (837I) NM1 segment should contain NPI for the Attending Provider. Loop 2310D (837P) NM1 segment should contain NPI for the service facility location if it is different from the Billing Provider NPI. If there is more than one site with the same NPI, the claim will be processed using the first provider site. For all such cases, we recommend using provider site ID (supplied by Beacon) in the EF segment to identify the specific provider site. Loop 2310E (837I) NM1 segment should contain NPI for the service facility location if it is different from the Billing Provider NPI. If there is more than one site with the same NPI, the claim will be processed using the first provider site. For all such cases, we recommend using provider site ID (supplied by Beacon) in the EF segment to identify the specific provider site. Beacon Health trategies, LLC Page 10 of 31

11 pecific Data equirements Interchange Control and Functional Group pecifications General This section outlines the specifications for the Interchange Control and Functional Group header and trailer information. LoopID/ Element / Description Usage QD Comments Values egment Headers IA Interchange Control Header Fixed record length segment IA01 - Authorization Info Qualifier No Authorization Info Present 00 IA02 - Authorization Information 10 spaces IA03 - ecurity Info Qualifier 00 IA04 - ecurity Information 10 spaces IA05 - Interchange ID Qualifier Mutually Defined ZZ IA06 - Interchange ender ID ubmitter ID Provided by Beacon IA07 - Interchange ID Qualifier Mutually Defined ZZ IA08 - Interchange eceiver ID Use "BH " IA09 - Interchange Date Format YYMMDD IA10 - Interchange Time Format HHMM IA11 epetition eparator ^ IA12 - Interchange Version Number IA13 - Interchange Control Number Assigned by sender. Must equal IEA02 IA14 - Acknowledgement equired 0 IA15 - Usage Indicator "T" for testing, "P" for production IA16 - Component Element eparator : G Functional Group Header G01 - Functional ID Code HC G02 - Application ender's Code ubmitter ID Provided by Beacon G03 - Application eceiver's Code Use "BH " G04 Date Format "CCYYMMDD" G05 Time Format "HHMM" G06 - Group Control Number Assigned by sender. Must equal GE02 G07 - esponsible Agency Code X G08 - Version / elease "005010X223A2" for 837 Institutional; "005010X222A1" for 837 Professional; Trailers GE Functional Group Trailer GE01 - Number of Transaction sets GE02 - Group Control Number ame as G06 IEA Interchange Control Trailer IEA01 - Number of Functional Groups IEA02 - Interchange Control Number ame as IA13 Beacon Health trategies, LLC Page 11 of 31

12 Professional Claims (837P) Data equirements General The purpose of this section is to clarify the data elements and segments that must be used for professional claims transactions. The following information is designed to help you complete the 837P transaction. If you follow these guidelines, we'll be better able to process your claims accurately and efficiently. Detail Data LoopID/ egment Element / Description Usage Q D Comments T Transaction set Header 1 T01 - Transaction set ID code This element should be hard coded when 837 submitting the claim. T02 - Transaction set control number Assigned by ender. Must equal E02 T03 - Transaction ame as G X222A1 BHT Beginning of HL Transaction 1 BHT01 - Hierarchical tructure Code This element should be hard coded when 0019 submitting the claim. BHT02 - Transaction set purpose code Allowed values : "00", "18". Use "00" 00 BHT03 - eference ID Assigned by ender. BHT04 Date Claim file creation date. Format CCYYMMDD BHT05 Time Claim file creation time. Format HHMM BHT06 - Transaction Type Code Allowed Values : "CH", "P". Use "CH" CH LOOP 1000A ubmitter Name 1 NM1 ubmitter name 1 NM101 - Entity ID Code 41 NM102 - Entity Type Qualifier Allowed Values : "1" for person, "2" for nonperson. NM103 - Last Name / Org Name Last name of physician or organization name NM104 - First Name equired if NM102 = "1" NM105 - Middle Name equired if NM102 = "1" NM107 - Name uffix equired if NM102 = "1" NM108 - ID Code qualifier 46 NM109 - ID Code LOOP 1000B eceiver Name 1 NM1 eceiver name 1 NM101 - Entity ID Code 40 NM102 - Entity Type Qualifier 2 NM103 - Last Name / Org Name Use "Beacon Health trategies, LLC" NM108 - ID Code qualifier ETIN 46 NM109 - ID Code Use "BH " LOOP 2000A Billing Provider Loop > 1 HL Billing Provider HL HL01 - Hierarchical ID Number equence number incremented for each occurrence of HL. HL03 - Hierarchical Level Code 20 HL04 - Hierarchical Child Code 1 PV Billing Provider Taxonomy Code Values Beacon Health trategies, LLC Page 12 of 31

