ASC X12N EDI Transactions Companion Guide

Transcription

1 Workers Compensation Services Electronic Billing ASC X12N EDI Transactions Companion Guide 837 Health Care Claim Professional X222A1 837 Health Care Claim Institutional X223A2 835 Health Care Claim Payment/Advice X221A1 Acknowledgments and Notifications Effective October 2011 Electronic Version F [ ] On the web: 1

2 Table of Contents About Labor and Industries... 4 Introduction... 5 Preface Workers Compensation Exemption How to Use This Document Web Site References National HIPAA and NPI Resources Getting Started... 7 Provider Requirements Clearinghouse Requirements Reporting Requirements Testing Overview with LNI... 9 Contact LNI Electronic Billing Test EDI Transactions Testing and file Submission/Retrieval Connectivity with LNI Provider Express Billing (PEB) PEB File Naming Conventions Transmission Minimum System Registration/Enrollment/Activation or Authorization Secure Access Washington (SAW) Provider Express Billing (PEB) Administrative Procedures Contact Information Technical Support Electronic Billing Clearinghouse/Software Vendor Provider Express Billing (PEB) Support Billing Customer Service Provider Hotline IVR (Interactive Voice Response) QUALIS Health Utilization Review and Authorization Crime Victims Claims Self-Insured Claims Federal Claims General Provider Information web sites Washington State Labor and Industries Health Services Analysis/Provider Information 2

3 LNI Specific Business Rules and Limitations EDI Transaction Submissions and Acknowledgments Provider Identification National Provider Identifier (NPI) Provider Account Number Taxonomy Codes Subscriber Identification Subscriber Secondary Identification LNI Claim Number Service Facility Location Loop Service Line Limits Units of Service Limits Date of Service Local Codes Revenue Codes DME Codes Explanation of Benefits LNI EOB s and HIPAA Adjustment Reason codes Remarks Clearinghouse Network Trace Number Medical Record Number Internal Control Number (ICN) Electronic Adjustments Warrants and Payment cycle cutoff schedule LNI Mapping to Transactions Professional Institutional Acknowledgements and Remittance Advice TA1 Interchange Acknowledgement Implementation Acknowledgement Application Advice Notification Payment Advice Appendix EDI Formatting Errors Place of Service Codes 5010 Change Summary Version Chart 3

4 About Labor and Industries (LNI) LNI is a diverse state agency dedicated to the safety, health and security of Washington's 3.2 million workers. We help employers meet safety and health standards and we inspect workplaces when alerted to hazards. As administrators of the state's workers' compensation system, we are similar to a large insurance company, providing medical and limited wage-replacement coverage to workers who suffer job-related injuries and illness. Our rules and enforcement programs also help ensure workers are paid what they are owed, that children's and teens' work hours are limited, and that consumers are protected from unsound building practices. Washington's workers' compensation system is funded by premiums from employers and workers and income from investments. In addition, we regulate about 400 large, self-insured employers who have qualified to provide their own workers' compensation insurance. In addition to the state s worker compensation system, Labor and Industries also provides help for Crime Victims. The Crime Victims Compensation Program is a separate program from the Workers Compensation State Fund program. Both the state fund workers compensation program and the crime victims compensation program allow providers to bill electronically for services provided to injured workers through Provider Express Billing (PEB). The information contained in this companion guide is exclusive to billing for the state fund workers compensation program. 4

5 Introduction Preface The Health Insurance Portability and Accountability Act (HIPAA) requires all health insurance payers in the United States to comply with the electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services (HHS). The ANSI X12N Standards for Data Interchange Technical Reports Type 3 (implementation guides) has been established as the standards of compliance for health care claims transactions. The implementation guides for these transactions are available electronically at This Companion Guide is to be used as a supplement to the ANSI Implementation Guides and is intended to provide information for conducting e-commerce with the Washington State Department of Labor and Industries (LNI) via the secure Provider Express Billing web site (PEB). Additional information for PEB is available at This companion guide contains data clarifications derived from specific business rules that apply exclusively to Washington State workers compensation bill processing with LNI and the department s Medical Information Payment System (MIPS). Using this companion guide does not mean that a bill will be paid or a transaction will be successfully processed, and does not imply payment policies of the payer or the benefits of the subscriber. Workers Compensation Exemption Workers Compensation programs are legally exempt from HIPAA requirements. Regardless of this exemption, LNI has adopted the HIPAA transaction and security standards in order to be as consistent as possible with other payers and the provider community. In order to accommodate our varied provider community, LNI currently accepts the following methods for submitting workers compensation billing: HIPAA 837 Institutional transaction in 5010 and 4010 format. HIPAA 837 Professional transaction in 5010 and 4010 format. HCFA Proprietary format. Direct Entry Online billing. Paper bills. How to Use This Document This version of the Companion Guide addresses changes to the EDI transaction standards to ASC X12N format from ASC X12N format. Refer to the Appendix - Version Chart and Appendix - Change Summary to review the changes to the specific format as they apply to Labor and Industries usage. After selecting the version you intend to use, review the LNI Mapping to Transactions section. This provides detailed requirements as they pertain to Labor and Industries. Also refer to the Getting Started section for the steps to establish an account with Labor and Industries, begin EDI testing, and transmitting live data through Provider Express Billing. The Implementation Checklist in the appendix will assist you with this step-by-step process. You may find the following reference links to other HIPAA resources helpful. This list is not all-inclusive, but is intended to provide more extensive information regarding HIPAA transactions and requirements. Please note the section for LNI Specific Business Rules and Limitations. This section outlines Labor and Industries restrictions and parameters when using the EDI ASC X12 transactions. LNI s Electronic Billing Unit, your clearinghouse, and/or software vendor can provide assistance with your electronic billing requirements. 5

6 References CMS - Centers for Medicare & Medicaid Services HIPAA Administrative Simplification - National Provider Identifier Standards (NPI) Transaction & code Sets Standard Versions 5010 and D.0 NPPES - National Plan & Provider Enumeration System The national enumerator contracted by CMS to assign National Provider Identifiers. This site provides access to the NPI application process. Department of Health and Human Services (HHS) - This website for HIPAA s administrative simplification provisions; contains electronic versions of the Transaction, Privacy, and Security rules as well as updates from HHS. ASC X12 The Accredited Standards Committee This organization is chartered by the American National Standards Institute (ANSI) and develops, maintains, interprets, publishes, and promotes the ANSI and UN/EDIFACT international standards for electronic data interchange (EDI) to national and global markets. ANSI American National Standards Institute This organization oversees the creation, promotion, and use of thousands of norms and guidelines that directly impact businesses in nearly every sector including healthcare. DISA Data Interchange Standards Association This organization advances the foundation of electronic business interchange standards and supports the ASC X12 and their X12 EDI and XML standards development process. DISA also publishes and provides the 5010 Technical Reports (TR3 s) and 4010 Implementation Guides for purchase. WEDI - Workgroup for Electronic Data Interchange - The website for the Workgroup for Electronic Data Interchange (WEDI), which is an advisory group dealing with electronic commerce in the health care industry. WEDI served as an advisory group for HHS as they developed the HIPAA regulations. This website deals primarily with transactions. WPC - Washington Publishing Company - The WPC is an active member of ASC X12 and publishes the X12 s 5010 Technical Reports (TR3 s), 4010 Implementation Guides, Addenda, and the HIPAA EOB and Taxonomy Code lists. DSHS Washington State Department of Social and Health Services - The Department of Social and Health Services (DSHS) website regarding HIPAA compliance. OHP - ONEHEALTHPORT This website provides information for business and clinical solutions to local healthcare sites and administrative simplification tools including Best Practice Recommendations (BPRs) adopted by Washington State Department of Labor and Industries. 6

7 Getting Started Provider Requirements Providers intending to submit and/or receive directly with LNI through Provider Express billing (PEB), must meet the following requirements: LNI Provider Account Number Completed Electronic Billing Authorization form (F ) for bill submissions Request setup for 835 and/or Proprietary electronic remittance advice if desired Provider account authorized EDI submission and/or remittance advice retrieval Registration with SecureAccess Washington (SAW) Established Provider Express Billing service for access to PEB application Successfully Test submissions until approved for production Clearinghouse Requirements Providers may authorize a clearinghouse to submit their billing and/or receive electronic remittance advice. Provider requirements are: Completed Electronic Billing Authorization form (F ) and identify the clearinghouse submitter Completed Power of Attorney for Electronic Remittance Advice form (F ) and identify the clearinghouse authorized to receive an electronic 835 and/or Proprietary remittance advice. Provider account updated with the clearinghouse authorized for electronic submission and/or remittance advice Clearinghouses are required to meet the following for submitting and receiving with LNI through PEB: LNI Provider Account Number (Submitter ID) Completed Electronic Billing Authorization form (F ) for bill submissions Request setup for 835 and/or Proprietary electronic remittance advice Submitter ID authorized for EDI submissions and/or remittance advice Registration with SecureAccess Washington (SAW) Established Provider Express Billing service for access to PEB application Successfully Test submissions until approved for production Provider s account updated authorizing your clearinghouse for submissions and remittance advice Note: LNI does not accept electronic submissions from the Office Ally clearinghouse. Assistance with electronic requirements, provider setup, testing, and questions: Website: Electronic Billing Unit Phone: [email protected] 7

8 Reporting Requirements Washington State law requires providers to submit health information to the department or self-insurer when it is required or requested. HIPAA does not overrule any state law that requires the disclosure of health information (45 CFR (a)). Washington State has specific laws that require medical providers to disclose health information to the department or self-insured employer for workers compensation. Billing electronically does not alter the existing reporting requirements for Labor and Industries. The department may deny or reduce payment if required documentation is not provided to support billing. Faxing is the recommended method for submitting documentation as these go directly to the patient s claim file. Remember to place the worker s LNI claim number in the upper right-hand corner of all documentation. Fax to: Or mail documentation to: Claims Administration Department of Labor and Industries PO Box Olympia WA

9 Testing Overview Contact the Electronic Billing Unit Prior to submitting Test transactions and during testing, contact the EBU to: Verify your provider account number is updated for testing EDI submissions Answer any questions regarding testing and acceptance Provide assistance with acknowledgments and notifications Provide Test submission results including notification of submission errors and EDI formatting issues Test EDI Transactions Refer to the LNI Mapping to Transactions section to verify your transactions include all the required data elements and data. In addition, you will need to refer to the specific 837 Implementation Guide for complete requirements in developing these transactions. The department does not provide test data for testing. Test Transaction considerations: A minimum number of bills to meet the submitter s typical submission needs All required loops, segments and data elements included in test data EDI test scripts should be representative of your live business scenarios Both inbound and outbound transactions tested and verified by trading partners 837 Professional/Institutional as applicable TA1 Interchange Acknowledgment (if requested) 999/997 Implementation/Functional Acknowledgments based on inbound submission format 277 Notification/ Unsolicited Acknowledgement 835 Payment/Remittance Advice 277 Pended Notification Do not use any type of file compression on your test or production files Clearinghouse trading partners: Should include multiple billing Payee providers in test transactions to ensure testing of multiple functional groups within the 837 Transaction 9

10 Testing and File Submission/Retrieval Secure Access Washington (SAW) Provider Express Billing (PEB) Submit Bills Retrieve Acknowledgments Retrieve Remittances 837 Professional 5010/ Institutional 5010/4010 EDI Syntax validation TA1/999/997 Acknowledgment 5010/4010 MIPS Bill formatting MIPS Adjudication 277 Notification /Unsolicited 5010/3070 MIPS Payment Cycle Remittance Advice 277 Pended Notification Payment Advice 5010/

11 Connectivity with PEB Provider Express Billing (PEB) PEB is an Internet-based system that allows providers and clearinghouses to securely send electronic billing files and retrieve acknowledgments and/or remittance advices. PEB supports the following transactions: HIPAA 5010/4010 formats Health Care Claim Submissions 837 Professional X222A1, X098A1 837 Institutional X223A2, X096A1 Direct Entry Online Billing Responses TA1 Interchange Acknowledgment 999 Implementation Acknowledgement X231A1 997 Functional Acknowledgment Application Reporting X161 Notices 835 Payment/Advice X221A1, X091A1 277 Health Care Claim Acknowledgment X Acknowledgment - Unsolicited Notification X Acknowledgment - Pended Notification X070 Non-HIPAA format Proprietary HCFA format to be discontinued/not supported by 10/1/2013 Proprietary Remittance Advice format to be discontinued/not supported by 10/1/2013 PDF Remittance Advice format As the department transitions to the HIPAA 5010 EDI format, we will continue to support EDI submissions and responses in the 4010 format. Responses and acknowledgments will be returned based on the EDI format received Professional & Institutional billing submitted in 5010 format will return a TA1/999/824 response based on EDI validation of the submission. LNI will return a 277 Claim Acknowledgement as a secondary acknowledgement to the original submission(s) after the nightly adjudication cycle Professional & Institutional billing submitted in the 4010 format will return a TA1/997/824 response based on EDI validation of the submission. The department will return a 277 Unsolicited Claim Acknowledgement (3070) as a secondary acknowledgement to the original submission(s) after the nightly adjudication cycle. 11

12 PEB File Naming Conventions LNI has no standard file naming convention it expects submitters to follow when naming their files for submission to PEB. Common file naming standards are recommended. File names may not contain spaces. PEB function Submit Bills Submitted File names must not include spaces. If the submitted file name contains spaces, PEB issues error message: The Filename cannot contain spaces The file naming conventions used for outbound files posted to PEB and available for download are as follows: PEB function Retrieve Acknowledgements Document Version PEB file name Frequency TA1 EDI TA1 Acknowledgement txt If requested ISA14 Immediately after submission EDI 999 Acknowledgement txt After acceptance of ISA - Immediately after 837 submission EDI 997 Acknowledgement txt After acceptance of ISA - Immediately after 837 submission EDI 824 Application Advice txt As applicable following rejection of Transaction Set(s) 277 TH 5010 Next day following EDI 277 Claim Acknowledgment adjudication cycle for ccyymmdd.txt business day submissions 277 TH NO 3070 PEB function Retrieve Remittances EDI 277 Unsolicited Acknowledgement ccyymmdd.txt EDI 277 UNSOLICITED PENDED CLAIMS ccyymmdd.TXT Next day following adjudication cycle for business day submissions 2 week payment cycle Document Version PEB file name Frequency EDI 835 Remittance Advice ccyymmdd.txt 2 week payment cycle EDI 835 Remittance Advice ccyymmdd.txt 2 week payment cycle Proprietary Proprietary RA ccyymmdd.TXT RA 2 week payment cycle Remittance Advice RemittanceAdvice_ _mmddyy.pdf PDF 2 week payment cycle PEB function View Transmission Activity Document Version PEB file name Frequency Direct DirectEntry_837P_lastname_claimid_mmddccyy_ After submission of Direct Entry hhmm Entry bill Where = Submitter Id and 0999 = 837/GS06 Control number. 12

13 Transmission PEB is available 24 hours a day, 7 days a week, except for scheduled maintenance and temporary outages. Notifications of scheduled outages and informational messages will be posted to the PEB Menu. Files submitted and accepted prior to 6:00 PM PST will typically be included in that business day s adjudication cycle. Files received and accepted after 6:00 PM PST will typically be included in the following day s adjudication cycle. Files received after 6:00 PM PST Friday to Monday 6:00 PM PST, will be included in Monday s adjudication cycle. Files submitted on Washington State observed holidays will be included in the next business day adjudication cycle. LNI cannot delete any file submissions received through PEB. 13

14 Registration / Enrollment / Activation or Authorization SecureAccess Washington (SAW) Access to Provider Express Billing (PEB) is provided though SecureAccess Washington (SAW) that allows access to multiple online government services with the use of a single user Id and password. Printable instructions for creating a SAW account and requesting access to Provider Express Billing service available at: Register with SAW and create a username and password at After SAW registration and account activation, follow these steps for access to Provider Express Billing (PEB). Login to your SAW account ADD Services Select Add a New Service tab (default if you have no services) o Select agency - Department of Labor and Industries o Select service Provider Express Billing o Select I am a first time visitor for the selected application and Continue o Enter your contact information telephone number and Continue o Access Agreement Read, acknowledge and initial using the initials of your registered name with SAW and Continue o Select Relationship PEB Provider o Enter the LNI provider account number or NPI your are requesting access to, and select Request Access by Provider Id o o If you are the first person to request access (Primary Request): You are the first person to register for this organization Read and accept the role of Access Manager for the organization Enter an organization name An Activation Code will be generated If an Access Manager already exists for the organization (Secondary Request): The organization you requested access to is already registered for LNI Secure Access The request for access will be ed to the organization s Access Manager(s) Select View list of your organization s access managers to view contact information for checking the status of your request. The organization s Access Manager will approve or deny the request and determine the level of your access (Access Manager and/or PEB Billing Agent). 14

15 Activation Code o An Activation Code is generated to the first individual who accepts the role of the Access Manager for their organization. o The Activation Code may be obtained by contacting the Electronic Billing Unit: Phone: [email protected] Or, an Activation Code letter will be printed and mailed to the location s physical address on file with the department and should arrive at the location within 5 to 7 business days. o Activation From the LNI Secure Access/My LNI Secure Access Profile screen: Select the Activate button for the Provider Id listed under My business relationships with LNI (PEB Provider) Enter the Activation Code and click the Activate button Congratulations! Provider Id. was successfully activated Select Return to My LNI Secure Access Profile Select Return to Application Provider Express Billing Menu Direct Entry Adjust Direct Entry Bills Submit Bills Retrieve Remittances Retrieve Acknowledgements View Transmission Activity Manage User Profile Logout 15

16 Administrative Procedures Access Manager Access Managers are responsible for the management and removal of user access within their organization. In addition to being able to update/view their own user information, Access Managers have additional functions available under Manage User Information. Each organization must have at least one Access Manager to manage user access The first user, who enrolls a provider or clearinghouse number for PEB, automatically becomes the Access Manager for that provider/clearinghouse number Additional Access Managers may be approved by the organization s Access Manager Secondary Access Each organization may allow multiple user access to their organization s access to PEB. Secondary access requests are ed to the organization s Access Manager(s) An Access manager must review and approve or deny the request for access Requesting Access to Multiple Providers A user may request access to multiple provider accounts. To request access: From the PEB Menu, Select Manage User Profile Select Request Access Read and acknowledge Access Agreement and Continue Select Relationship PEB Provider Enter the provider account number or NPI and select Request Access by Provider ID Managing User Access From the PEB Menu, Select Manage User Profile Under Manage user access for my business organizations o Select the Manage options drop-down list box o Select Users to review a list of all users with access to your organization o Select Pending Requests to review access requests pending action 16

17 Contact Information Technical Support Electronic Billing Unit (EBU) Monday through Friday, 8:00 AM to 4:30 PM PST Phone: Assist with troubleshooting electronic transaction errors causing rejected file submissions Assist with identifying EDI formatting errors resulting in bill denials Assist with verification of file submissions and/or missing acknowledgements Assist with electronic remittance advices Assist with establishing a new account or updating an account for electronic transactions Arrange testing for new providers and submitters Assist with SAW registration, and PEB enrollment and activation Assist with SAW user-id and passwords Assist with navigation and processes throughout PEB Your Clearinghouse and/or Software Vendor Provide assistance with your specific practice management billing software Provide clearinghouse requirements for submitting provider s bill data forwarded to LNI as EDI transactions Provide bill submission acceptance and error reporting Billing Customer Service Provider Hot Line (PHL) Monday through Friday, 8:00 AM to 5:00 PM PST Phone: or Answer questions on bill payment or denial, and pending bills Explain Explanation of Benefits (EOB) codes appearing on remittances Provide information on Provider Bulletins and updates Provide information on Medical Aid Rules and Fee Schedules Provide information on applicable Washington Administration Codes (WAC) or Revised Code of Washington (RCWs) Authorize routine services for a claim and verify whether specific services or procedures have been authorized Answer general questions about billing procedures and claim status Verify number of bills in process Verify warrant amounts Verify an inpatient or outpatient authorization number Send a priority message to claims staff or bill payment staff, where additional research or authorization needed Helpful references when contacting the EBU or PHL regarding a specific bill: 17-digit Internal Control Number (ICN) from remittance advice LNI claim number (Claim ID), Date of Service, and Total Charge submitted 17

18 Interactive Voice Response System (IVR) Monday through Friday, 6:00 AM to 7:00 PM PST Phone: (Claim related detail) Information available: Claim Numbers Diagnoses Procedures Drug Restrictions Basic status information What you need: Touch-tone telephone Your LNI Provider Number or National Provider Identifier (NPI) Claim number or patient s Social Security Number Date of Injury Additional information is available regarding this automated service by calling the Provider Hot Line at Qualis Health Washington State Department of Labor & Industries (Department) has contracted with Qualis Health to provide Utilization Review (UR) services for its Workers Compensation Program. Qualis Health reviews inpatient admissions, a select list of outpatient procedures and physical medicine services, which include physical therapy, occupational therapy and work conditioning. These are conducted on a prospective, concurrent and/or retrospective basis utilizing the Department s Medical Treatment Guidelines, if applicable; otherwise, Qualis Health will apply InterQual criteria. UR services are quality-focused and centered on achieving positive outcomes for workers in support of the Department's mission: to ensure that the medical care received by occupationally injured and ill workers is of the highest quality so that such care meets national and community standards for safety and efficacy. The success of the program depends on a collaborative partnership between providers, the Department and Qualis Health. This web site was designed to provide providers with educational tools to assist in the UR process. Requests for review of inpatient procedures and targeted outpatient procedures are outlined in LNI s Utilization Review web page at or by contacting Qualis Health at (800)

19 Crime Victims Claims The Crime Victims Compensation Program is a separate program from the Workers Compensation State Fund program and can be electronically submitted through Provider Express Billing (PEB). Crime Victims electronic billing requirements are defined within the Crime Victims electronic billing companion guide at: Crime Victims claims have a claim number/claim ID that begins with a V followed by six digits, or VA, VB, VC, VH, VJ or VK followed by five digits State Fund and Crime Victims claims MUST NOT be submitted within the same PEB file submission. Crime Victims claims submitted within a State Fund submission will be denied and vice-a-versa. Questions about billing crime victims electronically should be directed to the Crime Victims Program [email protected] General information concerning help for crime victims can be found at: Self-insured Claims Self-insured claims have a claim number/claim ID that begins with an S, T or W followed by six digits, or double alpha letters (example SA) followed by five digits. Questions about self-insurance claims should be directed to the employer, the employer s service representative or LNI s Self-insurance section at Federal Claims Federal claims begin with a claim number/claim ID of A13 or A14. Questions about federal claims should be directed to the U.S. Department of Labor at or General Provider Information Washington State Dept. of Labor and Industries web site: Health Services Analysis web site: Access to provider information i.e., Provider Bulletins and Updates, Medical Aid Rules and Fee Schedules, Warrant Schedule, etc. 19

20 LNI Specific Business Rules and Limitations to EDI ASC X12N/ Transactions EDI Transaction Submissions and Acknowledgments SUBMISSIONS Professional X222A1 837 Institutional X223A Professional X098A1 837 Institutional X096A1 ACKNOWLEDGMENTS 5010 TA1 Interchange Acknowledgement 999 Implementation Acknowledgement X231A1 277 Acknowledgement X Payment/Advice X221A TA1 Interchange Acknowledgement 997 Functional Acknowledgement Acknowledgement - Unsolicited Notification X Payment/Advice X091A1 824 Application Reporting Insurance X161 Other 277 Acknowledgement - Pended Notification X070 LNI generates a 277 Pended Notification although not required or supported by HIPAA. This response allows the department to continue communicating on bills that are in process in MIPS at the time of the payment cycle to the provider community. TA1 acknowledgement reports the acceptance/rejection of the Interchange (ISA). 999/997 acknowledgement reports the syntax acceptance/rejection of the Functional Groups (ST/SE). 824 application advice reports error identification information to a rejected submission when applicable. 277 Claim Receipt acknowledgement reports on all bills received from the submitter that are Accepted/Rejected into/from MIPS adjudication for that business day. o Accepted means the submitted bill(s) formatted into MIPS for processing without any EDI formatting errors and are accepted into adjudication processing. o Rejected means the submitted bill(s) formatted into MIPS for processing but contained EDI formatting errors causing auto-denial of the bill(s) and are rejected from adjudication processing. 277 Pended Notification reports on all bills that are in process at the time of the MIPS payment cycle. 835 Payment/Advice reports all bills finalized (Paid/Denied) from the MIPS payment cycle. 20

21 Provider Identification All providers treating workers and billing the department for services must have an LNI provider account number. Provider account number is 7-digits and contains one or more leading zeros. Leading zeros can be included but are not required within the billing detail loops of the EDI transaction. Provider identification for billing may be provided using the provider s NPI as the primary identifier when the provider has been NPI enumerated. Provider identification for billing may be provided using the provider s LNI provider account number as the primary identifier when the provider is atypical and is not NPI enumerated. Provider identification for billing may be provided as a Secondary ID using the provider s LNI provider account number. When submitted as a secondary identifier in addition to the NPI primary identifier, the Secondary ID will be used for bill processing. National Provider Identifier (NPI) The department will accept and process the provider s 10-digit National Provider Identifier (NPI) as the primary identifier in all instances to meet the business and processing needs of the provider, i.e. transaction submitter ID (ISA and GS) as well as bill detail loops (Billing, Rendering, Referring, Service Facility, etc.). Subpart NPI If your organization utilizes subpart National Provider Identifiers there will be less need to include taxonomy codes in your transactions. Refer to the federal CMS web site for detailed information concerning National Provider Identifiers. MIPS processing of the NPI when submitted as Primary Identifier Submitted NPI must be on file and cross-referenced to one or more provider account numbers o If not on file or not cross-referenced to a provider account number Then bill formats with EDI formatting error H22/H23 See EDI Formatting Errors page AA Billing Provider 2310B Rendering Provider NM108=XX NM109=10-digit NPI NPI Submission No Secondary Provider ID reference REF G2/X5 submitted in Billing/Rendering Provider loops. If Submitted NPI is cross-referenced to a single provider account number, the cross-referenced provider account number is used for bill processing. If Submitted NPI is cross-referenced to multiple provider account numbers, the following criteria is used to match the NPI to a provider account number for bill processing: Seq X-Ref Match on Loop Segment/element 1 Tax ID (EIN/SSN) 2010AA 2310B REF EI/SY REF02 If no match on TID the bill is denied with EOB P74. If multiple matches, match goes to Zip Code. 2 Zip Code 201AA N4 N403 If multiple matches, match goes to Taxonomy. 3 Taxonomy 2000A PRV*BI*PXC (5010) Taxonomy used if submitted and if Taxonomy PRV*BI*ZZ (4010) exists on NPI Master Record 2310B PRV*PE*PXC (5010 Taxonomy used if submitted and if Taxonomy PRV*PE*ZZ (4010) exists on NPI Master Record If a provider account number cannot be assigned to the bill, the bill is suspended for review requiring manual adjudication. This may result in delayed processing of the bill to pay or deny status. 21

22 Provider account number The department will accept and process the provider s department assigned LNI provider account number as the primary identifier for entities with no NPI and/or as a Secondary Provider Identifier for entities with an NPI, in the EDI transaction to meet the business and processing needs of the provider, i.e. transaction submitter ID (ISA and GS) as well as bill detail loops (Billing/Payer Name, Rendering, Referring, Service Facility, etc.). MIPS processing of the LNI provider account number submitted as Primary Identifier 2010AA Billing Provider and 2310B Rendering Provider loops o 5010 NM1 NM108/NM109 is not required/ not sent 2010BB/2310B REF*G2 segment required If no REF*G2 or REF02 is not a valid provider account number Bill formats and is auto denied with EDI formatting error EOB H02/H03 (Billing Provider) H11/H12 (Rendering) See EDI Formatting Errors page o 4010 NM1 NM108/NM109 is required EI/SY EIN/SSN 2010AA/2310B REF*X5segment required If no REF*X5 or REF02 is not a valid provider account number Bill is auto denied with EDI formatting error EOB H02/H03 (Billing Provider), H11/H12 (Rendering) See EDI Formatting Errors page MIPS processing of the LNI provider account number submitted as Secondary Identifier When submitted, the secondary provider identification reference is used as the primary provider identifier and in place of any NPI information submitted within that specific Loop/Segment of the EDI transaction. The Secondary Provider ID Reference is submitted in the situational REF segment and when present in the transaction, is validated. Missing and/or invalid REF01/REF02 information will result in EDI format error and auto-denial. Secondary Provider Identification reference Version Loop/Segment REF01 REF02 EDI Format EOB 2010BB Payer Name 7 digit LNI provider account number H02/H B Rendering Provider G2 Leading zeros not required. H11/H AA Billing Provider 2010AB Pay-To Provider 2310B Rendering Provider X5 7 digit LNI provider account number. Leading zeros not required. H02/H03 H01/H10 H11/H12 Notes: The above references are applicable to and ordered in 5010/4010 version formats. Bills submitted with EDI formatting errors are identified in the 277 Notification STC segment. 2200D STC-STC12 of the 277 is used to report the EOB text associated to the EDI formatting error. For additional information on EDI Formatting Errors see page of this guide. 22

23 Taxonomy Codes The national 10-digit provider type and specialty codes will be accepted in all PRV segments. LNI does not require use of taxonomy codes, however, it may assist in appropriate crossreferencing when the NPI is submitted as the primary provider identifier and the NPI is cross-referenced to multiple LNI provider accounts. Refer to the transaction specifications for segment and data element details. Loop/Segment Version PRV01 PRV02 PRV A Billing Provider HL BI PXC 10-digit provider taxonomy code 2310B Rendering Provider PE 2000A Billing Provider HL 2310B Rendering Provider BI PE ZZ 10-digit provider taxonomy code Subscriber Identification For Washington workers compensation billing, the Subscriber is the patient (worker) and identified by their assigned LNI Claim Number/Claim ID. Subscriber Secondary Identification The department does not require the workers Social Security Number (SSN) for bill processing. When available to the provider, the SSN may be included in the transaction using the Subscriber Secondary Identification REF segment. Patient Secondary Identification Loop/Segment Element Value 2010BA Subscriber REF SY Subscriber Social Security Number LNI Claim Number For identification of the patient and proper bill processing, LNI requires the worker s assigned claim number. Claim numbers are: 7 characters in length Begin with 1 or 2 alpha-characters followed by 5 or 6 numeric Derived from the Report of Accident (ROA). This LNI form is completed by the health care provider and/or the injured worker when filing a Workers compensation claim for work related injuries or illness. Patient Identification Loop/Segment Element Value 2000B HL SBR01 P Payer Responsibility Sequence Primary SBR02 18 Patient Relationship to Insured Self SBR03 LNI Claim ID Insured Group or Policy Number SBR09 WC Claim Filing Indicator Workers Compensation Health Claim 2010BA Subscriber REF Property and Casualty Claim Number NM108 MI Qualifier: Member ID Number NM109 LNI Claim ID Subscriber Primary Identifier REF*Y4 LNI Claim ID Note: LNI processing does not expect to receive this segment but if received, REF02 must contain the LNI Claim ID. Information received in this segment will override claim ID information received in 2000B/2010BA. 2010BA NM109 is the primary identifier of the Subscriber and overrides the value communicated in 2000B/SBR03 if present. 23

24 Service Facility Location Loop This loop is included to offer additional support in identifying the location of services for a provider who perform services in multiple locations and has a single NPI. Providing this information along with applicable taxonomy code may assist in appropriate cross-referencing to LNI provider account numbers cross-referenced to the provider s NPI. Service Line Limitations LNI s maximum Service Lines allowed for MIPS processing is as follows: Format Version Element Maximum Service Lines Professional / LX 50 Institutional / LX 99 Exceeding 50 lines of service on a bill submitted in the 837 Professional results in: Rejection of the Transaction Set within the Interchange 997 Acknowledgement: AK304 = 4 (Loop Occurs Over Maximum Times) AK5 = R (Rejected) Exceeding 99 lines of service on a bill submitted in the 837 Institutional format results in: Bill is formatted into MIPS and denied with EDI formatting error EOB H09 H09 LINE ITEM MAXIMUM EXCEEDED (SEE EDI COMPANION GUIDE). Units of Service Limitations LNI s maximum Units of Service allowed for MIPS processing is as follows: Format Version Element Maximum Units Professional /4010 SV Institutional /4010 SV All Units of Service submitted beyond these maximums will be truncated. Date of Service Per WAC Billing Procedures: Billed services must be received within one year of the date of service (original receipt). Bills submitted with future dates of service are not allowed and will be returned denied. 24

25 Local Codes LNI uses Local Codes to identify unique services or supplies specific to Washington State workers compensation billing. In many cases, LNI has converted local codes to using standard CPT coding or HCPCS. Where LNI continues to use Local Codes: Consist of four (4) numbers followed by one (1) letter (except F and T). Submitted in the 837 transaction with Product/Service ID Qualifier ER (5010) or ZZ (4010). Returned in the 835 Payment Advice and identified with Product/Service ID Qualifier ER. Clearinghouses are requested to accept LNI Local Codes when billed by providers using the following EDI submission requirements: Format Version Loop/Element Qualifier Service SV1 SV101-1 SV2 SV202-1 Professional 837 Institutional 837 ER Jurisdiction Specific Procedure/Supply Codes. Acceptable for workers compensation claims which are not covered under HIPAA. Professional 837 Institutional Payment Advice Service SV1 SV101-1 SV2 SV Service Payment SCV SVC Service Payment SCV SVC01-1 ZZ Mutually Defined, Jurisdiction Specific Procedure/Supply Codes ER Jurisdiction Specific Procedure/Supply Codes. Workers Compensation Specific Procedure and Supply codes ER Jurisdiction Specific Procedure/Supply Codes. Workers Compensation Specific Procedure and Supply codes effective on MM/DD/CCYY Payment Advice Note: Although previous versions of the LNI companion guide indicated ER as returned, the value HC was returned on local codes billed. Local code example: 1040M (Accident Report, Completion) Local code information is available in LNI s Fee Schedule(s) and Billing & Payment Policies: Revenue Codes LNI utilizes the National Revenue Codes maintained by the National Uniform Billing Committee. For a complete list of the National Revenue codes, please refer to the website Effective December 15, 2003 LNI accepts 4-digit revenue codes Current valid 3-digit revenue codes may be submitted with a leading zero DME Services When billing Durable Medical Equipment (DME) services: Submission of both the 2400 SV1 and 2400 SV5 segments is required. 25

26 Explanation of Benefits (EOB) LNI EOB s are reported on the provider s remittance for any bill denied or adjusted. LNI EOB s are cross-walked to the best fit HIPAA Claim Adjustment Reason Codes, and in some cases, Remittance Advice Remarks Codes. These HIPAA EOB codes are returned within the 835 Payment/Advice to the receiver of the 835. Providers receiving the 835 may need to refer to their electronic PDF or paper remittance for additional clarification of HIPAA EOB s, since LNI EOB s are more specific in many cases. Bills formatted into MIPS with invalid/missing EDI requirements will be DENIED with an EDI Formatting Error. EDI formatting errors are identified with the following EOB codes: EOB Code Description EOB1 H00 EDI FORMATTING ERROR. THIS BILLING IS DENIED/REJECTED THE SECOND EOB DETAILS THE ERROR. EOB2 H01-H39 series SPECIFIC EXPLANATION OF THE EDI FORMATTING ERROR. Bills with EDI formatting errors are: o Auto-denied and rejected from MIPS adjudication processing o Reported back to the submitter in the 277 Notification/Unsolicited acknowledgment o EOB text description associated to EOB2 is returned in STC012 Bills with EDI formatting errors may be corrected and resubmitted at any time by the provider Table of EDI formatting errors is listed on page of this companion guide Remarks Use of NTE Segments Unnecessary remarks entered in the NTE segments will cause delay in the processing of the bill Any Original bill or electronic adjustment (Replacement) bill submitted with Remarks at the bill or service line level will be suspended in MIPS and require manual adjudication. Any electronic adjustment (Void) bill submitted with Remarks at the bill or service line level will not be suspended in MIPS. Submitted Remarks will be retained for reference if needed. Suspended bills require manual adjudication by an LNI Medical Treatment Adjudicator (MTA) Loop/Segment Element Value Description 2300 Claim Note NTE01 ADD NTE02 - Bill level remarks 2400 Line Note NTE01 ADD NTE02 - Service Line level remarks Do not enter remarks such as: Routine procedure or diagnosis code descriptions Diagnostic study results, requests for authorization, or authorizing authority Work or LNI Claim Number, or On Job Injury, or OJT Do enter remarks for: Procedure codes referencing an unlisted service or supply Procedure code modifiers -22 or -99 Other appropriate entries to assist bill processing and payment. For questions regarding appropriate submission of billing remarks: Contact the Provider Hotline Phone:

27 Claim Identifier for Transmission Intermediaries 2300 REF*D9 LNI processing will support the submission of the 2300 Value Added Network Trace Number (Clearinghouse Claim/Trace Number segment REF*D9 when submitted in the 837 transaction. When submitted, this number will be returned in the 277 (5010) Notification. LNI processing will support up to 20 characters of the Clearinghouse Trace Number. Format Loop Segment/Qualifier Data Element Professional REF*D9 REF02 Institutional REF*D9 REF Notification 2200D REF*D9 REF02 Medical Record Number 2300 REF*EA LNI processing will support the submission of the 2300 Medical Record Identification Number segment REF*EA when submitted in the 837 transaction. When submitted, this number is returned in the 277 Unsolicited Acknowledgment. This segment is not supported in the 277 Notification for Format Loop Segment/Qualifier Data Element Professional REF*EA REF02 Institutional Unsolicited/Pended 2200D REF*EA REF02 Acknowledgment (3070) 835 Payment Advice 2100 Claim Payment Information REF*EA REF02 27

28 Internal Control Number ICN LNI assigns a 17-digit Internal Control Number (ICN) to each bill formatted into the Medical Information Payment System (MIPS) for processing. The ICN is returned to the Submitter/Provider in the following transactions: o o 277 Health Care Claim Acknowledgment Loop: 2200D Claim Status Tracking Number REF*1K - Payer Claim Control Number (REF02) 835 Health Care Claim Payment/Advice Loop: 2100 Claim Payment Information CLP CLP07 Payer Claim Control Number ICN composition: Example: The first position is the bill s Medium Type (Submission type) 7 = HIPAA EDI bill submission 6 = Pharmacy POS bill 5 = Direct Entry Online bill submission 3 = Proprietary electronic HCFA format bill submission 0 = Paper bill submission The next five positions 2-6, is the Julian Date the bill formatted into MIPS 2-3 = Julian Year 4-6 = Julian Day The next two positions 7-8, is the Machine Number (format) 08 = EDI 5010 Professional bill (005010X0222A1) 07 = EDI 5010 Institutional bill (005010X0223A2) 05 = EDI 4010 Professional bill (004010X098A1) 04 = EDI 4010 Institutional bill (004010X096A1) 98 = Electronic (Proprietary HCFA) 00 = Paper The next three positions 9-11, is the Batch Number And, the last six positions 12-17, is the Bill Number within the batch. 12 = High Digit Order 0 = Indicates Original Bill 1 = Indicates Credit ICN 2 = Indicates Adjustment ICN So, in the example above, ICN would be interpreted as a: HIPAA EDI bill submission Formatted into MIPS on March 11, 2011 And received as a Professional Health Care Claim in the 5010 format When contacting the Electronic Billing Unit or the Provider Hotline regarding bill status or inquiry, please have the ICN available if possible to help us assist you. 28

29 Electronic Adjustments Effective September 2011, LNI began utilizing the adjustment capability within the 837 transactions. The department will accept and process request for electronic adjustment (Replacement and Void) to all finalized bills regardless of the bill s original submission type (HIPAA, EMC proprietary and Paper). In addition, LNI will continue to accept paper adjustments for all bills using the Provider s Request for Adjustment form available online at: The provider s remittance advice and electronic 835 Payment/Advice will report any finalized adjustments along with other finalized bills. When to request an adjustment: If you made a mistake when you billed and it caused an underpayment or overpayment. If we paid an entire bill in error and you want us to reverse the charges paid. When to re-bill If the entire bill was denied. Submission guidelines: Bills finalized to a PAID Status may be Replaced or Voided. Bills finalized to a DENIED status may be Resubmitted or Replaced but not Voided. ICN submitted on adjustment must be found in MIPS and eligible for adjustment. Claim ID submitted on adjustment must match Claim ID on bill being adjusted. Rendering Provider of service must match Rendering Provider of service on bill being adjusted. Contain changes, additions and/or deletions to services being adjusted. Contain the same services previously billed and correctly paid on the bill (ICN) being adjusted. Bill Remarks are not required but may be submitted. o When submitted on Original or Replacement bill, will cause the bill to suspend and require manual adjudication. o When submitted on Void bill, will not cause the bill to suspend but remarks are retained for reference purposes. EOB E99 returned in EOB2 of MIPS bill indicating electronic adjustment made per provider request. Best Practice Recommendations To the extent possible, LNI has adopted the Best Practice Recommendations (BPRs) for Electronic Processing of Corrections to Professional and Institutional Claims created by the WORKSMART Institute of ONEHEALTHPORT (OHP). The BPR s are in response to Washington State Senate Bill 5346 Health Care Uniform Administrative Procedures Development. This bill calls for a variety of solutions (guidelines, standards, processes, etc.) to simplify health care administration in Washington State. The BPR s are models to be used to deliver these solutions. For additional information on the BPR s created for SB 5346 and the BPR s for Electronic Processing of Corrections to claims, please visit OHP s Administrative Simplification web page at: 29