13 PV01 BI PV02 PXC PV03 LOOP Billing provider AA NM1 Billing provider name 1 NM101 - Entity ID Code 85 NM102 - Entity Type Qualifier Allowed Values : "1" for person, "2" for nonperson. NM103 - Name Last or Organization Name NM104 - Name First equired if NM102 = "1" NM105 - Name Middle equired if NM102 = "1" NM107 - Name uffix equired if NM102 = "1" NM108 - ID Code qualifier XX - Health Care Financing Administration National Provider Identifier NM109 - ID Code National Provider ID / NPI N3 Billing provider address 1 N301 - Address N302 - Address N4 Billing provider city/state/zip 1 EF N401 - City N402 - tate N403 - Zip N404 - Country equired if billing address is outside of the U Billing Provider econdary Identification >=1 EF01 - eference ID Qualifier EI Employer s Identification Number 1G Medicaid Number (eton Only) 1G ImpactPlusProviderNo (HumanaCareKY) 1G ImpactPlusProviderNo (Passport) EF02 - eference ID Provider Tax ID Medicaid Number ImpactPlusProviderNo LOOP 2000B ubscriber HL Loop > 1 HL ubscriber HL 1 HL01 - Hierarchical ID Number Assigned by sender HL02 - Hierarchical Parent ID Number Assigned by sender HL03 - Hierarchical Level Code ubscriber 22 HL04 - Hierarchical Child Code "0" if ubscriber is the patient. "1" if subscriber is not the patient B ubscriber information 1 B01 - Payer esp eq No Code B02 - Individual elationship code Used if ubscriber is the Patient 18 B03 - eference ID Insured Group or Policy Number For Providers submitting via EMDEON Use this to identify the Plan Allowed Values : "001" for Neighborhood Health Plan of MA, "004" for Healthource/Hudson Health Plan, "005" for Fallon Community Health Plan, "006" for Neighborhood Health Plan of I, 009 for Affinity Health Plan, 013 for DC Chartered Health Plan 014 for Health ight 015 for Neighborhood Health Partners 018 for Touchstone Health 019 for Molina Health Plan 020 for BMC HealthNet Plan 021 for CalOptima XX EI,1G Beacon Health trategies, LLC Page 13 of 31

14 022 for Prestige Health Choice 024 for Anthem 026 for cott White Health Plan 027 for eton Health Plan 028 for Passport 029 for Amida Care, 030 for Centerlight 032 for Well ense Health Plan 036 for Alameda Alliance 037 for eniorwholehealthma 039 for eniorwholehealthny 041 for Preferred Medical Plan 042 for alubris 043 for Ultimate Health Plans 045 for HumanaCareourceKY 048 for Group Insurance Commission 049 for Healthsun Health Plan 050 for Empire, Inc. of NY 051 for Leon Medical Centers Health Plan 052 for Trusted Health Plans, Inc. 053 for LA Care Health Plan 060 for Cook Children s Health Plan 061 for Parkland Community Health Plan 064 for Physicians United Plan 069 for Managed Health Net of CA 070 for Health Net of CA 071 for Freedom Health 072 for Optimum Health Care 074 for America s 1 st Choice Health Plan 087 for Molina Healthcare of Florida B04 - Name Plan Name For Provider submitting via EMDEON Allowed Values : Neighborhood Health Plan of MA Health ource/hudson Health Plan Fallon Community Health Plan Neighborhood Health Plan of I Affinity Health Plan, DC Chartered Health Plan Health ight Neighborhood Health Partners Touchstone Health Abri Health Plan BMC HealthNet Plan CalOptima Prestige Health Choice Anthem cott & White Health Plan eton Health Plan Passport Amida Care Centerlight Well ense Health Plan Alameda Alliance enior Whole Health of MA enior Whole Health of NY Preferred Medical Plan alubris Ultimate Health Plans Humana Care ource of KY Group Insurance Commission Healthsun Health Plan Empire, Inc. of NY Leon Medical Centers Health Plan Trusted Health Plans, Inc. L.A. Care Health Plan Cook Children s Health Plan Parkland Community Health Plan Physicians United Plan Managed Health Net of CA Beacon Health trategies, LLC Page 14 of 31