30 Claim Frequency Type Code 2300 CLM05-3 LNI processing accepts the following Claim Frequency Type Codes for bill submission CLM05-3 Definition Situation 1 - Original Initial Claim or Resubmission of an Initial Claim claim that was returned as DENIED. 7 - Replacement Change to an Initial Claim 8 - Void Back out or remove an Initial Claim Use Claim Frequency Code 1 when submitting a claim for the first time (Initial Claim) OR when resubmitting a Use Claim Frequency Code 7 when making a request for adjustment to a claim that has been fully or partially paid. Use Claim Frequency Code 8 when making a request for adjustment to void a claim that has been fully or partially paid or submitted in error. If Not 1 or 7 or 8 EDI formatting error Bill is auto-denied with EOB H00/H08 and rejected from MIPS adjudication processing. Payer Claim Control Number 2300 REF*F8 This segment is required for processing of electronic adjustment requests when 2300 Claim Frequency Type Code CLM05-3 equals 7 Replacement or 8 Void. The LNI 17-dgit Internal Control Number (ICN) of the bill to be adjusted must be submitted in REF02 of this segment. LNI will process the ICN submitted in the 2300 Payer Claim Control Number segment REF*F8 of the 837 for adjustment of Replacement or Void. The ICN submitted for adjustment will be returned in the 2100 Other Claim Related Identification segment REF*F8, Original Reference Number, of the 835 Payment Advice and the finalized adjustment ICN reported in 2100 CLP07 Payer Claim Control Number. Format Loop Segment/Qualifier Data Element Description 837 Professional 2300 REF*F8 REF02 Original Reference Number/Payer Claim Control Number requested for adjustment 837 Institutional 2300 REF*F8 REF02 Original Reference Number/Payer Claim Control Number requested for adjustment 835 Payment Advice 2100 CLP CLP07 Payer Claim Control Number ICN of adjudicated bill for the payment cycle 835 Payment Advice 2100 REF*F8 REF02 Original Reference Number ICN Payer Claim Control Number requested for adjustment submitted in 837 REF*F8 30

31 Warrants and Payment cycle cutoff schedule Warrants will display both the LNI provider number and the NPI when available. Providers payments will not be consolidated to one warrant per NPI, if they have multiple Payee LNI accounts. One warrant will be produced for each LNI provider account designated as the Payee. LNI payment cycle for providers is every two weeks Warrant payments and remittances are typically produced on Tuesday Billing cutoff into the payment cycle is the Friday prior to the payment cycle Billing submitted on the Friday cutoff may not be finalized for that payment cycle To view LNI s Warrant Schedule go to: 31

32 LNI Mapping to Transactions The columns in the attached mapping can be understood as follows: TR3 PAGE # Segment/Field ID FIELD NAME Sample Data, TR3 Required Value [R] and Department Required Value [DRV] Seg/Field USAGE TR3 Page # - refers to the page number of the corresponding ASC X TR3 Implementation Guide. Segment/Field ID refers to the Implementation Guide segments and data elements within segments. Field Name refers to the Implementation Guide s defined element name or Implementation Name. Sample Data, TR3 Required Value and Department Required Values this provides examples of data and qualifiers that are either required or dependent on usage per the ASC X TR3 Implementation Guide and LNI requirements. [R] - indicates the exact data value that must be supplied in this field and is allowed as a valid value per the ASC X12 Implementation Guide. [DRV] - indicates the department s required value that must be supplied in this field for LNI s bill processing. For outbound transactions, indicates the department s returned value supplied in this field. Sample Data indicates an example of the data as sent or returned in the transaction. Seg/Field Usage refers to the ASC X12N Implementation Guides requirements and LNI requirements for that Loop within the transaction. R = Required. Segment and/or data element is required in the transaction. S = Situational. Segment and/or data element is situational based on the existence of other segments, data elements, and/or values within the transaction. Example EDI Data is the Electronic Data Interchange (EDI) display of the segment(s) with the sample billing data provided in the Loop above. Sample data is displayed as parsed by segment for readability purposes. Segment Count Example EDI Data Segment Count indicates the relative position of the segment in the sample data in relation to the beginning of the transaction set. The Transaction Set Header (ST) segment is the beginning of the transaction set and is segment position 1. Example EDI Data indicates sample data within the transaction. 32

33 File Structure Overview The HIPAA EDI file submission is made up of sets of data in a structured text file. The smallest piece of data is the Data Element, which represents a single field or value. As an example, the data element that represents the Billing Provider Last or Organizational Name is assigned a specific data element number (1035). Data Element Numbers can be found and are referenced in Appendix E Data Element Glossary, section E.1 Data element Name Index of the TR3 for Professional, Institutional, and Dental 837. The Data Elements are arranged in a defined structure to represent a Segment. As an example, the Billing Provider Contact Information segment includes data elements for the Billing Provider s contact information such as Contact name, telephone number, fax number and address. Sets of Segments make up Loops. As an example, Loop ID 2010AA Billing Provider Name includes name, address, geographical location, tax identification, and contact number segments. Every 837 file must contain at least one Transaction Set. The set of Loops in a Transaction Set may provide information for a single medical bill or many bills. The data elements, segments, and loops required depend on the types of bills contained in the file. A File is the entire submission. Every 837 file for Washington State Workers Compensation billing must contain a defined set of data elements, segments, and loops required in the file. The file includes one ISA header and trailer, one Functional Group header and trailer, and the Transaction Sets (pairs of headers and trailers and the medical billing data included between them). ISA Envelope Every HIPAA EDI file is identified by elements that define the ISA envelope. The ISA envelope provides information that identifies the sender, receiver, and identifying information of the file such as type of data, the date and time sent, tracking number, etc. The purpose of the ISA is to start and identify an interchange of zero or more functional groups and interchangerelated control segments. The ISA envelope includes the ISA, GS, GE, and IEA segments shown below. ISA Envelope: ISA (Interchange Control header segment) GS (Functional Group header segment) Transaction Set or Sets: ST/SE pairs (header segment and trailer segment and the medical billing data content between those segments). An 837 Transaction Set also is called a Batch. Optional Transaction Set 2: ST/SE Optional Transaction Set 3:... GE (trailer segment; end of the Functional Group) IEA (trailer segment; end of the ISA Envelope; end of the file) 33

34 Required Delimiters Delimiters are essential in deciphering the contents of the EDI submission and getting data out of it. Because LNI s parser needs to know the identity of these characters before it can do meaningful parsing, it must know where to find them. Delimiters are specified in the ISA Header segment. The ISA segment is a fixed length record 105 bytes long, counting the first character I of the ISA segment as byte 1. For LNI s EDI transaction processing, we recommend our trading partners use the following delimiters: Delimiter Character Description Byte Data element separator * (asterisk) Separates the data elements within a segment 4 Repetition separator ^ (caret) Separates repeated occurrences of a data element or a composite 83 data structure Component separator : (colon) Separates sub-elements within the same data element 105 Segment terminator ~ (tilde) Indicates the end of a segment. Do not follow with a Carriage Return/Line Feed (CR/LF), Line Space, or Line break character. 106 The data element separator (byte 4) and segment terminator (byte 106) defined, are used throughout the entire interchange submission. Delimiters are not to be used as a data element value within the interchange. ISA example: Scale: ISA*00*.*00*.*ZZ* *30* *110930*1800*^*00501* *1*P*:~ Spaces in the example above are represented by. 34

35 Interchange Control Header (ISA) The ISA Interchange Control Header for LNI will consist of standard and/or identical data values used for: 837 Professional X222A1 Health Care Claim 837 Institutional X223A2 Health Care Claim TR3 PAGE # Segment/Field ID INTERCHANGE CONTROL HEADER (ISA) Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Seg/Field USAGE Size Min/Max C.3 ISA Interchange Control Header Required 105/105 ISA01 Authorization Information Qualifier 00 [DRV] R 2/2 ISA02 Authorization Information. R 10/10 ISA03 Security Information Qualifier 00 [DRV] R 2/2 ISA04 Security Information. R 10/10 ISA05 ISA06 Interchange ID Qualifier (Sender) ZZ [DRV] Interchange Sender ID: Your National Provider Identifier (NPI) or your Washington State Department of Labor and Industries assigned 7-digit provider account number authorized for electronic submission. This Sender ID must match the Sender ID supplied in the GS02 field or R 2/2 R 15/15 ISA07 Interchange ID Qualifier (Receiver) 30 [DRV] R 2/2 ISA08 Interchange Receiver ID [DRV] R 15/15 ISA09 Interchange Date : YYMMDD R 6/6 ISA10 Interchange Time: HHMM 1800 R 4/4 ISA11 Repetition Separator: Caret ^ R 1/1 ISA12 Interchange Control Version Number [R] R 5/5 ISA13 Interchange Control Number R 9/9 ISA14 Acknowledgement Requested 1 [Recommended] R 1/1 ISA15 Usage Indicator P or T [R] R 1/1 ISA16 Component Element Separator: Colon : R 1/1 Segment Terminator: Tilde ~ 1/1 Segment Example EDI Data Count ISA*00*...*00*...*ZZ* *30* *110930*1800*^*00501* *1*P*:~ The. in the above example represent character position within a field. In an actual transmission the. within the above ISA example would be replaced with spaces. ISA Interchange Control Header information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.3 ISA Interchange Control Header of the 837 Implementation Guides (TR3 s). 35

36 ISA - Interchange Control Header notes For the purpose of Provider Express Billing (PEB) file submission, identification, and corresponding TA1 generation, the department requires the following ISA fields to be formatted as defined below for Professional and Institutional 837 submissions. Failure to follow these requirements will result in the department rejecting your submission and affect LNI s ability to generate the correct routing for the TA1 acknowledgement; therefore, no TA1 response will be generated for the submission. 1. ISA01 Authorization Information Qualifier: No Authorization Information Present ISA02 Authorization Information: Insert spaces into this data element Spaces 3. ISA03 Security Information Qualifier: No Security Information Present ISA04 Security Information: Insert spaces into this data element Spaces 5. ISA05 Interchange Sender ID Qualifier: Mutually Defined. Qualifies Sender in ISA06 ZZ If not equal ZZ PEB Submit Bills error message issued: INVALID ISA SENDER ID QUALIFIER (ISA05) XX. EXPECTING ZZ. (WHERE XX IS THE VALUE OF ISA05) 6. ISA06 Interchange Sender ID 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) Must equal the Provider ID (Submitter ID) registered with PEB authorized for EDI submissions Must equal GS02 Application Sender Code Do Not truncate leading zeros when using the LNI provider account number as Sender ID If not equal to PEB Submit Bills selected Submitter ID (ID registered with PEB) PEB Submit Bills error message issued: INVALID ISA SENDER ID (ISA06) XXXXXXX. THE SENDER ID SHOULD BE THE SAME AS THE PROVIDER ID CURRENTLY SELECTED. (WHERE XXXXXXX IS THE VALUE OF ISA06) If not equal to GS02 Sender Code PEB Submit Bills error message issued: INVALID ISA SENDER ID (ISA06) XXXXXXX TO GS SENDER CODE (GS02) XXXXXXX COMBINATION. THE ISA SENDER ID AND GS SENDER CODE MUST BE THE SAME. (WHERE XXXXXXX IS THE VALUE OF ISA06/GS02) 7. ISA07 Interchange Receiver ID Qualifier: U.S. Federal Tax Identification Number 30 If not equal 30 PEB Submit Bills error message issued - INVALID ISA RECEIVER ID QUALIFIER (ISA07) XX. EXPECTING 30. (WHERE XX IS THE VALUE OF ISA07) 8. ISA08 Interchange Receiver ID: LNI Federal Tax ID If not equal PEB Submit Bills error message issued - INVALID ISA RECEIVER ID (ISA08) XXXXXXXXX. EXPECTING (WHERE XXXXXXXXX IS THE VALUE OF ISA08) 9. ISA09 Interchange Date: format as YYMMDD ISA09 value is returned to submitter in TA1 TA102 Interchange Date 10. ISA10 Interchange Time: format as HHMM Where HH = Hours (00-23) and MM = Minutes (00-59) ISA10 value is returned to submitter in TA1 TA103 Interchange Time 36

37 ISA - Interchange Control Header notes continued 11. ISA11 Repetition Separator: Caret ^ Is a delimiter and not a data element Must be different than the: Data element separator ( * asterisk), and Component element separator ( : colon), and Segment terminator ( ~ tide) 12. ISA12 Interchange Control Version Number: ISA/IEA envelope version = version = version 13. ISA13 Interchange Control Number: positive unsigned number Must equal IEA02 Interchange Control Trailer If not equal to IEA02 The Interchange is rejected. TA1 Acknowledgement: TA104=R, TA105=001 (Interchange Control Number in the Header and Trailer Do Not Match) ISA13 value is returned to submitter in TA1 TA101 Interchange Control Number 14. ISA14 Acknowledgement Requested: TA1 requested 1 If equal to 1 TA1 Interchange Acknowledgement generated back to 837 Submitter (recommended). If equal to 0 TA1 Interchange Acknowledgement is not generated back to 837 Submitter Established Submitters may decide to suppress the TA1 acknowledgment and rely on the Functional acknowledgment 999/997 for submission acceptance/rejection 15. ISA15 Interchange Usage Indicator P or T If not equal P or T PEB Submit Bills error message issued: Invalid ISA Usage Indicator (ISA15) x. Expecting P or T. (where x is the value of ISA15) When equal P and the submitter is approved for production EDI submissions; The file submission is routed to the MIPS Production environment. PEB Submit Bills message issued: THE FILE WAS SUCCESSFULLY UPLOADED. When equal P and the submitter is approved for production EDI submissions; AND the PEB Submit Bills This is a Test file. Submit to the Test Environment checkbox is set to Y (checked) The submission is routed to the MIPS TEST environment. PEB Submit Bills message issued: THE FILE WAS SUCCESSFULLY UPLOADED TO THE TEST ENVIRONMENT. When equal P and the submitter is not approved for production EDI submissions; The file submission is routed to the MIPS TEST environment. PEB Submit Bills message issued: PLEASE NOTE. THE FILE YOU UPLOADED WAS SENT TO THE TEST ENVIRONMENT BECAUSE THIS PROVIDER IS CURRENTLY SET UP TO UPLOAD FILES TO THE TEST ENVIRONMENT ONLY. 37

38 ISA - Interchange Control Header notes continued 16. ISA16 Component Element Separator: Colon : (colon) Is a delimiter and not a data element Defined by value in ISA Header segment, byte 105 Must be different than the: Data element separator ( * asterisk), and Repetition separator, and Segment terminator ( ~ tide) 17. Segment Terminator: Tilde ~ (tilde) Is a delimiter and not a data element Defined by value is ISA Header segment, byte 106 Is one character in length, and is the last character of every segment Interchange Control Trailer (IEA) The Interchange Control Trailer (IEA) is used to end an interchange of zero or more functional groups, interchange-related control segments, and is part of the ISA envelope. INTERCHANGE CONTROL TRAILER (IEA) Sample Data, TR3 Required TR3 Segment/Field Seg/Field Size FIELD NAME Value [R] and Department PAGE # ID USAGE Min/Max Required Value [DRV] C.10 IEA Interchange Control Trailer Required IEA01 Number of Included Functional Groups 1 R 1/5 IEA02 Interchange Control Number R 9/9 Segment Count IEA*1* ~ Example EDI Data IEA Interchange Control Trailer information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.10 IEA Interchange Control Trailer of the 837 Implementation Guides (TR3 s). ISA Interchange Control Trailer notes 1. IEA01 Number of Included Segments 1 Is a count of the total number of functional groups (GS/GE segment sets) included in the Interchange 2. IEA02 Interchange Control Number Must equal ISA13 Interchange Control Number If not equal ISA13, see ISA13 Interchange Control Number notes 38

39 Functional Group Header (GS) The GS Functional Group Header for LNI will consist of standard and/or identical data values used for: 837 Professional X222A1 Health Care Claim 837 Institutional X223A2 Health Care Claim The Functional Group Header (GS) is used to indicate the beginning of a functional group and to provide control information, and is part of the ISA envelope. FUNCTIONAL GROUP HEADER (GS) Sample Data, TR3 Required TR3 Segment/Field Seg/Field Size FIELD NAME Value [R] and Department PAGE # ID USAGE Min/Max Required Value [DRV] C.7 GS Functional Group Header Required GS01 Functional Identifier Code: HC [R] R 2/2 GS02 Application Sender Code: Your National Provider Identifier (NPI) or your Washington State Department of Labor and Industries assigned 7-digit provider account R 2/15 number authorized for electronic submission. This Sender ID must match the Sender ID supplied in the ISA06 field or GS03 Application Receiver Code [DRV] R 2/15 GS04 Functional Group Creation Date R 8/8 GS05 Functional Group Creation Time 1800 R 4/8 GS06 Group Control Number R 1/9 GS07 Responsible Agency Code X [R] R 1/2 GS08 Version/Release/Industry Identifier Code X.. [R] R 1/12 Segment Count Example EDI Data GS*HC* * * *1800* *X*005010X222A1~ GS Functional Group Header information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.7 GS Functional Group Header of the 837 Implementation Guides (TR3 s). 39

40 GS Functional Group Header notes For the purpose of Provider Express Billing (PEB) file submission, identification and corresponding 999/997 generation, the department requires the following GS fields to be formatted as defined below for Professional and Institutional 837 submissions. Failure to follow these requirements will result in the department rejecting your submission and affect the department s ability to generate the correct routing for the 999/997 acknowledgement; therefore, no 999/997 response will be generated for the submission. 1. GS01 Functional Identifier Code: Health Care Claim (837) HC Value returned in the 999 AK1 AK101 Functional Identifier Code 2. GS02 Application Sender Code 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) Must equal the Provider ID registered with PEB authorized for EDI submissions Must equal ISA06 Interchange Sender ID Do Not truncate leading zeros when using the LNI provider account number If not equal to ISA06 PEB Submit Bills error message issued: INVALID ISA SENDER ID (ISA06) XXXXXXX TO GS SENDER CODE (GS02) XXXXXXX COMBINATION. THE ISA SENDER ID AND THE GS SENDER CODE MUST BE THE SAME. (WHERE XXXXXXX IS THE VALUE OF ISA06/GS02) 3. GS03 Application Receiver Id: LNI Federal Tax ID GS04 Functional Group Creation Date: formatted as CCYYMMDD 5. GS05 Functional Group Creation Time: formatted as HHMM Where HH = Hours (00-23) and MM = Minutes (00-59) 6. GS06 Group Control Number: positive unsigned number Must equal GE02 Group Control Number Value returned in the 999 AK1 AK102 Group Control Number If not equal GE02 The functional group of the Interchange is rejected. 999/997 Acknowledgement: AK901=R, AK905=4 (Group Control Number in the Functional Group Header and Trailer Do Not Agree) 7. GS07 Responsible Agency Code: Accredited Standards Committee X12 X 8. GS08 Version/Release Industry Identifier Code: transactions sets version number X.. Identifies the version of the transaction sets contained within the Interchange ISA/IEA envelope Value returned in the 999 AK1 Ak103 Version/Release/Industry Identifier Code Where X.. is: X222A1 for Health Care Claim: Professional X223A2 for Health Care Claim: Institutional

41 Functional Group Trailer (GE) The purpose of the Functional Group Trailer (GE) is to end the functional group and to provide control information. The GE Functional Group Trailer is part of the ISA envelope. TR3 PAGE # Segment/Field ID FUNCTIONAL GROUP TRAILER (GE) Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Seg/Field USAGE C.9 GS Functional Group Trailer Required Size Min/Max GE01 Number of Transaction Sets included 1 R 1/6 GE02 Group Control Number R 2/15 Segment Count GE*1* ~ Example EDI Data GE Functional Group Trailer information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.9 GE Functional Group Trailer of the 837 Implementation Guides (TR3 s). GE Functional Group Trailer notes 1. GE01 Number of Transaction Sets included Is a count of the total number of Transaction Sets (ST/SE segment sets) included in the Interchange 2. GE02 Group Control Number: positive unsigned number Must be identical to thegs06 Group Control Number If not equal GS06 The functional group of the Interchange is rejected 999/997 Acknowledgement: AK901=R, AK905=4 (Group Control Number in the Functional Group Header and Trailer Do Not Agree) 41

42 Transaction Sets The 837 Interchange may contain one or more Transaction Sets and each transaction set will contain billing information for one or more bills for workers with an LNI claim. LNI will validate each Transaction Set within the Functional Group of the 837 Interchange. Validation for acceptance/rejection of each transaction set will be reported in: 999 Implementation Acknowledgement for submissions in the 5010 format 997 Acknowledgment for submissions in the 4010 format. Transaction Set Header (ST) The purpose of the Transaction Set Header is to indicate the start of a transaction set and to assign a control number. The ST Transaction Set Header for LNI will consist of standard and/or identical data values used for: 837 Professional X222A1 Health Care Claim 837 Institutional X223A2 Health Care Claim TRANSACTION SET HEADER (ST) TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 837P (70-72) 837I Required (67-69) ST Transaction Set Header ST01 Transaction Set Identifier Code: Health Care Claim 837 [R] R ST02 Transaction Set Control Number R ST03 Implementation Convention Reference X.. [R] R BHT Beginning of Hierarchical Transaction Required BHT01 Hierarchical Structure Code 0019 [R] R BHT02 Transaction Set Purpose: Original 00 [R] R BHT03 Originator Application Transaction Identifier 1234 R BHT04 Transaction Set Creation Date (CCYYMMDD) R BHT05 Transaction Set Creation Time (HHMM) 1800 R BHT06 Claim or Encounter Identifier: Chargeable CH [DRV] R Segment Count Example EDI Data Professional 837 Institutional ST*837* *005010X222A1~ ST*837* *005010X223A2~ 2 BHT*0019*00*1234* *1800*CH~ BHT*0019*00*1234* *1800*CH~ 42

43 ST Transaction Set Header notes 1. ST01 Transaction Set Identifier Code: Health Care Claim 837 Value returned in the 999 AK2 AK201 Transaction Set Identifier Code 2. ST02 Transaction Set Control Number Positive unsigned number Must be identical to the SE02 Transaction Set Trailer Value returned in the 999 AK2 AK202 Transaction Set Control Number If ST02 and SE02 do not match the transaction set is rejected. 997 Acknowledgement: AK501=R, AK502=3 (Transaction Set Control Number in the Header and Trailer Do Not Match) 3. ST03 Implementation Convention Reference X.. Value indicates the specific implementation guide used to create the 837 transaction Must be identical to the GS08 Version Identifier Code Value returned in the 999 AK2 AK203 Implementation Convention Reference Where X.. is: X222A1 for Professional X223A2 for Institutional BHT01 Hierarchical Structure Code: Information Source, Subscriber, Dependent BHT02 Transaction Set Purpose Code: Original BHT03 Originator Transaction Identifier: Batch Control Number 7. BHT04 Transaction Set Creation Date: formatted as CCYYMMDD 8. BHT05 Transaction Set Creation Time: formatted as HHMM Where HH = Hours (00-23) and MM = Minutes (00-59) 9. BHT06 Claim or Encounter Identifier: Chargeable CH If Not Equal CH then bill formats with EDI formatting error H06 See EDI Formatting Errors - page

44 Transaction Set Trailer (SE) The purpose of the Transaction Set Trailer (SE) is to indicate the end of the transaction set and provide a count of the number of segments transmitted in the transaction set. TRANSACTION SET TRAILER (SE) TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 837P (496) 837I Required (488) SE Transaction Set Trailer SE01 Number of Included Segments 40 R SE02 Transaction Set Control Number R Segment Count SE*40* ~ Example EDI Data Professional 837 Institutional 837 SE*40* ~ SE Transaction Set Trailer notes 1. SE01 Number of included segments This value is a count of the total number of segments within the transaction set ST/SE The ST (beginning) and SE (ending) segments are included in the count 2. SE02 Transaction Set Control Number Positive unsigned number Must be identical to the ST02 Transaction Set Control Header If SE02 and ST02 do not match the transaction set is rejected. 999/997 Acknowledgement: AK501=R, AK502=3 (Transaction Set Control Number in the Header and Trailer Do Not Match) 44

45 837 HEALTH CARE CLAIM: PROFESSIONAL ASC X12N X222A1 The HIPAA requirements for communication of professional billing to the Department of Labor and Industries are listed below. These requirements adhere to the definitions set forth in the EDI ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (Implementation Guide) Version 5, Release 1. The diagram represents an overview of the interchange control and transaction structure. The details of this structure can be found in Appendix B ASC X12 Nomenclature of the X222A1 Health Care Claim Professional TR3. Communication Transport Protocol ISA Interchange Control Header GS Functional Group Header ST SE Transaction Set Header Detail Segments for example, Claim submission Transaction Set Trailer FUNCTIONAL GROUP INTERCHANGE ENVELOPE COMMUNICATION ENVELOPE GE Functional Group Trailer IEA Interchange Control Trailer Communication Transport Protocol 45

46 PROFESSIONAL 837 BILLING DATA This diagram lists the ASC X X222A1 Professional Health Care Claim 837 transaction set detail segments that will be utilized by the Department of Labor and Industries Workers Compensation Medical Information and Payment System (MIPS). The system will extract fields from the segments below for the purpose of claim/billing adjudication, payment and corresponding communication. Segments and fields not utilized by the department are excluded from this companion guide. However, the department will not reject transactions, which include segments and loops that are not utilized by the agency. Page references have been provided to the corresponding TR3 Implementation Guide for further details. LOOP ID A SUBMITTER NAME This loop identifies the entity responsible for creation, formatting and submission of the EDI transaction and provides the submitter s contact information to the receiver. 1000A SUBMITTER NAME NM1*41 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 74 NM1 Submitter Name Required 74 NM101 Entity Identifier Code 41 [R] R 75 NM102 Entity Type Qualifier 2 R 75 NM103 AMERICAN MEDICAL BILLING Submitter Last or Organization Name SERVICES R 75 NM108 Identification Code Qualifier 46 [R] R 75 NM109 Submitter Identifier National Provider Identifier (NPI) or LNI provider R account number authorized for electronic billing or PER Submitter EDI Contact Information Required 77 PER01 Contact Function Code IC [R] R 77 PER02 Submitter Contact Name BEN FRANKLIN S 77 PER03 Communication Number Qualifier TE R 77 PER04 Submitter Contact Phone R 77 PER05 Communication Number Qualifier EM S 77 PER06 Submitter Contact [email protected] S Segment Example EDI Data Professional 837 Count 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 1000A Submitter Name notes 1. NM101 Entity Identifier Code: Submitter NM102 Entity Type Qualifier: 1 or 2 Person (individual) 1 Non-Person Entity (organization) 2 3. NM108 Identification Code Qualifier: Electronic Transmitter Identification Number (ETIN) NM109 Submitter Identifier 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) registered with Provider Express Billing (PEB) and authorized for EDI submissions. Must be identical to the ISA06 Interchange Sender ID and GS02 Application Sender Code. Do Not truncate leading zeros when using the LNI provider account number. Used by the department to validate the provider s electronic billing authorization. Used for routing purposes of the 277 Notification. 46

47 1000A Submitter Name notes continued Clearinghouses If the provider is submitting electronic billing through a clearinghouse, the clearinghouse Submitter ID in NM109 must be authorized to submit electronic billing for the provider identified in the 2010AA Billing Provider and/or the 2310B Rendering Provider loops. Provider s may authorize only one clearinghouse for their electronic billing for their provider account. If the Submitter ID is not authorized to bill electronically for the provider, the bills may appear on the provider s remittance advice with the one of the following EOB s: EOB BILL SUSPENDED. SUBMITTER NOT AUTHORIZED TO SUBMIT BILLS FOR THIS PROVIDER. CALL EOB DENIED. THIS IS AN ELECTRONIC BILL. THE INTERMEDIARY/CLEARINGHOUSE IS NOT AUTHORIZED TO SUBMIT BILLS FOR THIS PROVIDER. CALL Provider s must authorize their clearinghouse for electronic billing by submitting an Electronic Billing Authorization Agreement to the department s Electronic Billing Unit. The EBA agreement is available online at: 5. PER Submitter EDI Contact Information Use this segment to communicate the submitter s contact information. This information may be used by the Electronic Billing Unit to contact the submitter of the file if needed. PER01 Contact Information Code: Information Contact PER02 Submitter Contact Name Contact name of the person submitting/supporting EDI with LNI Name must not be the same name submitted in 1000A NM103 PER03 Communication Number Qualifier: Telephone Number PER04 Communication Number Contact phone number of the person submitting/supporting EDI with LNI PER05 Communication Number Qualifier: Electronic Mail PER06 Communication Number Contact address of the person submitting/supporting EDI with LNI IC TE EM 47

48 LOOP ID B RECEIVER NAME This loop identifies the receiver of the EDI transaction file. 1000B RECEIVER NAME NM1*40 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 79 NM1 Receiver Name Required 79 NM101 Entity Identifier Code 40 [R] R 79 NM102 Entity Type Qualifier 2 [R] R 80 NM103 WASHINGTON STATE DEPT OF Receiver Name LABOR & INDUSTRIES [DRV] R 80 NM108 Identification Code Qualifier 46 [R] R 80 NM109 Receiver Identifier (ETIN) Washington State Department of Labor and Industries Federal Tax Identification Number [DRV] R Segment Example EDI Data Professional 837 Count 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 1000B Receiver Name notes 1. NM101 Entity Identifier Code: Receiver NM102 Entity Type Qualifier: Non-Person Entity 2 3. NM108 Identification Code Qualifier: Electronic Transmitter Identification Number (ETIN) NM109 Receiver Identifier (ETIN): WA State Dept of Labor & Industries Federal Tax ID

49 Detail, Billing Provider Hierarchical Level LOOP ID 2000A BILLING PROVIDER HIERARCHICAL LEVEL 2000A BILLING PROVIDER HIERARCHICAL LEVEL - HL TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 81 HL Billing Provider Hierarchical Level Required 81 HL01 Hierarchical ID Number 1 R 81 HL03 Hierarchical Level Code 20 [R] R 82 HL04 Hierarchical Child Code 1 [R] R 83 PRV Billing Provider Specialty Information Situational 83 PRV01 Provider Code BI [R] R 83 PRV02 Reference Identification Qualifier PXC [R] R 83 PRV03 Provider Taxonomy Code 261QM1300X R Segment Count 6 HL*1**20*1~ 7 PRV*BI*PXC*261QM1300X~ Example EDI Data Professional A Billing Provider HL notes 1. HL03 Hierarchical Level Code: Information Source HL04 Hierarchical Child Code 1 3. PRV01 Provider Code: Billing BI 4. PRV02 Reference Identification Qualifier: Health Care Provider Taxonomy Code PXC 5. PRV03 Provider Taxonomy Code 10-digit Provider Taxonomy code If submitted, the provider s taxonomy code may be used when processing the provider s National Provider Identifier (NPI) to assist the department in appropriately cross-referencing the NPI to the provider s LNI provider account number. 49

50 LOOP ID AA BILLING PROVIDER NAME 2010AA BILLING PROVIDER NAME NM1*85 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 87 NM1 Billing Provider Name Required 88 NM101 Entity Code Identifier 85 [R] R 88 NM102 Entity Type Qualifier 1 or 2 [R] R 88 NM103 Billing Provider Last or Organizational Name COMMUNITY HEALTH CLINIC R 89 NM108 Identification Code Qualifier XX [R] S 90 NM109 Billing Provider Identifier S 91 N3 Billing Provider Address Required 91 N301 Billing Provider Address 123 WATERS ST R 92 N4 Billing Provider City/State/Zip Code Required 92 N401 Billing Provider City OLYMPIA R 93 N402 Billing Provider State WA S 93 N403 Billing Provider Zip S 94 REF Billing Provider Tax Identification Required 94 REF01 Reference Identification Qualifier EI or SY [R] R 94 REF02 Billing Provider Tax Identification Number R 98 PER Billing Provider Contact Information Situational 99 PER01 Contact Function Code IC [R] R 99 PER02 Billing Provider Contact Name DOLLY MADISON S 99 PER03 Communication Number Qualifier TE [DRV] R 99 PER04 Billing Provider Contact Phone R 99 PER05 Communication Number Qualifier EM [DRV] S 100 PER06 Billing Provider Contact [email protected] S Segment Count Example EDI Data Professional NM1*85*2*COMMUNITY HEALTH CLINIC*****XX* ~ 9 N3*123 WATERS ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected]~ NM1*85*2*COMMUNITY HEALTH CLINIC~ N3*123 WATERS ST~ N4*OLYMPIA*WA*98555~ REF*EI* ~ PER*IC*DOLLY MADISON*TE* *EM*[email protected]~ 2010AA Billing Provider notes 1. NM101 Entity Identifier Code: Billing Provider NM102 Entity Type Qualifier 1 or 2 Person (individual) 1 Non-Person Entity (organization) 2 3. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Billing Provider s NPI is submitted in NM

51 2010AA Billing Provider notes continued 4. NM109 Billing Provider Identifier 10-digit National Provider Identifier (NPI). Individual provider types use your Individual NPI registered with LNI. Clinic/Group Provider types use your Organizational NPI registered with LNI. Non NPI provider s use 2010BB Payer Name Billing Provider Secondary Identification reference REF*G2. Optional Provider s submitting their NPI may also include the Billing Provider Secondary Identification reference in the 2010BB Payer Name loop using REF*G2. The submitted NPI is used as the provider s primary identifier when the 2010BB Payer Name loop does not include the Billing Provider Secondary Identification segment REF*G2. If the submitted NPI (NM109) is not on file Or is on file but not cross-referenced to an LNI provider account number And 2010BB Payer Name loop does not include the Billing Provider Secondary Identification segment REF *G2 o Then bill formats with EDI formatting error H22 See EDI Formatting Errors - page REF Billing Provider Tax Identification segment REF01 Reference Identification qualifier: EIN or SSN Employer Identification Number (EIN) EI Social Security Number (SSN) SY EI or SY REF02 Billing Provider Tax Identification Number Use the Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes. The provider s EIN or SSN is a string of exactly nine (9) numbers with no separators. 6. PER Billing Provider Contact Information Use this segment to communicate the Billing Provider s telephone and contact information. This segment is required when the contact information is different than that in the 1000A Submitter Name loop. PER01 Contact Information Code: Information Contact PER02 Billing Provider Contact Name Contact name of the person billing worker s compensation with LNI PER03 Communication Number Qualifier: Telephone Number PER04 Billing Provider Phone Number Contact phone number of the person billing workers compensation with LNI PER05 Communication Number Qualifier: Electronic Mail PER06 Billing Provider Address Contact address of the person billing workers compensation with LNI IC TE EM 51

52 LOOP ID AB PAY-TO ADDRESS NAME 2010AB PAY-TO ADDRESS NAME NM1*87 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE Pay-To Address Name Loop This loop is only used when the address for payment is Situational different than that of the Billing Provider. 101 NM1 Pay-to Address Name Required 101 NM101 Entity Code Identifier 87 [R] R 102 NM102 Entity Type Qualifier 1 or 2 [R] R 103 N3 Pay-to Provider Address Required 103 N301 Pay-to Provider Address R 104 N4 Pay-to Provider City/State/Zip code Required 104 N401 Pay-to Provider City R 105 N402 Pay-to Provider State S 105 N403 Pay-to Provider Zip code S 2010AB Pay-To Address Name notes The department does not utilize this information in MIPS bill payment processing. 1. NM101 Entity Identifier Code: Pay-to Provider NM102 Entity Type Qualifier Value 1 or 2 Person (individual) 1 Non-Person Entity (organization) 2 52

53 Detail, Subscriber Hierarchical Level LOOP ID B SUBSCRIBER HIERARCHICAL LEVEL 2000B SUBSCRIBER HIERARCHICAL - HL TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 114 HL Hierarchical Level - Subscriber Required 114 HL01 Hierarchical ID Number 2 R 115 HL02 Hierarchical Parent ID Number 1 R 115 HL03 Hierarchical Level Code 22 [R] R 115 HL04 Hierarchical Child Code 0 [DRV] R 116 Subscriber Information SBR Insured/Patient information Required 116 SBR01 Payer Responsibility Sequence Number Code P [DRV] R 117 SBR02 Patient Relationship to Insured 18 [DRV] S 117 SBR03 Insured Group or Policy Number: Washington State Department of Labor and Industries A or AB12345 [Alpha+6Numeric] S 7-character assigned Claim Number. or [2Alpha+5Numeric] 118 SBR09 Claim Filing Indicator WC [DRV] S Segment Count 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ Example EDI Data Professional B Subscriber notes 1. HL03 Hierarchical Level Code: Subscriber HL04 Hierarchical Child Code: No subordinate HL segment in this structure 0 The Subscriber is the patient and there are no dependent claims. 3. SBR01 Payer Responsibility Sequence Number Code: Primary P 4. SBR02 Patient Relationship to Insured: Self 18 If SBR02 is absent (not sent) and loop 2000C is absent (not sent) The transaction will fail EDI validation and be rejected. Rejection reported in 999/997 Acknowledgment and 824 application advice. 5. SBR03 Insured Group or Policy Number 7-character LNI Claim Number/Claim ID Begin with single alpha-character + 6 numbers or double alpha-characters + 5 numbers. LNI Claim Numbers are derived from the Report of Accident (ROA) completed by the injured worker or by the provider on behalf of the injured worker. A valid LNI claim number MUST be present in 2000B-SBR03 or/and 2010BA-NM109. If SBR03 is absent (not sent) and 2010BA NM109 is Invalid the bill formats with a blank Claim ID And with EDI formatting error H05 See EDI Formatting Errors - page If SBR03 is absent (not sent) and 2010BA NM109 is equal to 7-characters and the 7-characters are not a valid LNI Claim ID, the bill formats with the 7-characters as the claim ID, and bill is denied: Returned on the provider s paper remittance with: EOB 280 DENIED. CLAIM ID BILLED IS NOT ACTIVE. CALL TO CONFIRM THE ID BEFORE REBILLING 6. SBR09 Claim Filing Indicator: Workers Compensation Health Claim Value : WC If Not Equal WC then bill formats with EDI formatting error H04 See EDI Formatting Errors - page

54 LOOP ID BA SUBSCRIBER NAME TR3 PAGE # 121 Segment/Field ID 2010BA SUBSCRIBER NAME NM1*IL FIELD NAME Subscriber Name: The subscriber will be the same person as the patient for Washington State Department of Labor and Industries Workers Compensation. Sample Data, TR3 Required Value [R] and Department Required Value [DRV] NM1 121 NM101 Entity Identifier Code IL [R] R 122 NM102 Entity Type Qualifier 1 [DRV] R 122 NM103 Subscriber Last Name PUBLIC R 122 NM104 Subscriber First Name JOHN S 122 NM105 Subscriber Middle Name Q S 123 NM108 Identification Code Qualifier MI [DRV] R Subscriber Primary Identifier: Washington State Department of Labor and Industries 7-character assigned Claim Number. Seg/Field USAGE Required 123 NM109 A or AB12345 [Alpha+6Numeric] R or [2Alpha+5Numeric] 124 N3 Subscriber Address Situational 124 N301 Subscriber Address PO BOX 123 R 125 N4 Subscriber City/State/ZIP Code Required 125 N401 Subscriber City OLYMPIA R 125 N402 Subscriber State WA S 126 N403 Subscriber Zip S 127 DMG Subscriber Demographic Information Situational 127 DMG01 Date Qualifier D8 [R] R 127 DMG02 Subscriber Birth Date: (CCYYMMDD) R 128 DMG03 Subscriber Gender Code M or F or U R 129 REF Subscriber Secondary Identification Situational 129 REF01 Reference ID Qualifier SY [R] R 129 REF02 Subscriber Supplemental Identifier R Segment Count 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ Example EDI Data Professional BA Subscriber Name notes 1. NM101 Entity Identifier Code: Insured or Subscriber IL 2. NM102 Entity Type Qualifier: Person 1 3. NM108 Identification Code Qualifier: Member Identification Number MI 4. NM109 Subscriber Primary Identifier 7-character LNI Claim Number/Claim ID Begin with single alpha-character + 6 numbers or double alpha-characters + 5 numbers. LNI Claim Numbers are derived from the Report of Accident (ROA) completed by the injured worker or by the provider on behalf of the injured worker. A valid LNI claim number MUST be present in 2010BA-NM109 or/and 2000B-SBR03. If the LNI claim number is invalid (see 2000B-SBR03 notes) Or is valid and NM108 is not equal to MI Then bill formats with EDI formatting error H05 See EDI Formatting Errors - page