15 B05 - Insurance Type Code B09 - Claim File Indicator Code Type Of Claim LOOP ubscriber name BA NM1 ubscriber name 1 Health Net of CA Freedom Health Optimum Healthcare America s 1 st Choice Health Plan Molina Healthcare of Florida NM101 - Entity ID Code IL NM102 - Entity Type Qualifier Allowed Values: "1" for person, "2" for nonperson. NM103 - Name Last or Organization Name NM104 - Name First NM105 - Name Middle NM107 - Name uffix NM108 - ID Code qualifier MI NM109 - ID Code Use Member ID from membership card N3 ubscriber s address 1 N301 - Address N302 - Address N4 ubscriber s city/state/zip 1 N401 - City N402 - tate N403 - Zip DMG ubscriber s demographic info 1 DMG01 - Date Time Format Qualifier D8 DMG02 - Date Time Period Date of Birth of subscriber (CCYYMMDD format) DMG03 - Gender Code Allowed Values : "M", "F", "U" LOOP Payer name BB NM1 Payer name 1 NM101 - Entity ID Code P NM102 - Entity Type Qualifier 2 NM103 - Name Last or Organization Name For Providers submitting via EMDEON - Allowed Value : Beacon Health trategies, LLC For all other Providers - Allowed Values : Neighborhood Health Plan of MA Health ource/hudson Health Plan Fallon Community Health Plan Neighborhood Health Plan of I Affinity Health Plan, DC Chartered Health Plan Health ight Neighborhood Health Partners Touchstone Health Abri Health Plan BMC HealthNet Plan CalOptima Prestige Health Choice Anthem cott & White Health Plan eton Health Plan Passport Amida Care Centerlight Beacon Health trategies, LLC Page 15 of 31

16 Well ense Health Plan Alameda Alliance enior Whole Health of MA enior Whole Health of NY Preferred Medical Plan alubris Ultimate Health Plans Humana Care ource of KY Group Insurance Commission Healthsun Health Plan Empire, Inc. of NY Leon Medical Centers Health Plan Trusted Health Plans, Inc. L.A. Care Health Plan Cook Children s Health Plan Parkland Community Health Plan Physicians United Plan Managed Health Net of CA Health Net of CA Freedom Health Optimum Healthcare America s 1 st Choice Health Plan Molina Healthcare of Florida NM108 - ID Code qualifier PI NM109 - ID Code For Provider submitting via EMDEON Allowed Value : For all other Providers - Allowed Values: "001" for Neighborhood Health Plan of MA, "004" for Healthource/Hudson Health Plan, "005" for Fallon Community Health Plan, "006" for Neighborhood Health Plan of I, 009 for Affinity Health Plan, 013 for DC Chartered Health Plan 014 for Health ight 015 for Neighborhood Health Partners 018 for Touchstone Health 019 for Molina Health Plan 020 for BMC HealthNet Plan 021 for CalOptima 022 for Prestige Health Choice 024 for Anthem 026 for cott White Health Plan 027 for eton Health Plan 028 for Passport 029 for Amida Care, 030 for Centerlight 032 for Well ense Health Plan 036 for Alameda Alliance 037 for eniorwholehealthma 039 for eniorwholehealthny 041 for Preferred Medical Plan 042 for alubris 043 for Ultimate Health Plans 045 for HumanaCareourceKY 048 for Group Insurance Commission 049 for Healthsun Health Plan 050 for Empire, Inc. of NY 051 for Leon Medical Centers Health Plan 052 for Trusted Health Plans, Inc. 053 for LA Care Health Plan 060 for Cook Children s Health Plan 061 for Parkland Community Health Plan 064 for Physicians United Plan 069 for Managed Health Net of CA 070 for Health Net of CA 071 for Freedom Health 072 for Optimum Health Care 074 for America s 1 st Choice Health Plan 087 for Molina Healthcare of Florida Beacon Health trategies, LLC Page 16 of 31

17 EF Billing Provider econdary Identification >=1 EF01 - eference ID Qualifier G2 Medicaid Number G2 EF02 - eference ID Medicaid Number LOOP 2000C Patient HL > 1 equired when the Patient is different from the subscriber HL Patient HL 1 HL01 - Hierarchical ID Number Assigned by sender HL02 - Hierarchical Parent ID Number Assigned by sender HL03 - Hierarchical Level Code 23 HL04 - Hierarchical Child Code 0 PAT Patient information 1 PAT01 - Individual relationship code LOOP Patient name CA NM1 Patient name NM101 - Entity ID Code QC NM102 - Entity Type Qualifier 1 NM103 - Name Last or Organization Name NM104 - Name First NM105 - Name Middle NM107 - Name uffix NM108 - ID Code qualifier MI NM109 - ID Code Use Member ID from membership card N3 Patient address 1 N301 - Address N302 - Address N4 Patient city/state/zip 1 N401 - City N402 - tate N403 - Zip DMG Patient s demographic info 1 DMG01 - Date Time Format Qualifier D8 DMG02 - Date Time Period Date of Birth of subscriber (CCYYMMDD format) DMG03 - Gender Code Allowed Values : "M", "F", "U" LOOP 2300 Claim information 100 CLM Claim information 1 CLM01 Patient Account Number Claim Number. Will be sent back in 835 for CLP01 CLM02 - Monetary Amount Total Claim Amount CLM Facility Code Value Place of ervice Code (First two positions of Bill Type CLM Facility Code Qualifier B CLM Claim Frequency Type Code Third position of Bill Type Original = 1, esend = 7, Void = 8 CLM06 - Yes/No Condition or esponse Code CLM07 - Provider Accept Assignment Code CLM08 - Yes/No Condition or esponse Code Beacon Health trategies, LLC Page 17 of 31

18 CLM09 - elease of Information Code CLM10 - Patient ignature ource Code CLM11 CLM11 contains ELATED CAUE INFOMATION and is only required when Accident or Employment elated Causes are indicated. CLM elated Cause Code CLM elated Cause Code CLM elated Cause Code CLM tate CLM Country CLM12 - pecial Program Code CLM16 - Provider Agreement Code CLM20 - Delay eason Code DTP Date - Admission 1 DTP01 - Date/Time qualifier 435 DTP02 - Date/Time Period Format Qualifier DTP03 - Date Time Period In the format CCYYMMDD DTP Date - Discharge 1 DTP01 - Date/Time qualifier 096 DTP02 - Date/Time Period Format Qualifier DTP03 - Date Time Period In the format CCYYMMDD D8 D8 EF Original eference Number 1 Must send if CLM05-3 = 7 EF01 - eference ID Qualifier F8 EF02 - eference ID Use 8 digit Beacon ClaimID ( provided by Beacon on EOB eport) HI Health care diagnosis 1 HI01 - Healthcare Code Information HI Code List qualifier code Principal Diagnosis BK HI Industry Code ICD-9 Code HI02 - Healthcare Code Information HI Code List qualifier code Other Diagnosis BF HI Industry Code ICD-9 Code HI03 - Healthcare Code Information HI Code List qualifier code Other Diagnosis BF HI Industry Code ICD-9 Code HI04 - Healthcare Code Information HI Code List qualifier code Other Diagnosis BF HI Industry Code ICD-9 Code HI05 - Healthcare Code Information HI Code List qualifier code Other Diagnosis BF HI Industry Code ICD-9 Code HI06 - Healthcare Code Information HI Code List qualifier code Other Diagnosis BF HI Industry Code ICD-9 Code HI07 - Healthcare Code Information HI Code List qualifier code Other Diagnosis BF HI Industry Code ICD-9 Code HI08 - Healthcare Code Information Beacon Health trategies, LLC Page 18 of 31

19 HI Code List qualifier code Other Diagnosis BF HI Industry Code ICD-9 Code LOOP 2310B endering Provider NM1 endering Provider Name 1 EF NM101 - Entity ID Code 82 NM102 - Entity Type Qualifier NM103 - Name Last or Organization Name endering Physician Last Name NM104 - Name First endering Physician First Name NM105 - Name Middle NM108 - ID Code qualifier XX - Health Care Financing Administration National Provider Identifier NM109 - ID Code endering Provider National Provider ID / NPI endering Provider econdary Identification 1 EF01 - eference ID Qualifier G2 Medicaid Number 1G Medicaid Number (eton Only) EF02 - eference ID Medicaid Number XX G2,1G LOOP 2310D ervice Facility Location NM1 ervice Facility Location 1 EF NM101 - Entity ID Code 77 NM102 - Entity Type Qualifier NM103 - Name Last or Organization Name NM104 - Name First NM105 - Name Middle Provider ite Name. NM108 - ID Code qualifier XX - Health Care Financing Administration National Provider Identifier NM109 - ID Code National Provider ID / NPI ervice Facility Location econdary Identification 1 EF01 - eference ID Qualifier LU EF02 - eference ID Provider ite ID Number( provided by Beacon) XX LOOP 2400 ervice Line 50 LX ervice line 1 LX01 - Assigned Number Counter. Assigned by sender V1 Professional service 1 V Product/ervice ID Qualifier V Product/ ervice ID Procedure Code V Procedure Modifier Modifier 1 V Procedure Modifier Modifier 2 V Procedure Modifier Modifier 3 V Procedure Modifier Modifier 4 V102 - Monetary Amount ervice line charge V103 - Units or basis of measurement code V104 Quantity ervice Units V105 - Facility Code value Place of ervice V Diagnosis Code Pointer V Diagnosis Code Pointer V Diagnosis Code Pointer UN Beacon Health trategies, LLC Page 19 of 31

20 V Diagnosis Code Pointer V109 - Yes/No Condition or esponse Code hould be blank for Medicare claims DTP ervice date 1 ervice line tart/end DTP01 - Date/Time qualifier 472 DTP02 - Date/Time Period Format Qualifier Allowed Values : "D8" for Date, "8" for Date ange DTP03 - Date Time Period Format "CCYYMMDD" for D8, "CCYYMMDD - CCYYMMDD" for 8 E Transaction et Trailer 1 E01 Number of included segments E02 Transaction et Control Number Assigned by ender. Must equal E02 Beacon Health trategies, LLC Page 20 of 31