55 2010BA Subscriber Name notes continued 5. NM103 Subscriber Last Name and NM109 Subscriber Primary Identifier LNI s processing compares the first two characters of the last name and claim ID submitted and formatted on the MIPS bill to the Claim Id and first two characters of the claimant s last name in the department s Claim Master file. If the comparison does not match, the bill may deny and returned on the provider s remittance advice with: EOB 259 Denied. Claim ID/Claimant Name Mismatch. Call to Confirm Claim ID Before Rebilling 6. REF Subscriber Secondary Identification Use this segment to send the injured worker s Social Security Number (SSN) if known or available. The SSN is not required for bill adjudication but may be used by the department as a secondary Id source for bill processing if needed. REF01 Reference Identification Qualifier: Social Security Number REF02 Subscriber Supplemental Identifier 9-digit Social Security Number (SSN) The Social Security Number is a string of exactly nine numbers with no separators. SY 7. REF Property and Casualty Claim Number Recommendation Do not use for WA State workers compensation billing LNI does not expect to receive this segment for identification of the worker s Claim ID If sent, the value in REF02 must be the same LNI 7-digit Claim ID sent in 2010BA NM109 or 2000B SBR03. If not a valid claim ID, the bill will format with an invalid Claim ID REF01 Reference Identification Qualifier: Agency Claim Number REF02 Property Casualty Claim Number Must be valid 7-digit LNI Claim ID. Y4 55

56 LOOP ID BB PAYER NAME 2010BB PAYER NAME NM1*PR TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 133 NM1 Payer Name Required 133 NM101 Entity Identifier Code PR [R] R 134 NM102 Entity Type Qualifier 2 [R] R 134 NM103 WASHINGTON STATE DEPT OF LABOR Payer Name & INDUSTRIES R 134 NM108 Identification Code Qualifier PI [R] R 134 NM109 Payer Identifier (ETIN): Washington State Department of Labor and R Industries Federal Tax Identification Number [DRV] 136 N4 Payer City, State, Zip Code Required 136 N401 Payer City Name OLYMPIA R 136 N402 Payer State Code WA S 137 N403 Payer Zip Code S 140 REF Billing Provider Secondary Identification Situational 140 REF01 Reference ID Qualifier: Provider Commercial Number G2 [DRV] R 141 REF02 Billing Provider Secondary ID: The provider s Washington State Department of Labor and Industries assigned 7-digit provider account number (if available. Leading R zeros are not required) Segment Count Example EDI Data Professional NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ N4*OLYMPIA*WA*98504~ REF*G2*12345~ 2010BB Payer Name notes The Billing Provider Secondary ID segment is moved from the 2010AA Billing Provider loop in 4010A1 to the 2010BB Payer Name loop in the 5010 format. REF01 qualifier G2 Provider Commercial Number replaces qualifier X5 State Industrial Accident Provider Number. When the Billing Provider Secondary ID REF*G2 is present, it will be used as the provider s primary Billing Provider identifier. 1. NM101 Entity Identifier Code: Payer PR 2. NM102 Entity Type Qualifier: Non-person Entity 2 3. NM108 Identification Code Qualifier: Payer Identification PI 4. NM109 Payer Identifier Washington State Department of Labor & Industries Federal Tax ID 56

57 2010BB Payer Name notes continued 5. REF Billing Provider Secondary Identification Use this segment to report the Billing Provider s LNI Provider Account Number as the Billing Provider s Secondary Identification in addition to the provider s NPI submitted in 2010AA NM109. Use this segment to report the Billing Provider s LNI Provider Account Number as the Billing Provider s Primary Identification when the provider is not NPI enumerated or the Provider s NPI is unknown. When Segment/Qualifier REF*G2 is present, REF02 will be used as the provider s identifier for bill formatting and adjudication processing. REF01 Reference ID Qualifier: Provider Commercial Number G2 If 2010AA-NM109 is not submitted (NPI) And REF01 not equal G2 Then bill formats with EDI formatting error H02 See EDI Formatting Errors - page REF02 Billing Provider Secondary Identifier 7-digit LNI provider account number. Leading zeros may be included but are not required. If REF02 is not a valid LNI provider account number Then bill formats with EDI formatting error H03 See EDI Formatting Errors - page

58 Detail, Patient Hierarchical Level LOOP ID CLAIM INFORMATION 2300 CLAIM INFORMATION - CLM TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 157 CLM Claim Information Required 158 CLM01 Patient Control Number: PUBLICJQ R 159 CLM02 Total Claim Charge Amount R 159 CLM05-1 Place of Service 11 R 159 CLM05-2 Facility Code Qualifier B [R] R 159 CLM05-3 Claim Frequency Code: Original 1 or 7 or 8 [DRV] R 159 CLM06 Provider or Supplier Signature Indicator Y R 160 CLM07 Provider Accept Assignment Code A R 160 CLM08 Assignment of Benefits Indicator Y R 161 CLM09 Release of Information Code Y R 161 CLM10 Patient Signature Source Code P S 161 CLM11-1 Related Causes Code EM [DRV] R 168 DTP Date Accident: Injury Date Situational 168 DTP01 Date Time Qualifier 439 [R] R 168 DTP02 Date Time Format Qualifier: CCYYMMDD D8 [R] R 168 DTP03 Accident Date R 193 REF Referral Number Situational 193 REF01 Reference ID Qualifier 9F [R] [DRV] R 193 REF02 Referral Number R 194 REF Prior Authorization Situational 194 REF01 Reference ID Qualifier G1 [R] [DRV] R 195 REF02 Prior Authorization Number R 196 REF Payer Claim Control Number Situational 196 REF01 Reference ID Qualifier F8 [R] R 196 REF02 Payer Claim Control Number (ICN) R 202 REF Claim Identifier for Transmission Intermediaries Situational 202 REF01 Reference ID Qualifier D9 [R] R 203 REF02 Value Added Network Trace Number VANTN R 204 REF Medical Record Number (optional) Situational 204 REF01 Reference ID Qualifier EA [R] R 204 REF02 Medical Record Number R 209 NTE Claim Note Situational 209 NTE01 Note Reference Code ADD [R] [DRV] R 210 NTE02 Claim Note Text (bill level remarks) R 226 HI Health Care Diagnosis Code (Principal) Required 226 HI01-1 Diagnosis Type Code BK [R] ICD-9 or ABK [R] ICD-10 R 227 HI01-2 Diagnosis Code: Principal Diagnosis 724 or 7240 or [ICD-9-CM] R HI Health Care Diagnosis Code (Other) Situational HI02-1/HI12-1 Diagnosis Type Code BF [R] ICD-9 or ABF [R] ICD-10 S HI02-2/HI12-2 Diagnosis Code : Other Diagnosis 821 or 8210 or [ICD-9-CM] S Segment Count Example EDI Data Professional CLM* *175.50***11:B:1*Y*A*Y*Y**EM ~ 23 DTP*439*D8* ~ 24 REF*G1* REF*D9*VANTN HI*BK:7241*BF:8210~ Electronic Adjustment - Replacement CLM* *175.50***11:B:7*Y*A*Y*Y**EM ~ REF*F8* NTE*ADD*CORRECTED PROC CODE BILLED AND UNITS ON SVC LINE 3 Electronic Adjustment - Void CLM* *175.50***11:B:8*Y*A*Y*Y**EM ~ REF*F8* NTE*ADD*BILLED INCORRECT CLAIM ID FOR DOS 58

59 2300 Claim Information notes 1. CLM01 Patient Account Number This number identifies the patient s account number in the provider s medical billing system. MIPS processing supports up to 20 characters for the patient account number The patient account number is returned in following outbound transactions: o 835 Payment Advice (5010/4010) 2100-CLP01 Patient Control Number. o 277 Notification (5010) 2200D-TRN02 Patient Control Number. o 277 Unsolicited Notification (3070) D-TRN02 Patient Control Number. o 277 Pended Notification (3070) 2200D-TRN02 Patient Control Number. 2. CLM02 Total Claim Charge Amount Must balance to the sum of all service line charge amounts reported in SV1-SV102 Line Item Charge Amount. The Total Claim Charge amount is returned in the following outbound transactions: o 835 Payment Advice (5010/4010) 2100-CLP03 Total Claim Charge Amount. o 277 Notification (5010) 2200D-STC04 Total Claim Charge Amount. o 277 Unsolicited Notification (3070) D-STC04 Total Claim Charge Amount. o 277 Pended Notification (3070) 2200D-STC04 Total Claim Charge Amount. 3. CLM05-1 Place of Service Code Place of Service codes are two-digit codes used to indicate the setting in which the health care service(s) is provided. See Appendix for Place of Service codes and descriptions. 4. CLM05-2 Facility Code Qualifier: Place of Service for Professional/Dental services B 5. CLM05-3 Claim Frequency Code: Original, Replacement, Void 1 or 7 or 8 This field will be used to determine if the submitted bill is one of the following: o Original 1 - Original bill submission or resubmission of a previously denied bill. o Replacement 7 - Request for Adjustment to a previously paid bill that is fully or partially paid. o Void 8 - Request for Void to a previously paid bill or a bill still in process. If CLM05-3 equals 7 (Replacement) or 8 (Void) Then Payer Claim Control Number 2300 REF*F8 segment is required If CLM05-3 not equal 1 (Original) or 7 (Replacement) or 8 (Void) Then bill formats with EDI formatting error H08 See EDI Formatting Errors - page CLM06 Provider or Supplier Signature Indicator: Provider signature is on file Y 7. CLM07 Provider Accept Assignment Code: Assigned A 8. CLM08 Assignment of Benefits Indicator: Yes Y Insured or authorized person authorizes benefits to be assigned to the provider 9. CLM09 Release of Information Code: Yes Y Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim. 10. CML10 Patient Signature Source Code P Patient signature generated by provider because the patient was not physically present for services. Patient signature generated by an entity other than the patient according to State or Federal law. 11. CLM11-1 Related Causes code: Employment EM Must equal EM for Washington State Workers Compensation billing for work related injuries and occupational disease. 59

60 2300 Claim Information notes continued 12. Date of Accident The Date of Accident (Injury Date) is required for Washington State Workers Compensation billing for work related injuries and/or occupational disease. Date of Accident is required when CLM11-1 Related Causes Code equal EM. DTP01 Date Time Qualifier: Accident 439 DTP02 Date Time Period Format Qualifier: CCYYMMDD DTP03 Accident Date Date of Accident or Industrial Illness or injury 13. REF Referral Number REF01 Reference Identification Qualifier: Referral Number REF02 Referral Number For Vocational Rehabilitation bills, this number represents the Voc Referral ID number D8 9F 14. REF Prior Authorization REF01 Reference Identification Qualifier: Prior Authorization Number G1 REF02 Prior Authorization Number 10 digit Prior Authorization number assigned by Claim Manager/Qualis for procedure/service 5010 note If Referral Number REF*F8 and Prior Authorization REF*G1 each are submitted in 2300 CLM. MIPS processing will use Prior Authorization REF*G1 for bill formatting and processing note If Referral Number REF*F8 and Prior Authorization REF*G1 each are submitted in 2300 CLM, MIPS processing will use the REF 9F/G1 segment occurring first in sequence for bill formatting and processing. 15. Payer Claim Control Number Required for electronic adjustment request CLM05-3 Claim Frequency Code equals 7 (Replacement) or 8 (Void) REF01 Reference Identification Qualifier: Original Reference Number F8 REF02 Payer Claim Control Number (LNI Internal Control Number) 17-digit LNI Internal Control Number (ICN) assigned to the Original bill There exists a series of possible EDI formatting errors associated to electronic adjustments H31 H39 See EDI Formatting Errors - page REF Claim Identifier for Transmission Intermediaries REF01 Reference Identification Qualifier: Claim Number D9 REF02 Value Added Network Trace Number/Clearinghouse Trace Number Clearinghouses may assign and submit this number for their tracing purposes. If submitted, LNI will support up to 20 characters of the Clearinghouse assigned trace number. The clearinghouse trace number will be returned in the following outbound transactions: o 277 Notification (5010) 2200D REF*D9 REF01 o 277 Unsolicited Notification (3070) 2200D REF*D9 REF02 o 277 Pended Notification (3070) 2200D REF*D9 REF02 60

61 2300 Claim Information notes continued 17. REF Medical Record Number REF01 Reference Identification Qualifier: Medical Record Identification Number EA REF02 Medical Record Number The provider may submit this number at their discretion. If submitted, the Medical Record Number will be returned in the following outbound transactions: o 835 (5010/4010) 2100 REF*EA REF02 Returned when received in the 837 transaction AND the bill contains an invalid Claim ID (i.e. EDI formatting error H05) o 277 Notification (5010) Not supported. o 277 Unsolicited Notification (3070) 2200E REF*EA REF02 o 277 Pended Notification (3070) 2200E REF*EA REF NTE Bill Level Claim Note NTE01 Note Reference Code: Additional Information ADD NTE02 Claim Note Text: free-form description for Bill Level Remarks This segment applies to the entire bill If submitted, will cause the bill to suspend during MIPS processing requiring manual adjudication of the bill to a finalized (paid/denied) status, Caution - improper use of billing remarks may cause delay in the processing and payment of the bill. Remarks such as routine descriptions of procedures or diagnosis codes or the results of diagnostic studies or requests for authorization of services should be avoided and not entered. In some cases, further explanation of services rendered is required when the procedure code references an unlisted service or contains a modifier(s). In these cases, you may provide the nature of the unlisted service or explain the nature for additional charges (modifier - 22) where applicable. If submitted on electronic adjustment Replacement, will cause the replacement bill to suspend and require manual adjudication to a finalized status. If submitted on electronic adjustment Void, will not cause the void bill to suspend. Bill remarks retained for reference purposes. 19. HI Health Care Diagnosis Code (Required) HI01 Health Care Code Information. The diagnosis listed in this field is assumed to be the principal diagnosis. Do Not transmit the decimal point for ICD codes. The decimal point is implied. HI01-1 Diagnosis Type Code BK or ABK ICD-9-CM Principal Diagnosis is reported using code BK ICD-10-CM Principal Diagnosis is reported using code ABK (effective October 1, 2013) HI01-2 Diagnosis Code Principal Diagnosis of injury or illness HI02 through HI12 Health Care Code Information (Situational) Use HI02 through HI12 to report additional diagnosis as applicable. HI02-1 through HI12-1 Diagnosis Type Code BF or ABF ICD-9-CM additional/other diagnosis is reported using code BF ICD-10-CM additional/other diagnosis is reported using code ABF (effective October 1, 2013) HI02-2 through HI12-02 Diagnosis Code Additional/other Diagnosis of injury or illness 61

62 LOOP ID A REFERRING PROVIDER NAME 2310A REFERRING PROVIDER NAME NM1*DN TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 257 NM1 Referring Provider Name Situational 258 NM101 Entity Identifier Code DN [R] R 258 NM102 Entity Type Qualifier 1 [R] R 258 NM103 Referring Provider Last or Organization Name JEFFERSON R 258 NM104 Referring Provider First Name THOMAS S 258 NM105 Referring Provider Middle Name A S 259 NM108 Identification Code Qualifier XX [R] S 259 NM109 Referring Provider Identifier S 260 REF Referring Provider Secondary Identification Situational 260 REF01 Reference Identification Qualifier G2 [DRV] R 261 REF02 Referring Provider Secondary Identifier R Segment Count Example EDI Data Professional NM1*DN*1*JEFFERSON*THOMAS*A***XX* ~ LNI Provider Account Number NM1*DN*1*JEFFERSON*THOMAS*A~ REF*G2*12345~ NPI + LNI Provider Account Number NM1*DN*1*JEFFERSON*THOMAS*A***XX* ~ REF*G2*12345~ 2310A Referring Provider Name notes: 1. NM101 Entity Identifier Code: Referring Provider DN 2. NM102 Entity Type Qualifier: Person 1 3. NM103 Referring Provider Last Name 4. NM104 Referring Provider First Name 5. NM105 Referring Provider Middle Initial 6. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Referring Provider s NPI is submitted in NM NM109 Referring Provider Identifier 10-digit National Provider Identifier (NPI). 8. REF Referring Provider Secondary ID Use when provider is not NPI enumerated or unknown. This segment is not validated for MIPS bill EDI formatting. May be included as an additional ID to the NPI submitted in NM109 of this loop.. REF01 Reference ID Qualifier: Provider Commercial Number REF02 Referring Provider Secondary ID 7-digit LNI provider account number. Leading zeros may be included but are not required. G2 62

63 LOOP ID B RENDERING PROVIDER NAME 2310B RENDERING PROVIDER NAME NM1*82 Sample Data, TR3 Required Value [R] TR3 Segment/Field Seg/Field FIELD NAME and Department Required Value PAGE # ID USAGE [DRV] 262 NM1 Rendering Provider Name Situational 263 NM101 Entity Identifier Code 82 [R] R 263 NM102 Entity Type Qualifier 1 [R] R 263 NM103 Rendering Provider Last or Organization Name WASHINGTON R 263 NM104 Rendering Provider First Name GEORGE S 263 NM105 Rendering Provider Middle Name S 264 NM108 Identification Code Qualifier XX [R] S 264 NM109 Rendering Provider Identifier S 265 PRV Rendering Provider Specialty Information Situational 265 PRV01 Provider Code PE [R] R 265 PRV02 Reference Identification Qualifier PXC [R] R 265 PRV03 Provider Taxonomy Code X R 267 REF Rendering Provider Secondary Identification Situational 267 REF01 Reference Identification Qualifier G2 [DRV] R 268 REF02 Rendering Provider Secondary Identifier R Segment Count Example EDI Data Professional NM1*82*1*WASHINGTON*GEORGE***XX* ~ 29 PRV*PE*ZZ* X~ LNI Provider Account Number NM1*82*1*WASHINGTON*GEORGE~ PRV*PE*ZZ* X~ REF*G2*23456~ NPI + LNI Provider Account Number NM1*82*1*WASHINGTON*GEORGE***XX* ~ PRV*PE*ZZ* X~ REF*G2*23456~ 2310B Rendering Provider notes Required when the Rendering Provider information is different than that carried in loop ID 2010AA Billing Provider. For Clinic Provider Types that have individual providers attached to their group (payee) provider account number, the individual provider performing services is reported in this loop using the provider s individual NPI in NM109 and/or the provider s individual LNI provider account number using the Rendering Provider Secondary Identification segment. This loop is not required for individual providers who are not attached to an LNI Group/payee provider account. 1. NM101 Entity Identifier Code: Rendering Provider NM102 Entity Type Qualifier: Person 1 3. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Rendering Provider s NPI is submitted in NM NM109 Rendering Provider Identifier 10-digit National Provider Identifier (NPI). The submitted NPI is used as the provider s primary identifier when this loop does not include the Rendering Provider Secondary Identification segment REF*G2. If the submitted NPI (NM109) is not on file Or is on file but not cross-referenced to an LNI provider account number And this loop does not include the Rendering Provider Secondary Identification segment REF*G2 Then bill formats with EDI formatting error H23 See EDI Formatting Errors - page

64 Rendering Provider notes continued 5. Rendering Provider Specialty Information 10-digit Provider Taxonomy code If submitted, the provider s taxonomy code may be used when processing the provider s National Provider Identifier (NPI) to assist the department in appropriately cross-referencing the NPI to the provider s LNI provider account number. PRV01 Provider Code: Performing PRV02 Reference Identification Qualifier: Health Care Provider Taxonomy Code PRV03 Provider Taxonomy Code PE PXC 6. REF Rendering Provider Secondary Identification Use when provider is not NPI enumerated or unknown. When Segment/Qualifier REF*G2 is present, REF02 will be used as the provider s identifier for bill formatting and adjudication processing. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number G2 If 2310B-NM109 is not submitted (NPI) And REF01 not equal G2 Then bill formats with EDI formatting error H11 See EDI Formatting Errors - page REF02 Billing Provider Secondary ID 7-digit LNI provider account number Leading zeros may be included but are not required. If REF01 equals G2 and REF02 is not a valid LNI provider account number Then bill formats with EDI formatting error H12 See EDI Formatting Errors - page For Clinic Provider Types that have individual providers attached to their group (payee) provider account number, REF02 must be the provider s individual LNI provider account number. IF REF02 contains the clinic s group (payee) provider account number The bill is denied and returned on the provider s paper remittance with: EOB 072 DENIED. REBILL SERVICES UNDER THE PERFORMING PROVIDER S NAME AND PROVIDER NUMBER AND/OR NPI IF REF02 contains a valid LNI provider account number And the LNI provider account is not associated to the clinic s group (payee) provider account number The bill is denied and returned on the provider s paper remittance advice with: EOB 292 DENIED. OUR RECORDS DON T SHOW THE PROVIDER/GROUP ACCOUNT NUMBERS AS RELATED. CALL