21 Institutional Claims (837I) Data equirements General The purpose of this section is to clarify the data elements and segments that must be used for institutional claims transactions. The following information is designed to help you complete the 837I transaction. If you follow these guidelines, we'll be better able to process your claims accurately and efficiently. Detail Data LoopID/ egment Element / Description Usage Q D Comments Values T Transaction set Header 1 T01 - Transaction set ID code This element should be hard coded when 837 submitting the claim. T02 - Transaction set control number Assigned by ender. Must equal E02 T03 - Transaction ame as G X223A2 BHT Beginning of HL Transaction 1 BHT01 - Hierarchical tructure Code This element should be hard coded when 0019 submitting the claim. BHT02 - Transaction set purpose code Allowed values : "00", "18". Use "00" 00 BHT03 - eference ID Assigned by ender. BHT04 - Date Claim file creation date. Format CCYYMMDD BHT05 - Time Claim file creation time. Format HHMM BHT06 - Transaction Type Code Allowed Values : "CH", "P". Use "CH" CH LOOP 1000A ubmitter Name 1 NM1 ubmitter name 1 NM101 - Entity ID Code 41 NM102 - Entity Type Qualifier Allowed Values : "1" for person, "2" for nonperson. NM103 - Last Name / Org Name Last name of physician or organization name NM104 - First Name equired if NM102 = "1" NM105 - Middle Name equired if NM102 = "1" NM107 - Name uffix equired if NM102 = "1" NM108 - ID Code qualifier 46 NM109 - ID Code LOOP 1000B eceiver Name 1 NM1 eceiver name 1 NM101 - Entity ID Code 40 NM102 - Entity Type Qualifier 2 NM103 - Last Name / Org Name Use "Beacon Health trategies, LLC" NM108 - ID Code qualifier ETIN 46 NM109 - ID Code Use "BH " LOOP 2000A Billing Provider Loop > 1 HL Billing Provider HL HL01 - Hierarchical ID Number equence number incremented for each occurrence of HL. HL03 - Hierarchical Level Code 20 HL04 - Hierarchical Child Code 1 Beacon Health trategies, LLC Page 21 of 31

22 PV Billing Provider Taxonomy Code PV01 BI PV02 PXC PV03 LOOP Billing provider AA NM1 Billing provider name 1 NM101 - Entity ID Code 85 NM102 - Entity Type Qualifier Allowed Values : "1" for person, "2" for nonperson. NM103 - Name Last or Organization Name NM104 - Name First equired if NM102 = "1" NM105 - Name Middle equired if NM102 = "1" NM107 - Name uffix equired if NM102 = "1" NM108 - ID Code qualifier y XX - Health Care Financing Administration National Provider Identifier NM109 - ID Code y Provider Tax ID / NPI N3 Billing provider address 1 N301 - Address N302 - Address N4 Billing provider city/state/zip 1 N401 - City N402 - tate N403 - Zip N404 - Country equired if billing address is outside of the U EF Billing Provider econdary Identification >=1 XX EF01 - eference ID Qualifier EI Employer s Identification Number 1G Medicaid Number (eton Only) 1G ImpactPlusProviderNo (HumanaCareKY) 1G ImpactPlusProviderNo (Passport) EF02 - eference ID Provider Tax ID Medicaid Number ImpactPlusProviderNo LOOP 2000B ubscriber HL > 1 HL ubscriber HL 1 HL01 - Hierarchical ID Number Assigned by sender HL02 - Hierarchical Parent ID Number Assigned by sender HL03 - Hierarchical Level Code ubscriber 22 HL04 - Hierarchical Child Code "0" if ubscriber is the patient. "1" if subscriber is not the patient B ubscriber information 1 B01 - Payer esp eq No Code B02 - Individual elationship code Used if ubscriber is the Patient 18 B03 - eference ID Insured Group or Policy Number For Providers submitting via EMDEON Use this to identify the Plan Allowed Values : "001" for Neighborhood Health Plan of MA, "004" for Healthource/Hudson Health Plan, "005" for Fallon Community Health Plan, "006" for Neighborhood Health Plan of I, 009 for Affinity Health Plan, 013 for DC Chartered Health Plan EI,1G Beacon Health trategies, LLC Page 22 of 31