65 LOOP ID 2310C SERVICE FACILITY LOCATION NAME TR3 PAGE # 269 Segment/Field ID 2310C SERVICE FACILITY LOACTION NAME NM1*77 FIELD NAME Service Facility Location Required when location of health care service is different than from the Billing (2010AA) loop. Sample Data, TR3 Required Value [R] and Department Required Value [DRV] Seg/Field USAGE Situational NM1 270 NM101 Entity Identifier Code 77 [R] R 270 NM102 Entity Type Qualifier 2 [R] R 270 NM103 Laboratory or Facility Name MEDICAL DIAGNOSTICS R 270 NM108 Identification Code Qualifier XX [R] S 271 NM109 Laboratory or Facility Primary Identifier S 272 N3 Service Facility Location Address Required 272 N301 Service Facility Location Address: Address Line WATER STREET R 272 N302 Service Facility Location Address: Address Line 2 S 273 N4 Service Facility Location City/State/Zip Code Required 273 N401 Service Facility Location City OLYMPIA R 274 N402 Service Facility Location State WA S 274 N403 Service Facility Location Zip S 275 REF Service Facility Location Secondary Identification Situational 275 REF01 Reference Identification Qualifier G2 [R] [DRV] R 276 REF02 Laboratory or Facility Secondary Identifier R Segment Count Example EDI Data Professional NM1*77*2*MEDICAL DIAGNOSTICS CENTER*****XX* ~ 31 N3*456 WATER STREET~ 32 N4*OLYMPIA*WA*98555~ LNI Provider Account Number NPI + LNI Provider Account Number NM1*77*2*MEDICAL DIAGNOSTICS~ NM1*77*2*MEDICAL DIAGNOSTICS*****XX* ~ N3*456 WATER STREET~ N3*456 WATER STREET~ N4*OLYMPIA*WA*98555~ N4*OLYMPIA*WA*98555~ REF*G2*23456~ REF*G2*23456~ 2310C Service Facility Location Name notes Required when the location of health service is different than that carried in loop 2010AA Billing Provider. 1. NM101 Entity Identifier Code: Service Location NM102 Entity Type Qualifier: Non-Person Entity 2 3. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Service Location s NPI is submitted in NM NM109 Laboratory or Facility Primary Identifier 10-digit National Provider Identifier (NPI). 5. REF Service Facility Location Secondary Identification Use when provider is not NPI enumerated or unknown. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Billing Provider Secondary ID 7-digit LNI provider account number Leading zeros may be included but are not required. G2 65

66 LOOP ID SERVICE LINE NUMBER 2400 SERVICE LINE NUMBER - LX TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 350 LX Service Line (max. 50 occurrences) Loop Repeat: 50 Required 350 LX01 Service Line Number 1 R 351 SV1 Professional Service Required First Line Item 352 SV101-1 Product/Service ID Qualifier HC [R] or ER [DRV for LNI local codes] R 353 SV101-2 Procedure Code R 353 SV101-3 Procedure Modifier-1 AA S 353 SV101-4 Procedure Modifier-2 25 S 353 SV101-5 Procedure Modifier-3 S 354 SV101-6 Procedure Modifier-4 S 354 SV102 Line Item Charge Amount R 355 SV103 Unit or Basis for Measurement Code UN [DRV] R 355 SV104 Service Unit Count 3 R 355 SV105 Place of Service Code 11 S SV107 Composite Diagnosis Code Pointer Required 356 SV107-1 Diagnosis Code Pointer (first DX pointer only) 1 [R] R 357 SV109 Emergency Indicator Y [R] S 359 SV5 Durable Medical Equipment Service Situational 359 SV501-1 Product /Service ID Qualifier HC [R] R 360 SV501-2 Procedure Code R 360 SV502 Basis for Measurement Code DA [R] R 360 SV503 Length of Medical Necessity (Quantity) R 360 SV504 DME Rental Price R 360 SV505 DME Purchase Price R 361 SV506 Rental Unit Price Indicator 1 or 4 or 6 [R] R 380 DTP Date - Service Date Required 380 DTP01 Date Qualifier: Service 472 [R] R 380 DTP02 Date Format Qualifier D8 [R] R 381 DTP03 Service Date R 401 REF Line Item Control Number Situational 401 REF01 Reference ID Qualifier 6R [R] R 402 REF02 Line Item Control Number R 413 NTE Line Note Situational 413 NTE01 Note Reference Code ADD [R] R 413 NTE02 Line Text Service Line level remark R Second/Additional Line Item(s) LX Service Line Situational LX01 Service Line Number 2 SV1 Professional Service Required Second Line Item SV107 Composite Diagnosis Code Pointer Required SV5 Durable Medical Equipment Service Situational DTP Date - Service Date Required REF Line Item Control Number Situational NTE Line Note Situational Segment Count 33 LX*1~ 34 SV1*HC:99213:AA:25*67*UN*3*11**1**Y~ 35 DTP*472*D8* ~ 36 LX*2~ 37 SV1*HC:L3800:25*12.25*UN*3*11**2**~ 38 DTP*472*D8* ~ Example EDI Data Professional

67 2400 Service Line notes 1. HIPAA implementation and MIPS processing supports up to and including fifty (50) lines of service for 837 Professional billing. The Maximum number of Service Lines is 50. LX01 Service Line Number The Service Line LX segment must begin with one (1) And is incremented by one (1) for each additional service line billed. 2. SV101-1 Product/Service ID Qualifier HC or ER Use code HC when billing Health Care Financing Administration Common Procedural Coding system (HCPCS) codes. The AMA s CPT codes are level 1 HCPCS codes and are reported with code HC. Use code ER when billing LNI Local Codes (Jurisdiction Specific Procedure and Supply Codes). Note: Clearinghouse trading partners are request to accept LNI local codes billed by Washington State LNI providers when billed with Product/Service ID Qualifier ER. 3. SV101-2 Procedure Code Service or Product code provided. 4. SV101-3 through SV101-6 Procedure Modifiers 1 through 4 For information on billing Procedure Code Modifiers visit: Fee Schedules, Billing & Payment Policies at Professional Services Fee Schedule at 5. SV102 Line Item Charge Amount The sum total of all Service Line Charges must balance to the Total Claim Charge Amount in 2300 CLM SV103 Unit or Basis for Measurement Code: Unit UN 7. SV104 Service Unit Count Enter Units or Days as whole numbers. Do not use fractions or decimals. 8. SV105 Place of Service Code Required when the value is different than the value carried in Place of Service 2300 CLM05-1. For convenience, a list of Place of Service codes can be found on page of this guide. 9. SV107-1 Diagnosis Code Pointer: Principal Diagnosis 1 This Diagnosis Code Pointer is considered to be the principal diagnosis on this claim. A Diagnosis Code Pointer is required for each line of service submitted. 10. SV109 Emergency Indicator: Yes Y or blank Required when the service is known to be an emergency by the provider. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. 11. SV5 Durable Medical Equipment Service Required when necessary to report both the rental and purchase price information for durable medical equipment. Not used for claims where the provider is reporting only the rental price or only the purchase price. SV501-1 Product/Service ID Qualifier: HCPCS SV501-2 Procedure Code This value must be the same as that reported in SV101-2 HC 67

68 2400 Service Line notes continued SV502 Unit or Basis for Measurement Code: Days SV503 Length of Medical Necessity: Quantity Number of days medical treatment/equipment is required. SV504 DME Rental Price SV505 DME Purchase Price DA SV506 Rental Unit Price Indicator 1 or 4 or 6 Use code 1 to indicate frequency of Weekly. Use code 4 to indicate frequency of Monthly. Use code 6 to indicate frequency of Daily. 12. Date Service Date DTP01 Date/Time Qualifier: Service 472 DTP02 Date Time Format Qualifier: CCYYMMDD or CCYYMMDD-CCYYMMDD D8 or RD8 DTP03 Service Date 13. REF Line Item Control Number REF01 Reference Identification Qualifier: Provider Control Number REF02 Line Item Control Number 6R Provided at the discretion of the submitter. Must be unique within a Patient Control Number CLM01. The department will support up to 30 characters of the Line Item Control Number. If submitted, the Line Item Control Number will be returned in the following transactions: o 835 (5010/4010) 2110 REF*6R REF02 o 277 Notification (5010) REF*FJ REF02 o Note: LNI processing does not currently return the Line Item Control Number submitted in the REF*6R to the 835/277 Under development for future release. 14. NTE Service Line Notes NTE01 Note Reference Code: Additional Information NTE02 Line Text ADD This segment applies to the specific Service Line If submitted, will cause the bill to suspend during MIPS process requiring manual adjudication of the bill to a finalized (paid/denied) status. Caution - improper use of billing remarks may cause delay in the processing and payment of the bill. Remarks such as routine descriptions of procedures or diagnosis codes or the results of diagnostic studies or requests for authorization of services should be avoided and not entered. In some cases, further explanation of services rendered is required when the procedure code references an unlisted service or contains a modifier(s). In these cases, you may provide the nature of the unlisted service or explain the nature for additional charges (modifier - 22) where applicable. 68

69 837 Professional Sample Billing Data NPI Provider ID This sample EDI data represents sample billing for professional services and includes the use of the Provider s NPI as the primary provider identifier within all applicable areas of the transaction. SEG No. ISA*00*...*00*...*ZZ* *30* *110930*1800*U*00501* *1*P*:~ GS*HC* * * *1800*101*X*005010X222A1~ 1 ST*837* *005010X222A1~ 2 BHT*0019*00*1234* *1800*CH~ 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 6 HL*1**20*1~ 7 PRV*BI*PXC*261QM1300X~ 8 NM1*85*2*COMMUNITY HEALTH CLINIC*****XX* ~ 9 N3*123 WATERS ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected]~ 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ 20 NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ 22 CLM* *175.50***11:B:1*Y*A*Y*Y**EM ~ 23 DTP*439*D8* ~ 24 REF*G1* ~ 25 REF*D9*VANTN012345~ 26 HI*BK:7241*BF:8210~ 27 NM1*DN*1*JEFFERSON*THOMAS*A***XX* ~ 28 NM1*82*1*WASHINGTON*GEORGE***XX* ~ 29 PRV*PE*ZZ* X~ 30 NM1*77*2*COMMUNITY HEALTH DIAGNOSTICS CENTER*****XX* ~ 31 N3*456 WATER STREET*~ 32 N4*OLYMPIA*WA*98555~ 33 LX*1~ 34 SV1*HC:99213:AA:25*67*UN*3*11**1**Y~ 35 DTP*472*D8* ~ 36 LX*2~ 37 SV1*HC:L3800:25*12.25*UN*3*11**2**~ 38 DTP*472*D8* ~ 39 SE*39* ~ GE*1*101~ IEA*1* ~ The Sample EDI Data Shown below is Parsed by Segment for readability purposes and does not represent the Continuous Data format used when uploading the file through Provider Express Billing (PEB) 69

70 837 Professional Sample Billing Data LNI Provider ID This sample EDI data represents sample billing for professional services and includes the use of the Provider s LNI Provider Account Number as the primary provider identifier within all applicable areas of the transaction. SEG No. ISA*00*...*00*...*ZZ* *30* *110930*1800*U*00501* *1*P*:~ GS*HC* * * *1800*101*X*005010X222A1~ 1 ST*837* *005010X222A1~ 2 BHT*0019*00*1234* *1800*CH~ 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 6 HL*1**20*1~ 7 PRV*BI*PXC*261QM1300X~ 8 NM1*85*2*COMMUNITY HEALTH CLINIC~ 9 N3*123 WATERS ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected]~ 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ 20 NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ 22 REF*G2*123456~ 23 CLM* *175.50***11:B:1*Y*A*Y*Y**EM ~ 24 DTP*439*D8* ~ 25 REF*G1* REF*D9*VANTN HI*BK:7241*BF:8210~ 28 NM1*DN*1*JEFFERSON*THOMAS*A~ 29 REF*G2*12345~ 30 NM1*82*1*WASHINGTON*GEORGE~ 31 PRV*PE*ZZ* X~ 32 REF*G2*23456~ 33 NM1*77*2*COMMUNITY HEALTH DIAGNOSTICS CENTER*****XX* ~ 34 N3*456 WATER STREET*~ 35 N4*OLYMPIA*WA*98555~ 36 REF*G2*23456~ 37 LX*1~ 38 SV1*HC:99213:AA:25*67*UN*3*11**1**Y~ 39 DTP*472*D8* ~ 40 LX*2~ 41 SV1*HC:L3800:25*12.25*UN*3*11**2**~ 42 DTP*472*D8* ~ 43 SE*43* ~ GE*1*101~ IEA*1* ~ The Sample EDI Data Shown below is Parsed by Segment for readability purposes and does not represent the Continuous Data format used when uploading the file through Provider Express Billing (PEB) 70

71 837 Professional Sample Billing Data NPI + LNI Provider ID This sample EDI data represents sample billing for professional services and includes the use of the Provider s NPI as the primary provider identifier and the LNI Provider Account Number as the secondary provider identifier within all applicable areas of the transaction. SEG No. ISA*00*...*00*...*ZZ* *30* *110930*1800*U*00501* *1*P*:~ GS*HC* * * *1800*101*X*005010X222A1~ 1 ST*837* *005010X222A1~ 2 BHT*0019*00*1234* *1800*CH~ 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 6 HL*1**20*1~ 7 PRV*BI*PXC*261QM1300X~ 8 NM1*85*2*COMMUNITY HEALTH CLINIC*****XX* ~ 9 N3*123 WATERS ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected]~ 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ 20 NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ 22 REF*G2*123456~ 23 CLM* *175.50***11:B:1*Y*A*Y*Y**EM ~ 24 DTP*439*D8* ~ 25 REF*G1* REF*D9*VANTN HI*BK:7241*BF:8210~ 28 NM1*DN*1*JEFFERSON*THOMAS*A***XX* ~ 29 REF*G2*12345~ 30 NM1*82*1*WASHINGTON*GEORGE***XX* ~ 31 PRV*PE*ZZ* X~ 32 REF*G2*23456~ 33 NM1*77*2*COMMUNITY HEALTH DIAGNOSTICS CENTER~ 34 N3*456 WATER STREET*~ 35 N4*OLYMPIA*WA*98555~ 36 REF*G2*23456~ 37 LX*1~ 38 SV1*HC:99213:AA:25*67*UN*3*11**1**Y~ 39 DTP*472*D8* ~ 40 LX*2~ 41 SV1*HC:L3800:25*12.25*UN*3*11**2**~ 42 DTP*472*D8* ~ 43 SE*43* ~ GE*1*101~ IEA*1* ~ The Sample EDI Data Shown below is Parsed by Segment for readability purposes and does not represent the Continuous Data format used when uploading the file through Provider Express Billing (PEB) 71

72 837 HEALTH CARE CLAIM: INSTITUTIONAL ASC X12N X223A2 The HIPAA requirements for communication of professional billing to the Department of Labor and Industries are listed below. These requirements adhere to the definitions set forth in the EDI ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (Implementation Guide) Version 5, Release 1. The diagram represents an overview of the interchange control and transaction structure. The details of this structure can be found in Appendix B ASC X12 Nomenclature of the X223A2 Health Care Claim Institutional TR3. In addition, refer to the Addenda for updates to this version. Communication Transport Protocol ISA Interchange Control Header GS Functional Group Header ST SE Transaction Set Header Detail Segments for example, Claim submission Transaction Set Trailer FUNCTIONAL GROUP INTERCHANGE ENVELOPE COMMUNICATION ENVELOPE GE Functional Group Trailer IEA Interchange Control Trailer Communication Transport Protocol 72

73 INSTITUTIONAL 837 BILLING DATA This diagram lists the ASC X X223A2 Institutional Health Care Claim 837 transaction set detail segments that will be utilized by the Washington State Department of Labor and Industries Workers Compensation Medical Information and Payment System (MIPS). The system will extract fields from the segments below for the purpose of claim/billing adjudication, payment and corresponding communication. Segments and fields not utilized by the department are excluded from this companion guide. The department will not reject transactions, which include segments and loops that are not utilized by the agency. Page references have been provided to the corresponding Implementation Guide for further details. LOOP ID A SUBMITTER NAME This loop identifies the entity responsible for creation, formatting and submission of the EDI transaction and provides the submitter s contact information to the receiver. 1000A SUBMITTER NAME NM1*41 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 71 NM1 Submitter Name Required 71 NM101 Entity Identifier Code 41 [R] R 72 NM102 Entity Type Qualifier 2 R 72 NM103 AMERICAN MEDICAL BILLING Submitter Last or Organization Name SERVICES R 72 NM108 Identification Code Qualifier 46 [R] R 72 NM109 Submitter Identifier National Provider Identifier (NPI) or LNI provider account number authorized for electronic billing or R 73 PER Submitter EDI Contact Information Required 74 PER01 Contact Function Code IC [R] R 74 PER02 Submitter Contact Name BEN FRANKLIN S 74 PER03 Communication Number Qualifier TE R 74 PER04 Submitter Contact Phone R 74 PER05 Communication Number Qualifier EM S 75 PER06 Submitter Contact [email protected] S Segment Example EDI Data Institutional 837 Count 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 1000A Submitter Name notes 1. NM101 Entity Identifier Code: Submitter NM102 Entity Type Qualifier: Person (individual) 1 1 Non-Person Entity (organization) NM108 Identification Code Qualifier: Electronic Transmitter Identification Number (ETIN) NM109 Submitter Identifier 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) registered with Provider Express Billing (PEB) and authorized for EDI submissions. Must be identical to the ISA06 Interchange Sender ID and GS02 Application Sender Code. Do Not truncate leading zeros when using the LNI provider account number. Used by the department to validate the provider s electronic billing authorization. Used for routing purposes of the 277 Notification. 73

74 1000A Submitter Name notes: continued Clearinghouses If the provider is submitting electronic billing through a clearinghouse, the clearinghouse Submitter ID in NM109 must be authorized to submit electronic billing for the provider identified in the 2010AA Billing Provider and/or the 2310B Rendering Provider loops. Provider s may authorize only one clearinghouse for their electronic billing for their provider account. If the Submitter ID is not authorized to bill electronically for the provider, the bills may appear on the provider s remittance advice with the one of the following EOB s: EOB BILL SUSPENDED. SUBMITTER NOT AUTHORIZED TO SUBMIT BILLS FOR THIS PROVIDER. CALL EOB DENIED. THIS IS AN ELECTRONIC BILL. THE INTERMEDIARY/CLEARINGHOUSE IS NOT AUTHORIZED TO SUBMIT BILLS FOR THIS PROVIDER. CALL Provider s must authorize their clearinghouse for electronic billing by submitting an Electronic Billing Authorization Agreement to the department s Electronic Billing Unit. The EBA agreement is available online at: 5. PER Submitter EDI Contact Information Use this segment to communicate the submitter s contact information. This information may be used by the Electronic Billing Unit to contact the submitter of the file if needed. PER01 Contact Information Code: Information Contact PER02 Submitter Contact Name Contact name of the person submitting/supporting EDI with LNI. Name must not be the same name submitted in 1000A NM103. PER03 Communication Number Qualifier: Telephone Number PER04 Communication Number Contact phone number of the person submitting/supporting EDI with LNI. PER05 Communication Number Qualifier: Electronic Mail PER06 Communication Number Contact address of the person submitting/supporting EDI with LNI. IC TE EM 74

75 LOOP ID B RECEIVER NAME This loop identifies the receiver of the EDI transaction file. 1000B RECEIVER NAME NM1*40 TR3 Segment/Field Sample Data, TR3 Required Value [R] FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 76 NM1 Receiver Name Required 76 NM101 Entity Identifier Code 40 [R] R 76 NM102 Entity Type Qualifier 2 [R] R 77 NM103 WASHINGTON STATE DEPT OF Receiver Name LABOR & INDUSTRIES [DRV] R 77 NM108 Identification Code Qualifier 46 [R] R 77 NM109 Receiver Identifier (ETIN) Washington State Department of Labor and Industries Federal Tax Identification Number [DRV] R Segment Example EDI Data Institutional 837 Count 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 1000B Receiver Name notes 1. NM101 Entity Identifier Code: Receiver NM102 Entity Type Qualifier: Non-Person Entity 2 3. NM108 Identification Code Qualifier: Electronic Transmitter Identification Number (ETIN) NM109 Receiver Identifier (ETIN): WA State Dept of Labor & Industries Federal Tax ID

76 Detail, Billing Provider Hierarchical Level LOOP ID 2000A BILLING PROVIDER HIERARCHICAL LEVEL 2000A BILLING PROVIDER HIERARCHICAL LEVEL - HL TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 78 HL Billing Provider Hierarchical Level Required 78 HL01 Hierarchical ID Number 1 R 78 HL03 Hierarchical Level Code 20 [R] R 79 HL04 Hierarchical Child Code 1 [R] R 80 PRV Billing Provider Specialty Information Situational 80 PRV01 Provider Code BI [R] R 80 PRV02 Reference Identification Qualifier PXC [R] R 80 PRV03 Provider Taxonomy Code 282N00000X R Segment Count 6 HL*1**20*1~ 7 PRV*BI*PXC*282N00000X~ Example EDI Data Institutional A Billing Provider HL notes 1. HL03 Hierarchical Level Code: Information Source HL04 Hierarchical Child Code 1 3. PRV01 Provider Code: Billing BI 4. PRV02 Reference Identification Qualifier: Health Care Provider Taxonomy Code PXC 5. PRV03 Provider Taxonomy Code 10-digit Provider Taxonomy code. If submitted, the provider s taxonomy code may be used when processing the provider s National Provider Identifier (NPI) to assist the department in appropriately cross-referencing the NPI to the provider s LNI provider account number. 76

77 LOOP ID AA BILLING PROVIDER NAME 2010AA BILLING PROVIDER NAME NM1*85 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 84 NM1 Billing Provider Name Required 85 NM101 Entity Code Identifier 85 [R] R 85 NM102 Entity Type Qualifier 1 or 2 [R] R 85 NM103 Billing Provider Last or Organizational Name COMMUNITY HOSPITAL R 86 NM108 Identification Code Qualifier XX [R] S 86 NM109 Billing Provider Identifier S 87 N3 Billing Provider Address Required 87 N301 Billing Provider Address 123 MAIN ST R 88 N4 Billing Provider City/State/Zip Code Required 88 N401 Billing Provider City OLYMPIA R 89 N402 Billing Provider State WA S 89 N403 Billing Provider Zip S 90 REF Billing Provider Tax Identification Required 90 REF01 Reference Identification Qualifier EI or SY [R] R 90 REF02 Billing Provider Tax Identification Number R 91 PER Billing Provider Contact Information Situational 92 PER01 Contact Function Code IC [R] R 92 PER02 Billing Provider Contact Name DOLLY MADISON S 92 PER03 Communication Number Qualifier TE R 92 PER04 Billing Provider Contact Phone R 92 PER05 Communication Number Qualifier EM S 93 PER06 Billing Provider Contact [email protected] S Segment Count Example EDI Data Institutional NM1*85*2*COMMUNITY HOSPITAL*****XX* ~ 9 N3*123 MAIN ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected] NM1*85*2*COMMUNITY HOSPITAL~ N3*123 MAIN ST~ N4*OLYMPIA*WA*98555~ REF*EI* ~ PER*IC*DOLLY MADISON*TE* *EM*[email protected] 2010AA Billing Provider notes 1. NM101 Entity Identifier Code: Billing Provider NM102 Entity Type Qualifier 1 or 2 Person (individual) 1. Non-Person Entity (organization) NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Billing Provider s NPI is submitted in NM

78 2010AA Billing Provider notes continued 4. NM109 Billing Provider Identifier 10-digit National Provider Identifier (NPI). Individual provider types use your Individual NPI registered with LNI. Clinic/Group Provider types use your Organizational NPI registered with LNI. Non NPI provider s use 2010BB Payer Name Billing Provider Secondary Identification reference REF*G2. Optional Provider s submitting their NPI may also include the Billing Provider Secondary Identification reference in the 2010BB Payer Name loop using REF*G2. The submitted NPI is used as the provider s primary identifier when the 2010BB Payer Name loop does not include the Billing Provider Secondary Identification segment REF*G2. If the submitted NPI (NM109) is not on file Or is on file but not cross-referenced to an LNI provider account number And 2010BB Payer Name loop does not include the Billing Provider Secondary Identification segment REF *G2 o Then bill formats with EDI formatting error H22 See EDI Formatting Errors - page REF Billing Provider Tax Identification segment REF01 Reference Identification qualifier: EIN or SSN Employer Identification Number (EIN) EI. Social Security Number (SSN) SY. EI or SY REF02 Billing Provider Tax Identification Number Use the Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes. The provider s EIN or SSN is a string of exactly nine (9) numbers with no separators. 6. PER Billing Provider Contact Information Use this segment to communicate the Billing Provider s telephone and contact information. This segment is required when the contact information is different than that in the 1000A Submitter Name loop. PER01 Contact Information Code: Information Contact PER02 Billing Provider Contact Name Contact name of the person billing worker s compensation with LNI. PER03 Communication Number Qualifier: Telephone Number PER04 Billing Provider Phone Number Contact phone number of the person billing workers compensation with LNI. PER05 Communication Number Qualifier: Electronic Mail PER06 Billing Provider Address Contact address of the person billing workers compensation with LNI. IC TE EM 78

79 LOOP ID AB PAY-TO ADDRESS NAME 2010AB PAY-TO ADDRESS NAME NM1*87 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE Pay-To Address Name Loop This loop is only used when the address for payment is Situational different than that of the Billing Provider. 94 NM1 Pay-to Address Name Required 94 NM101 Entity Code Identifier 87 [R] R 95 NM102 Entity Type Qualifier 1 or 2 [R] R 96 N3 Pay-to Provider Address Required 96 N301 Pay-to Provider Address R 97 N4 Pay-to Provider City/State/Zip code Required 97 N401 Pay-to Provider City R 98 N402 Pay-to Provider State S 98 N403 Pay-to Provider Zip code S 2010AB Pay-To Address Name notes The department does not utilize this information in MIPS bill payment processing. 1. NM101 Entity Identifier Code: Pay-to Provider NM102 Entity Type Qualifier 1 or 2 Person (individual) 1 Non-Person Entity (organization) 2 79

80 Detail, Subscriber Hierarchical Level LOOP ID B SUBSCRIBER HIERARCHICAL LEVEL 2000B SUBSCRIBER HIERARCHICAL - HL TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 107 HL Hierarchical Level - Subscriber Required 107 HL01 Hierarchical ID Number 2 R 108 HL02 Hierarchical Parent ID Number 1 R 108 HL03 Hierarchical Level Code 22 [R] R 108 HL04 Hierarchical Child Code 0 [DRV] R 109 Subscriber Information SBR Insured/Patient information Required 109 SBR01 Payer Responsibility Sequence Number Code P [DRV] R 110 SBR02 Patient Relationship to Insured 18 [DRV] S 110 SBR03 Insured Group or Policy Number: Washington State Department of Labor and Industries A or AB12345 [Alpha+6Numeric] S 7-character assigned Claim Number. or [2Alpha+5Numeric] 110 SBR09 Claim Filing Indicator WC [DRV] S Segment Count 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ Example EDI Data Institutional B Subscriber notes 1. HL03 Hierarchical Level Code: Subscriber HL04 Hierarchical Child Code: No subordinate HL segment in this structure 0 The Subscriber is the patient and there are no dependent claims. 3. SBR01 Payer Responsibility Sequence Number Code: Primary P 4. SBR02 Patient Relationship to Insured: Self 18 If SBR02 is absent (not sent) and loop 2000C is absent (not sent) The transaction will fail EDI validation and be rejected. Rejection reported in 999/997 Acknowledgment and 824 application advice. 5. SBR03 Insured Group or Policy Number 7-character LNI Claim Number/Claim ID Begin with single alpha-character + 6 numbers or double alpha-characters + 5 numbers. LNI Claim Numbers are derived from the Report of Accident (ROA) completed by the injured worker or by the provider on behalf of the injured worker. A valid LNI claim number MUST be present in 2000B-SBR03 or/and 2010BA-NM109. If SBR03 is absent (not sent) and 2010BA NM109 is Invalid the bill formats with a blank Claim ID And with EDI formatting error H05 See EDI Formatting Errors - page If SBR03 is absent (not sent) and 2010BA NM109 is equal to 7-characters and the 7-characters are not a valid LNI Claim ID, the bill formats with the 7-characters as the claim ID, and bill is denied: Returned on the provider s paper remittance with: EOB 280 DENIED. CLAIM ID BILLED IS NOT ACTIVE. CALL TO CONFIRM THE ID BEFORE REBILLING 6. SBR09 Claim Filing Indicator: Workers Compensation Health Claim Value : WC If Not Equal WC then bill formats with EDI formatting error H04 See EDI Formatting Errors - page

81 LOOP ID BA SUBSCRIBER NAME TR3 PAGE # 112 Segment/Field ID 2010BA SUBSCRIBER NAME NM1*IL FIELD NAME Subscriber Name: The subscriber will be the same person as the patient for Washington State Department of Labor and Industries Workers Compensation. Sample Data, TR3 Required Value [R] and Department Required Value [DRV] NM1 112 NM101 Entity Identifier Code IL [R] R 113 NM102 Entity Type Qualifier 1 [DRV] R 113 NM103 Subscriber Last Name PUBLIC R 113 NM104 Subscriber First Name JOHN S 113 NM105 Subscriber Middle Name Q S 113 NM108 Identification Code Qualifier MI [DRV] R Subscriber Primary Identifier: Washington State Department of Labor and Industries 7-character assigned Claim Number. Seg/Field USAGE Required 114 NM109 A or AB12345 [Alpha+6Numeric] R or [2Alpha+5Numeric] 115 N3 Subscriber Address Situational 115 N301 Subscriber Address PO BOX 123 R 116 N4 Subscriber City/State/ZIP Code Required 116 N401 Subscriber City OLYMPIA R 116 N402 Subscriber State WA S 117 N403 Subscriber Zip S 118 DMG Subscriber Demographic Information Situational 118 DMG01 Date Qualifier D8 [R] R 118 DMG02 Subscriber Birth Date: (CCYYMMDD) R 119 DMG03 Subscriber Gender Code M or F or U R 120 REF Subscriber Secondary Identification Situational 120 REF01 Reference ID Qualifier SY [R] R 120 REF02 Subscriber Supplemental Identifier R Segment Count 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ Example EDI Data Institutional BA Subscriber Name notes 1. NM101 Entity Identifier Code: Insured or Subscriber IL 2. NM102 Entity Type Qualifier: Person 1 3. NM108 Identification Code Qualifier: Member Identification Number MI 4. NM109 Subscriber Primary Identifier 7-character LNI Claim Number/Claim ID. Begin with single alpha-character + 6 numbers or double alpha-characters + 5 numbers. LNI Claim Numbers are derived from the Report of Accident (ROA) completed by the injured worker or by the provider on behalf of the injured worker. A valid LNI claim number MUST be present in 2010BA-NM109 or/and 2000B-SBR03. If the LNI claim number is invalid (see 2000B-SBR03 notes) Or is valid and NM108 is not equal to MI Then bill formats with EDI formatting error H05 See EDI Formatting Errors - page

82 2010BA Subscriber Name notes continued 5. NM103 Subscriber Last Name and NM109 Subscriber Primary Identifier LNI s processing compares the first two characters of the last name and claim ID submitted and formatted on the MIPS bill to the Claim Id and first two characters of the claimant s last name in the department s Claim Master file. If the comparison does not match, the bill may deny and returned on the provider s remittance advice with: EOB 259 DENIED. CLAIM ID/CLAIMANT NAME MISMATCH. CALL TO CONFIRM CLAIM ID BEFORE REBILLING. 6. REF Subscriber Secondary Identification Use this segment to send the injured worker s Social Security Number (SSN) if known or available. The SSN is not required for bill adjudication but may be used by the department as a secondary Id source for bill processing if needed. REF01 Reference Identification Qualifier: Social Security Number REF02 Subscriber Supplemental Identifier 9-digit Social Security Number (SSN). The Social Security Number is a string of exactly nine numbers with no separators. SY 7. REF Property and Casualty Claim Number Recommendation Do not use for WA State workers compensation billing LNI does not expect to receive this segment for identification of the worker s Claim ID If sent, the value in REF02 must be the same LNI 7-digit Claim ID sent in 2010BA NM109 or 2000B SBR03. If not a valid claim ID, the bill will format with an invalid Claim ID REF01 Reference Identification Qualifier: Agency Claim Number REF02 Property Casualty Claim Number Must be valid 7-digit LNI Claim ID. Y4 82

83 LOOP ID BB PAYER NAME 2010BB PAYER NAME NM1*PR TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 122 NM1 Payer Name Required 122 NM101 Entity Identifier Code PR [R] R 123 NM102 Entity Type Qualifier 2 [R] R 123 NM103 WASHINGTON STATE DEPT OF LABOR Payer Name & INDUSTRIES R 123 NM108 Identification Code Qualifier PI [R] R 123 NM109 Payer Identifier (ETIN): Washington State Department of Labor and R Industries Federal Tax Identification Number [DRV] 125 N4 Payer City, State, Zip Code Required 125 N401 Payer City Name OLYMPIA R 125 N402 Payer State Code WA S 126 N403 Payer Zip Code S 129 REF Billing Provider Secondary Identification Situational 129 REF01 Reference ID Qualifier: Provider Commercial Number G2 [DRV] R 130 REF02 Billing Provider Secondary ID: The provider s Washington State Department of Labor and Industries assigned 7-digit provider account number (if available. Leading R zeros are not required) Segment Count Example EDI Data Institutional NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ N4*OLYMPIA*WA*98504~ REF*G2*12345~ 2010BB Payer Name notes The Billing Provider Secondary ID segment is moved from the 2010AA Billing Provider loop in 4010A1 to the 2010BB Payer Name loop in the 5010 format. REF01 qualifier G2 Provider Commercial Number replaces qualifier X5 State Industrial Accident Provider Number. When the Billing Provider Secondary ID REF*G2 is present, it will be used as the provider s primary Billing Provider identifier. 1. NM101 Entity Identifier Code: Payer PR 2. NM102 Entity Type Qualifier: Non-person Entity 2 3. NM108 Identification Code Qualifier: Payer Identification PI 4. NM109 Payer Identifier Washington State Department of Labor & Industries Federal Tax ID. 83

84 2010BB Payer Name notes continued 5. REF Billing Provider Secondary Identification Use this segment to report the Billing Provider s LNI Provider Account Number as the Billing Provider s Secondary Identification in addition to the provider s NPI submitted in 2010AA NM109. Use this segment to report the Billing Provider s LNI Provider Account Number as the Billing Provider s Primary Identification when the provider is not NPI enumerated or the Provider s NPI is unknown. When Segment/Qualifier REF*G2 is present, REF02 will be used as the provider s identifier for bill formatting and adjudication processing. REF01 Reference ID Qualifier: Provider Commercial Number G2 If 2010AA-NM109 is not submitted (NPI) And REF01 not equal G2 Then bill formats with EDI formatting error H02 See EDI Formatting Errors - page REF02 Billing Provider Secondary Identifier 7-digit LNI provider account number. Leading zeros may be included but are not required. If REF02 is not a valid LNI provider account number Then bill formats with EDI formatting error H03 See EDI Formatting Errors - page

85 Detail, Patient Hierarchical Level LOOP ID CLAIM INFORMATION 2300 CLAIM INFORMATION - CLM TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 143 CLM Claim Information Required 144 CLM01 Patient Account Number PUBLICJQ R 145 CLM02 Total Claim Charge Amount R 145 CLM05-1 Facility Type Code 11 R 145 CLM05-2 Facility Code Qualifier A [R] R 145 CLM05-3 Claim Frequency Code 1 or 7 or 8 [DRV] R 146 CLM07 Assignment or Plan Participation Code A [DRV] R 146 CLM08 Assignment of Benefits Indicator Y [R] R 147 CLM09 Release of Information Code Y [R] R 150 DTP Statement Dates Required 150 DTP01 Date Time Qualifier 434 [R] R 150 DTP02 Date Time Period Format Qualifier RD8 R 150 DTP03 Statement From and To Date R 151 DTP Admission Date/Hour (Required on inpatient bills) Situational 151 DTP01 Date/Time Qualifier 435 [R] R 151 DTP02 Date/Time Format Qualifier DT [R] R 151 DTP03 Admission Date and Hour R 153 CL1 Institutional Claim Code (Inpatient only) Required 153 CL101 Admission Type Code 3 S 153 CL102 Admission Source Code 1 S 153 CL103 Patient Status Code 30 R 164 REF Prior Authorization Number Situational 164 REF01 Reference Identification Qualifier G1 [R] R 165 REF02 Prior Authorization Number R 166 REF Payer Claim Control Number Situational 166 REF01 Reference ID Qualifier F8 [R] R 166 REF02 Payer Claim Control Number (ICN) R 170 REF Claim Identifier for Transmission Intermediaries Situational 170 REF01 Reference Identification Qualifier D9 [R] R 171 REF02 Value Added Network Trace Number R 173 REF Medical Record Number Situational 173 REF01 Reference Identification Qualifier EA [R] R 173 REF02 Reference Identification: R 178 NTE Claim Note Situational 178 NTE01 Note Reference Code: (DME, MED, UPI, etc.) R 179 NTE02 Description: (bill level remarks) R 180 NTE Billing Note Situational 180 NTE01 Note Reference Code: Additional Information ADD [R] R 180 NTE02 Description: Additional remarks R 184 HI Principal Diagnosis Required 184 HI01 Health Care Code Information R 184 HI01-1 Code List Qualifier: Principal BK [R] ICD-9 or ABK [R] ICD-10 R 185 HI01-2 Principal Diagnosis Code 7241 R 187 HI Admitting Diagnosis (Required for Inpatient) Situational 187 HI01 Health Care Code Information R 187 HI01-1 Code List Qualifier: Admitting Diagnosis BJ [R] ICD-9 or ABJ [R] ICD-10 R 188 HI01-2 Admitting Diagnosis Code 7241 R 193 HI External Cause of Injury (E-Code) Situational 193 HI01 Health Care Code Information R 193 HI01-1 Code List Qualifier BN [R] ICD-9 or ABN [R] ICD-10 R 193 HI01-2 External Cause of Injury Code (E-Code) E8210 R 220 HI Other Diagnosis Information Situational 220 HI01 Health Care Code Information R 221 HI01-1 Code List Qualifier: Other Diagnosis BF [R] ICD-9 or ABF [R] ICD-10-CM R 221 HI01-2 Other Diagnosis 821 or 8210 or R 239 HI Principal Procedure Information Situational 240 HI01-1 Code List Qualifier: Principal Procedure Codes BR [R] ICD-9 or BBR [R] ICD-10-PCS R 240 HI01-2 Principal Procedure Code R 240 HI01-3 Date Format Qualifier D8 [R] R 240 HI01-4 Principal Procedure Date R 242 HI Other Procedure Information Situational 85

86 242 HI01 Health Care Code Information R 243 HI01-1 Code List Qualifier: Procedure Code BQ [R] ICD-9 or BBQ [R] ICD-10-PCS R 243 HI01-2 Procedure Code R 243 HI01-3 Date Format Qualifier D8 [R] R 243 HI01-4 Procedure Date R 258 HI Occurrence Span Information Situational 258 HI01 Health Care Code Information R 258 HI01-1 Code List Qualifier : Occurrence Span BI [R] R 258 HI01-2 Occurrence Span Code R 259 HI01-3 Date Format Qualifier RD8 [R] R 259 HI01-4 Occurrence Span Date R 271 HI Occurrence Information Situational 271 HI01 Health Care Code Information R 271 HI01-1 Code List Qualifier: Occurrence BH [R] R 271 HI01-2 Occurrence Code: Accident/Employment Related 04 [R] R 272 HI01-3 Date Qualifier: (CCYYMMDD) D8 [R] R 272 HI01-4 Occurrence Date: Injury Date R 294 HI Condition Information Situational 294 HI01 Health Care Code Information R 294 HI01-1 Code List Qualifier: Condition BG [R] R 294 HI01-2 Condition Code 17 R Segment Count Example EDI Data Institutional CLM* PUBLICJQ-00100*468*13:A:1*Y**Y*********Y~ 23 DTP*434*RD8* ~ 24 DTP*435*DT* ~ 25 CL1*3*1*30~ 26 REF*G1* ~ 27 REF*D9*VANTN012345~ 28 REF*EA*MEDRECNUM001~ 29 NTE*ADD*ADDITIONAL REMARKS~ 30 HI*BK:724.1*BJ:724.1*BN:E821.0~ 31 HI*BH:04:D8: ~ Electronic Adjustment - Replacement CLM* PUBLICJQ-00100*468*13:A:7*Y**Y*********Y~ REF*F8* NTE*ADD*CORRECTED PROC/REV CODE SVC LINE 2 Electronic Adjustment - Void CLM* PUBLICJQ-00100*468*13:A:8*Y**Y*********Y~ REF*F8* NTE*ADD*BILLED INCORRECT CLAIMID FOR DOS 2300 Claim Information notes 1. CLM01 Patient Account Number This number identifies the patient s account number in the provider s medical billing system. MIPS processing supports up to 20 characters for the patient account number. The patient account number is returned in following outbound transactions: o 835 Payment Advice (5010/4010) 2100-CLP01 Patient Control Number. o 277 Notification (5010) 2200D-TRN02 Patient Control Number. o 277 Unsolicited Notification (3070) D-TRN02 Patient Control Number. o 277 Pended Notification (3070) 2200D-TRN02 Patient Control Number. 2. CLM02 Total Claim Charge Amount Must balance to the sum of all service line charge amounts reported in SV203 Line Item Charge Amount. The Total Claim Charge amount is returned in the following outbound transactions: o 835 Payment Advice (5010/4010) 2100-CLP03 Total Claim Charge Amount. o 277 Notification (5010) 2200D-STC04 Total Claim Charge Amount. o 277 Unsolicited Notification (3070) D-STC04 Total Claim Charge Amount. o 277 Pended Notification (3070) 2200D-STC04 Total Claim Charge Amount. 86