23 014 for Health ight 015 for Neighborhood Health Partners 018 for Touchstone Health 019 for Molina Health Plan 020 for BMC HealthNet Plan 021 for CalOptima 022 for Prestige Health Choice 024 for Anthem 026 for cott White Health Plan 027 for eton Health Plan 028 for Passport 029 for Amida Care, 030 for Centerlight 032 for Well ense Health Plan 036 for Alameda Alliance 037 for eniorwholehealthma 039 for eniorwholehealthny 041 for Preferred Medical Plan 042 for alubris 043 for Ultimate Health Plans 045 for HumanaCareourceKY 048 for Group Insurance Commission 049 for Healthsun Health Plan 050 for Empire, Inc. of NY 051 for Leon Medical Centers Health Plan 052 for Trusted Health Plans, Inc. 053 for LA Care Health Plan 060 for Cook Children s Health Plan 061 for Parkland Community Health Plan 064 for Physicians United Plan 069 for Managed Health Net of CA 070 for Health Net of CA 071 for Freedom Health 072 for Optimum Health Care 074 for America s 1 st Choice Health Plan 087 for Molina Healthcare of Florida B04 - Name Plan Name For Provider submitting via EMDEON Allowed Values : Neighborhood Health Plan of MA Health ource/hudson Health Plan Fallon Community Health Plan Neighborhood Health Plan of I Affinity Health Plan, DC Chartered Health Plan Health ight Neighborhood Health Partners Touchstone Health Abri Health Plan BMC HealthNet Plan CalOptima Prestige Health Choice Anthem cott & White Health Plan eton Health Plan Passport Amida Care Centerlight Well ense Health Plan Alameda Alliance enior Whole Health of MA enior Whole Health of NY Preferred Medical Plan alubris Ultimate Health Plans Humana Care ource of KY Group Insurance Commission Healthsun Health Plan Empire, Inc. of NY Leon Medical Centers Health Plan Beacon Health trategies, LLC Page 23 of 31

24 B05 - Insurance Type Code B09 - Claim File Indicator Code Type Of Claim LOOP ubscriber name BA NM1 ubscriber name 1 Trusted Health Plans, Inc. L.A. Care Health Plan Cook Children s Health Plan Parkland Community Health Plan Physicians United Plan Managed Health Net of CA Health Net of CA Freedom Health Optimum Healthcare America s 1 st Choice Health Plan Molina Healthcare of Florida NM101 - Entity ID Code IL NM102 - Entity Type Qualifier Allowed Values : "1" for person, "2" for nonperson. NM103 - Name Last or Organization Name NM104 - Name First NM105 - Name Middle NM107 - Name uffix NM108 - ID Code qualifier MI NM109 - ID Code Use Member ID from membership card N3 ubscriber s address 1 N301 - Address N302 - Address N4 ubscriber s city/state/zip 1 N401 - City N402 - tate N403 - Zip DMG ubscriber s demographic info 1 DMG01 - Date Time Format Qualifier D8 DMG02 - Date Time Period Date of Birth of subscriber (CCYYMMDD format) DMG03 - Gender Code Allowed Values : "M", "F", "U" LOOP Payer name BB NM1 Payer name 1 NM101 - Entity ID Code P NM102 - Entity Type Qualifier 2 NM103 - Name Last or Organization Name For Providers submitting via EMDEON - Allowed Value: Beacon Health trategies, LLC For all other Providers - Allowed Values : Neighborhood Health Plan of MA Health ource/hudson Health Plan Fallon Community Health Plan Neighborhood Health Plan of I Affinity Health Plan, DC Chartered Health Plan Health ight Neighborhood Health Partners Touchstone Health Abri Health Plan BMC HealthNet Plan CalOptima Prestige Health Choice Beacon Health trategies, LLC Page 24 of 31

25 NM108 - ID Code qualifier Anthem cott & White Health Plan eton Health Plan Passport Amida Care Centerlight Well ense Health Plan Alameda Alliance enior Whole Health of MA enior Whole Health of NY Preferred Medical Plan alubris Ultimate Health Plans Humana Care ource of KY Group Insurance Commission Healthsun Health Plan Empire, Inc. of NY Leon Medical Centers Health Plan Trusted Health Plans, Inc. L.A. Care Health Plan Cook Children s Health Plan Parkland Community Health Plan Physicians United Plan Managed Health Net of CA Health Net of CA Freedom Health Optimum Healthcare America s 1 st Choice Health Plan Molina Healthcare of Florida NM109 - ID Code For Provider submitting via EMDEON Allowed Value : For all other Providers - Allowed Values : "001" for Neighborhood Health Plan of MA, "004" for Healthource/Hudson Health Plan, "005" for Fallon Community Health Plan, "006" for Neighborhood Health Plan of I, 009 for Affinity Health Plan, 013 for DC Chartered Health Plan 014 for Health ight 015 for Neighborhood Health Partners 018 for Touchstone Health 019 for Molina Health Plan 020 for BMC HealthNet Plan 021 for CalOptima 022 for Prestige Health Choice 024 for Anthem 026 for cott White Health Plan 027 for eton Health Plan 028 for Passport 029 for Amida Care, 030 for Centerlight 032 for Well ense Health Plan 036 for Alameda Alliance 037 for eniorwholehealthma 039 for eniorwholehealthny 041 for Preferred Medical Plan 042 for alubris 043 for Ultimate Health Plans 045 for HumanaCareourceKY 048 for Group Insurance Commission 049 for Healthsun Health Plan 050 for Empire, Inc. of NY 051 for Leon Medical Centers Health Plan 052 for Trusted Health Plans, Inc. 053 for LA Care Health Plan 060 for Cook Children s Health Plan 061 for Parkland Community Health Plan 064 for Physicians United Plan 069 for Managed Health Net of CA Beacon Health trategies, LLC Page 25 of 31

26 EF Billing Provider econdary Identification >=1 070 for Health Net of CA 071 for Freedom Health 072 for Optimum Health Care 074 for America s 1 st Choice Health Plan 087 for Molina Healthcare of Florida EF01 - eference ID Qualifier G2 Medicaid Number G2 EF02 - eference ID Medicaid Number LOOP 2000C Patient HL > 1 equired when the Patient is different from the subscriber HL Patient HL 1 HL01 - Hierarchical ID Number Assigned by sender HL02 - Hierarchical Parent ID Number Assigned by sender HL03 - Hierarchical Level Code 23 HL04 - Hierarchical Child Code 0 PAT Patient information 1 PAT01 - Individual relationship code LOOP Patient name CA NM1 Patient name NM101 - Entity ID Code QC NM102 - Entity Type Qualifier 1 NM103 - Name Last or Organization Name NM104 - Name First NM105 - Name Middle NM107 - Name uffix NM108 - ID Code qualifier MI NM109 - ID Code Use Member ID from membership card N3 Patient address 1 N301 - Address N302 - Address N4 Patient city/state/zip 1 N401 - City N402 - tate N403 - Zip DMG Patient s demographic info 1 DMG01 - Date Time Format Qualifier D8 DMG02 - Date Time Period Date of Birth of Patient (CCYYMMDD format) DMG03 - Gender Allowed Values : "M", "F", "U" LOOP 2300 Claim information 100 CLM Claim information 1 CLM01 - Claim ubmitters ID Claim Number. Will be sent back in 835 for CLP01 CLM02 - Monetary Amount Total Claim Amount CLM Facility Code Value First two positions of Bill Type CLM Facility Code Qualifier A CLM Claim Frequency Type Code Third position of Bill Type Original = 1, esend = 7, Void = 8 Beacon Health trategies, LLC Page 26 of 31

27 CLM06 - Yes/No Condition or esponse Code CLM07 - Provider Accept Assignment Code CLM08 - Yes/No Condition or esponse Code CLM09 - elease of Information Code CLM10 - Patient ignature ource Code CLM11 CLM11 contains ELATED CAUE INFOMATION and is only required when Accident or Employment elated Causes are indicated. CLM elated Cause Code CLM elated Cause Code CLM elated Cause Code CLM tate CLM Country CLM12 - pecial Program Code CLM16 - Provider Agreement Code CLM20 - Delay eason Code DTP Discharge Hour 1 Inpatient Claims Only DTP01 - Date/Time qualifier 096 DTP02 - Date/Time Period Format Qualifier TM DTP03 - Date Time Period In the format HHMM DTP tatement Dates 1 Inpatient Claims Only DTP01 - Date/Time qualifier 434 DTP02 - Date/Time Period Format Qualifier Allowed Values : "D8" for Date, "8" for Date ange DTP03 - Date Time Period Format "CCYYMMDD" for D8, "CCYYMMDD - CCYYMMDD" for 8 DTP Admission Date/ Hour 1 DTP01 - Date/Time qualifier 435 DTP02 - Date/Time Period Format Qualifier TM DTP03 - Date Time Period In the format CCYYMMDDHHMM CL1 Institutional Claim Code 1 CL101 - Admission Type Code From Code ource 231 CL102 - Admission ource Code From Code ource 230 CL103 - Patient tatus Code From Code ource 239 EF Original eference Number 1 Must send if CLM05-3 = 7 or 8 EF01 - eference ID Qualifier F8 EF02 - eference ID Use 8 digit Beacon ClaimID ( provided by Beacon on EOB eport) HI Principal Diagnosis Information 1 HI01 - Healthcare Code Information Principal Diagnosis HI Code List qualifier code BK HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI Admitting Diagnosis Information 1 HI01 - Healthcare Code Information Admitting Diagnosis HI Code List qualifier code BJ HI Industry Code ICD-9 Code Beacon Health trategies, LLC Page 27 of 31

28 HI Diagnosis elated Group (DG) Info 1 HI Code List qualifier code D HI Industry Code Diagnosis elated Group HI Other Diagnosis Information 1 Diagnosis Codes HI01 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI02 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI03 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI04 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI05 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI06 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI07 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI08 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI09 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI10 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI11 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI12 - Healthcare Code Information Other Diagnosis HI Code List qualifier code BF Beacon Health trategies, LLC Page 28 of 31

29 HI Industry Code ICD-9 Code HI Yes/No Condition or esp. Code Present On Admission Indicator Y or N or U HI Value Information 1 HI01 - Healthcare Code Information HI Code List qualifier code BE HI01-2 Industry Code Value Code HI01-5 Monetary Amount Value Code Amount HI02 - Healthcare Code Information HI Code List qualifier code BE HI01-2 Industry Code Value Code HI02-5 Monetary Amount Value Code Amount HI03 - Healthcare Code Information HI Code List qualifier code BE HI03-2 Industry Code Value Code HI03-5 Monetary Amount Value Code Amount HI04 - Healthcare Code Information HI Code List qualifier code BE HI04-2 Industry Code Value Code HI04-5 Monetary Amount Value Code Amount HI05 - Healthcare Code Information HI Code List qualifier code BE HI05-2 Industry Code Value Code HI05-5 Monetary Amount Value Code Amount HI06 - Healthcare Code Information HI Code List qualifier code BE HI06-2 Industry Code Value Code HI06-5 Monetary Amount Value Code Amount HI07 - Healthcare Code Information HI Code List qualifier code BE HI07-2 Industry Code Value Code HI07-5 Monetary Amount Value Code Amount HI08 - Healthcare Code Information HI Code List qualifier code BE HI08-2 Industry Code Value Code HI08-5 Monetary Amount Value Code Amount HI09 - Healthcare Code Information HI Code List qualifier code BE HI09-2 Industry Code Value Code HI09-5 Monetary Amount Value Code Amount HI10 - Healthcare Code Information HI Code List qualifier code BE HI10-2 Industry Code Value Code HI10-5 Monetary Amount Value Code Amount HI11 - Healthcare Code Information HI Code List qualifier code BE HI11-2 Industry Code Value Code HI11-5 Monetary Amount Value Code Amount HI12 - Healthcare Code Information HI Code List qualifier code BE Beacon Health trategies, LLC Page 29 of 31

30 HI12-2 Industry Code Value Code HI12-5 Monetary Amount Value Code Amount LOOP 2310A Attending Physician NM1 Attending Physician Name 1 EF NM101 - Entity ID Code 71 NM102 - Entity Type Qualifier NM103 - Name Last or Organization Name Attending Physician Last Name NM104 - Name First Attending Physician First Name NM105 - Name Middle NM108 - ID Code qualifier XX - Health Care Financing Administration National Provider Identifier NM109 - ID Code National Provider ID / NPI Attending Physician econdary Identification 1 EF01 - eference ID Qualifier G2 Medicaid Number 1G Medicaid Number (eton Only) EF02 - eference ID LOOP 2310E ervice Facility Location NM1 ervice Facility Location 1 EF NM101 - Entity ID Code 77 NM102 - Entity Type Qualifier NM103 - Name Last or Organization Name Provider ite Name. NM104 - Name First NM105 - Name Middle NM108 - ID Code qualifier XX - Health Care Financing Administration National Provider Identifier NM109 - ID Code National Provider ID / NPI ervice Facility Location econdary Identification 1 EF01 - eference ID Qualifier LU EF02 - eference ID Provider ite ID Number provided by Beacon LOOP 2400 ervice Line (efer Notes Below) 50 LX ervice line 1 LX01 - Assigned Number Counter. Assigned by sender V2 Institutional service 1 V201 - Product/ervice ID UB92 ev Code V202 -Composite Medical Procedure ID V Product/ervice ID Qualifier HC V Product/ ervice ID Procedure Code V Procedure Modifier Modifier 1 V Procedure Modifier Modifier 2 V Procedure Modifier Modifier 3 V Procedure Modifier Modifier 4 V203 - Monetary Amount ervice line charge V204 - Units or basis of measurement code V205 Quantity ervice Units V206 - Unit ate For Inpatient Claim, ervice Line Accommodation rate amount XX G2,1G XX DA / UN Beacon Health trategies, LLC Page 30 of 31

31 V207 - Monetary Amount Non covered charge amount DTP ervice date 1 ervice line tart/end DTP01 - Date/Time qualifier 472 DTP02 - Date/Time Period Format Qualifier Allowed Values : "D8" for Date, "8" for Date ange DTP03 - Date Time Period Format "CCYYMMDD" for D8, "CCYYMMDD - CCYYMMDD" for 8 E Transaction et Trailer 1 E01 Number of included segments E02 Transaction et Control Number Assigned by ender. Must equal E02 Notes: For Institutional claims the first claim line is treated as the primary claim line and the rest are treated as ancillary claim lines. The claim is paid based on the units and revenue/procedure code of the primary claim line. Beacon Health trategies, LLC Page 31 of 31