87 2300 Claim Information notes continued 3. CLM05-1 Facility Type Code Values: 11, 13 or 18 Code identifying where services were, or may be, performed; The first and second positions of the Uniform Bill Type Code for Institutional services: Code 11 used for Inpatient services. Code 13 used for Outpatient services. Code 18 used for Critical Access Hospitals, Swing Beds for Sub-Acute care. 4. CLM05-2 Facility Code Qualifier: Uniform Billing Claim Form Bill Type A 5. CLM05-3 Claim Frequency Code: Original, Replacement, Void 1, 7, or 8 This field will be used to determine if the submitted bill is one of the following: o Original 1 - Original bill submission or resubmission of a previously denied bill. o Replacement 7 - Request for Adjustment to a previously paid bill that is fully or partially paid. o Void 8 - Request for Void to a previously paid bill or a bill still in process. If CLM05-3 equals 7 (Replacement) or 8 (Void) Then Payer Claim Control Number REF*F8 segment is required If CLM05-3 not equal 1 (Original) or 7 (Replacement) or 8 (Void) Then bill formats with EDI formatting error H08 See EDI Formatting Errors - page CLM07 Assignment or Plan Participation Code: Assigned A 7. CLM08 Assignment of Benefits Indicator: Yes Y Y Insured or authorized person authorizes benefits to be assigned to the provider. 8. CLM09 Release of Information Code: Yes Y Y Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim 9. DTP Statement Dates DTP01 Date Time Qualifier: Statement 434 DTP02 Date Time Period Format Qualifier Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD. DTP03 Statement From and To Date If the Statement Date is for a single day of service, the From and To Date are the same. RD8 10. DTP Admission Date/Hour (Required on inpatient bills) DTP01 Date Time Qualifier: Admission 435 DTP02 Date Time Period Format Qualifier D8 Date Expressed in format CCYYMMDD. DT Date and Time Expressed in format CCYYMMDDHHMM. D8 or DT DTP03 Statement From and To Date If the Statement Date is for a single day of service, the From and To Date are the same. 87

88 2300 Claim Information notes continued 11. CL1 Institutional Claim Code This segment is used to provide information specific to hospital bills. CL101 Admission Type Code Required when patient is being admitted for inpatient services. CL102 Admission Source Code Required for all inpatient and outpatient services. CL103 Patient Status Code Indicates patient status as of the Statement Dates. 12. REF Prior Authorization Use this segment to communicate the Prior Authorization Number assigned to the service requiring prior authorization. REF01 Reference Identification Qualifier: Prior Authorization Number REF02 Prior Authorization Number Prior Authorization number (Qualis). G1 13. Payer Claim Control Number Required for electronic adjustment request CLM05-3 Claim Frequency Code equals 7 (Replacement) or 8 (Void) REF01 Reference Identification Qualifier: Original Reference Number F8 REF02 Payer Claim Control Number (LNI Internal Control Number) 17-digit LNI Internal Control Number (ICN) assigned to the Original bill There exists a series of possible EDI formatting errors associated to electronic adjustments H31 H37 See EDI Formatting Errors - page REF Claim Identifier for Transmission Intermediaries REF01 Reference Identification Qualifier: Claim Number D9 REF02 Value Added Network Trace Number/Clearinghouse Trace Number Clearinghouses may assign and submit this number for their tracing purposes. If submitted, LNI will support up to 20 characters of the Clearinghouse assigned trace number. The clearinghouse trace number will be returned in the following outbound transactions: o 277 Notification (5010) 2200D REF*D9 REF01. o 277 Unsolicited Notification (3070) 2200D REF*D9 REF02. o 277 Pended Notification (3070) 2200D REF*D9 REF REF Medical Record Number REF01 Reference Identification Qualifier: Medical Record Identification Number EA REF02 Medical Record Number The provider may submit this number at their discretion. If submitted, the Medical Record Number will be returned in the following outbound transactions: o 835 (5010/4010) 2100 REF*EA REF02 Returned when received in the 837 transaction AND the bill contains an invalid Claim ID (i.e. EDI formatting error H05) o 277 Notification (5010) Not supported. o 277 Unsolicited Notification (3070) 2200E REF*EA REF02. o 277 Pended Notification (3070) 2200E REF*EA REF02. 88

89 2300 Claim Information notes continued 16. NTE Claim Note (DME, MED, UPI, etc.) Use this segment where applicable to substantiate the medical treatment and services provided. This segment applies to the entire bill and if submitted, will cause the bill to suspend during processing requiring manual adjudication of the bill to a finalized (paid/denied) status. NTE01 Note Reference Code DME Durable Medical Equipment (DME) and Supplies. MED Medications. UPI Updated Information. See the X223 TR3 Implementation Guide, pages 178, 179 for additional code values. NTE02 Claim Note Text 17. NTE Bill Level Claim Note This segment applies to the entire bill and if submitted, will cause the bill to suspend during processing requiring manual adjudication of the bill to a finalized (paid/denied) status. NTE01 Note Reference Code: Additional Information NTE02 Billing Note Text ADD Caution - improper use of claim and billing remarks may cause delay in the processing and payment of the bill. Remarks such as routine descriptions of procedures or diagnosis codes or the results of diagnostic studies or requests for authorization of services should be avoided and not entered. In some cases, further explanation of services rendered is required when the procedure code references an unlisted service or contains a modifier(s). In these cases, you may provide the nature of the unlisted service or explain the nature for additional charges (modifier -22) where applicable. 18. HI Principal Diagnosis (Required on all inpatient and outpatient bills) HI01 Principal Diagnosis Code Information. The diagnosis listed in this field is assumed to be the principal diagnosis. Do Not transmit the decimal point for ICD codes. The decimal point is implied. HI01-1 Diagnosis Type Code BK or ABK ICD-9-CM Principal Diagnosis is reported using code BK. ICD-10-CM Principal Diagnosis is reported using code ABK (effective October 1, 2013). HI01-2 Principal Diagnosis Code Principal diagnosis of injury or illness. 19. HI Admitting Diagnosis (Required on all inpatient admissions) HI01 Admitting Diagnosis Code Information. The diagnosis listed in this field is the Admitting Diagnosis for inpatient services. Do Not transmit the decimal point for ICD codes. The decimal point is implied. HI01-1 Code List Qualifier Type Code ICD-9-CM Admitting Diagnosis use code BJ. ICD-10-CM Admitting Diagnosis use code ABJ (effective October 1, 2013). HI01-2 Admitting Diagnosis Code Admitting diagnosis of injury or illness. BJ or ABJ 89

90 2300 Claim Information notes continued 20. HI External Cause of Injury (E-Codes) HI01 External Cause of Injury Diagnosis Code Information. The diagnosis listed in this field is used when an External Cause of Injury is needed to describe an injury, poisoning, or adverse effect. Do Not transmit the decimal point for ICD codes. The decimal point is implied. HI01-1 Code List Qualifier Type Code BN or ABN ICD-9-CM External Cause of Injury Code (E-Codes) is reported using code BN. ICD-10-CM External Cause of Injury Code (E-Codes) is reported using code ABN (effective October 1, 2013). HI01-2 External Cause of Injury Code External cause of injury or illness. HI02 through HI12 Health Care Code Information Use these segments to report additional External Cause of Injury Diagnosis Code information as applicable. 21. HI - Other Diagnosis Information HI01 Other Diagnosis Code Information. The diagnosis listed in this field is used when other condition(s) coexist or develop(s) subsequently during the patient s treatment. Do Not transmit the decimal point for ICD codes. The decimal point is implied. HI01-1 Code List Qualifier Type Code ICD-9-CM other diagnosis is reported using code BF. ICD-10-CM other diagnosis is reported using code ABF (effective October 1, 2013). HI01-2 Other Diagnosis Other diagnosis related to injury or illness. BF or ABF HI02 through HI12 Health Care Code Information Use these segments to report additional Other Diagnosis Code information as applicable. 22. HI - Principal Procedure Information Required on inpatient bills when a procedure is performed. Do Not transmit the decimal point for ICD codes. The decimal point is implied. HI01-1 Code List Qualifier Code: Principal Procedure BR or BBR ICD-9-CM Principal Procedure Code is reported using code BR. ICD-10-CM Principal Procedure Code is reported using code BBR (effective October 1, 2013). HI01-2 Principal Procedure Code Principal procedure performed. HI01-3 Date Time Period Format Qualifier: CCYYMMDD format HI01-4 Date Time Period Principal Procedure Date Date principal procedure was performed. D8 90

91 2300 Claim Information notes continued 23. HI - Other Procedure Information Required on inpatient bills when additional procedures must be reported. Do Not transmit the decimal point for ICD codes. The decimal point is implied. HI01-1 Code List Qualifier Code: Other Procedure BQ or BBQ ICD-9-CM Other Procedure Code is reported using code BQ. ICD-10-CM Other Procedure Code is reported using code BBQ (effective October 1, 2013). HI01-2 Procedure Code Other procedure(s) performed. HI01-3 Date Time Period Format Qualifier: CCYYMMDD format HI01-4 Date Time Period Procedure Date D8 HI02 through HI12 Health Care Code Information Use these segments to report additional Other Procedure Code information as applicable. 24. HI - Occurrence Span Information Required when there is an Occurrence Span Code that applies to the bill. HI01-1 Code List Qualifier Code: Occurrence Span HI01-2 Occurrence Span Code HI01-3 Date Time Period Format Qualifier: CCYYMMDD-CCYYMMDD format HI01-4 Date Time Period Occurrence Span Code Date BI RD8 HI02 through HI12 Health Care Code Information Use these segments to report additional Occurrence Span information as applicable. 25. HI - Occurrence Information Required when there is an Occurrence Code that applies to the bill. HI01-1 Code List Qualifier Code: Occurrence HI01-2 Occurrence Span Code HI01-3 Date Time Period Format Qualifier: CCYYMMDD format HI01-4 Date Time Period Occurrence Code Date BH D8 HI02 through HI12 Health Care Code Information Use these segments to report additional Occurrence information as applicable. 26. HI - Condition Information Required when there is a Condition Code that applies to the bill. HI01-1 Code List Qualifier Code: Condition HI01-2 Condition Code BG HI02 through HI12 Health Care Code Information Use these segments to report additional Condition information as applicable. 91

92 LOOP ID 2310A ATTENDING PROVIDER NAME 2310A ATTENDING PROVIDER NM1*71 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 319 NM1 Attending Provider Name Situational 319 NM101 Entity Code Identifier: Attending Provider 71 [R] R 320 NM102 Entity Type Qualifier: Person 1 [R] R 320 NM103 Attending Provider Last Name LINCOLN R 320 NM104 Attending Provider First Name ABRAHAM S 320 NM105 Attending Provider Middle Name H S 321 NM108 Identification Code Qualifier: NPI XX [R] S 321 NM109 Identification Code (National Provider Identifier) S 322 PRV Attending Provider Specialty Information Situational 322 PRV01 Provider Code: Attending AT [R] R 322 PRV02 Reference ID Qualifier: Health Care Provider Taxonomy Code PXC [R] R 322 PRV03 Provider Taxonomy Code X R 324 REF Attending Provider Secondary ID Situational 324 REF01 Reference ID Qualifier: Provider Commercial Number G2 [R] [DRV] R 325 REF02 Reference ID: Washington State Department of Labor and Industries assigned 7-digit provider account number R Segment Count Example EDI Data Institutional NM1*71*1*LINCOLN*ABRAHAM*H***XX* ~ 33 PRV*AT*ZZ* X~ LNI Provider Account Number NM1*71*1*LINCOLN*ABRAHAM*H~ PRV*AT*ZZ* X~ REF*G2* NPI + LNI Provider Account Number NM1*71*1*LINCOLN*ABRAHAM*H***XX* ~ PRV*AT*ZZ* X~ REF*G2* A - Attending Provider Name notes The Attending Provider is the individual who has overall responsibility for the patient s medical care and treatment. 1. NM101 Entity Identifier Code: Attending Physician NM102 Entity Type Qualifier: Person 1 3. NM103 Attending Provider Last Name 4. NM104 Attending Provider First Name 5. NM105 Attending Provider Middle Initial 6. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Attending Provider s NPI is submitted in NM NM109 Attending Provider Primary Identifier 10-digit National Provider Identifier (NPI). 8. Attending Provider Specialty Information If submitted, may be used to assist with NPI cross-referencing to the provider s LNI provider account number. PRV01 Provider Code: Attending PRV02 Reference Identification Qualifier: Health Care Provider Taxonomy Code PRV03 Provider Taxonomy Code 10-digit Provider Taxonomy code. AT PXC 92

93 2310A - Attending Provider Name notes continued 9. REF Attending Provider Secondary Identification Use when provider is not NPI enumerated or unknown. This segment is not validated for MIPS bill EDI formatting. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Attending Provider Secondary ID 7-digit LNI provider account number. Leading zeros may be included but are not required. G2 93

94 LOOP ID 2310B OPERATING PHYSICIAN NAME 2310B OPERATING PHYSICIAN NM1*72 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 326 NM1 Operating Physican Name Situational 327 NM101 Entity Identifier Code 72 [R] R 327 NM102 Entity Type Qualifier 1 [R] R 327 NM103 Operating Physician Last Name LINCOLN R 327 NM104 Operating Physician First Name ABRAHAM S 327 NM105 Operating Physician Middle Name H S 328 NM108 Identification Code Qualifier: NPI XX [R] S 328 NM109 Identification Code: (National Provider Identifier) S 329 REF Operating Physician Secondary ID Situational 329 REF01 Reference ID Qualifier: Provider Commercial Number G2 [R] [DRV] R 330 REF02 Reference ID: Washington State Department of Labor and Industries assigned 7-digit provider account number R Segment Count NM1*72*1* LINCOLN*ABRAHAM*H***XX* ~ Example EDI Data Institutional 837 LNI Provider Account Number NM1*72*1* LINCOLN*ABRAHAM*H~ REF*G2*12345~ NPI + LNI Provider Account Number NM1*72*1* LINCOLN*ABRAHAM*H***XX* ~ REF*G2*12345~ 2310B Operating Physician Name notes The Operating Physician is the individual with primary responsibility for performing surgical procedure(s). Required when a surgical procedure code is listed on the bill. 1. NM101 Entity Identifier Code: Operating Physician NM102 Entity Type Qualifier: Person 1 3. NM103 Operating Provider Last Name 4. NM104 Operating Provider First Name 5. NM105 Operating Provider Middle Initial 6. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Operating Physician s NPI is submitted in NM NM109 Operating Provider Identifier 10-digit National Provider Identifier (NPI). 8. REF Operating Physician Secondary Identification Use when provider is not NPI enumerated or unknown. This segment is not validated for MIPS bill EDI formatting. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Operating Provider Secondary ID 7-digit LNI provider account number. Leading zeros may be included but are not required. G2 94

95 LOOP ID 2310C OTHER OPERATING PHYSICIAN NAME 2310C OTHER OPERATING PHYSICIAN NM1*ZZ TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 331 NM1 Other Operating Physician Name Situational 332 NM101 Entity Identifier Code: Other Physician ZZ [R] R 332 NM102 Entity Type Qualifier: Person 1 [R] R 332 NM103 Other Provider Last Name MADISON R 332 NM104 Other Provider First Name JAMES S 332 NM105 Other Provider Middle Name R S 333 NM108 Identification Code Qualifier: NPI XX [R] S 333 NM109 Identification Code: (National Provider Identifier) S 334 REF Other Operating Physician Secondary ID Situational 334 REF01 Reference ID Qualifier: Provider Commercial Number G2 [R] [DRV] R 335 REF02 Reference ID: Washington State Department of Labor and Industries assigned 7-digit provider account number R Segment Count NM1*ZZ*1* MADISON*JAMES*R***XX* ~ Example EDI Data Institutional 837 LNI Provider Account Number NM1*ZZ*1* MADISON*JAMES*R~ REF*G2*12345~ NPI + LNI Provider Account Number NM1*ZZ*1* MADISON*JAMES*R***XX* ~ REF*G2*12345~ 2310C Other Operating Physician notes The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This loop can only be used if 2310B Operating Physician is present. 1. NM101 Entity Identifier Code: Mutually Defined ZZ Used to indicate Other Operating Physician 2. NM102 Entity Type Qualifier: Person 1 3. NM103 Other Operating Provider Last Name 4. NM104 Other Operating Provider First Name 5. NM105 Other Operating Provider Middle Initial 6. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Other Operating Physician s NPI is submitted in NM NM109 Operating Provider Identifier 10-digit National Provider Identifier (NPI). 8. REF Other Operating Physician Secondary Identification Use when provider is not NPI enumerated or unknown. This segment is not validated for MIPS bill EDI formatting. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Other Operating Provider Secondary ID 7-digit LNI provider account number. Leading zeros may be included but are not required. G2 95

96 LOOP ID 2310D RENDERING PROVIDER NAME 2310D RENDERING PROVIDER NM1*82 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 336 NM1 Rendering Provider Name Situational 337 NM101 Entity Identifier Code: Rendering Provider 82 [R] R 337 NM102 Entity Type Qualifier: Person 1 [R] R 337 NM103 Rendering Provider Last Name MADISON R 337 NM104 Rendering Provider First Name JAMES S 337 NM105 Rendering Provider Middle Name R S 338 NM108 Identification Code Qualifier: NPI XX [R] S 338 NM109 Identification Code: (National Provider Identifier) S 334 REF Rendering Provider Secondary ID Situational 334 REF01 Reference ID Qualifier: Provider Commercial Number G2 [R] [DRV] R 335 REF02 Reference ID: Washington State Department of Labor and Industries assigned 7-digit provider account number R Segment Count NM1*82*1* MADISON*JAMES*R***XX* ~ Example EDI Data Institutional 837 LNI Provider Account Number NM1*82*1* MADISON*JAMES*R~ REF*G2*12345~ NPI + LNI Provider Account Number NM1*82*1* MADISON*JAMES*R***XX* ~ REF*G2*12345~ 2310D Rendering Provider Name notes: The Rendering Provider is the health care professional who delivers or completes a particular medical service or nonsurgical procedure. 1. NM101 Entity Identifier Code: Rendering Provider NM102 Entity Type Qualifier: Person 1 3. NM103 Rendering Provider Last Name 4. NM104 Rendering Provider First Name 5. NM105 Rendering Provider Middle Initial 6. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Rendering Provider s NPI is submitted in NM NM109 Operating Provider Identifier 10-digit National Provider Identifier (NPI). 8. REF Rendering Provider Secondary Identification Use when provider is not NPI enumerated or unknown. This segment is not validated for MIPS bill EDI formatting. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Rendering Provider Secondary ID 7-digit LNI provider account number. Leading zeros may be included but are not required. G2 96

97 LOOP ID 2310E SERVICE FACILITY LOCATION NAME TR3 PAGE # 341 Segment/Field ID 2310E SERVICE FACILITY LOCATION NM1*77 FIELD NAME Service Facility Location Name Required when location of health care service is different than that of the 2010AA Billing Provider loop. Sample Data, TR3 Required Value [R] and Department Required Value [DRV] Seg/Field USAGE Situational NM1 342 NM101 Entity Identifier Code 77 [R] R 342 NM102 Entity Type Qualifier 2 [R] R 342 NM103 Service Facility Name FOREST GROVE CLINIC R 342 NM108 Identification Code Qualifier XX [R] S 342 NM109 Service Facility Location Identifier S 344 N3 Service Facility Location Address Required 344 N301 Service Facility Location Address: Address Line FOREST GROVE R 344 N302 Service Facility Location Address: Address Line 2 S 345 N4 Service Facility Location City, State, Zip Code Required 345 N401 Service Facility Location City OLYMPIA R 346 N402 Service Facility Location State WA S 346 N403 Service Facility Location Zip Code S 347 REF Service Facility Location Secondary Identification Situational 347 REF01 Reference Identification Qualifier G2 [R] [DRV] R 348 REF02 Service Facility Location Secondary ID R Segment Count Example EDI Data Institutional NM1*77*2* FOREST GROVE CLINIC***XX* ~ 35 N3*500 FOREST GROVE~ 36 N4*OLYMPIA*WA*98501~ LNI Provider Account Number NPI + LNI Provider Account Number NM1*77*2* FOREST GROVE CLINIC~ NM1*77*2* FOREST GROVE CLINIC***XX* ~ N3*500 FOREST GROVE~ N3*500 FOREST GROVE~ N4*OLYMPIA*WA*98501~ N4*OLYMPIA*WA*98501~ REF*G2*12345~ REF*G2*12345~ 2310E Service Facility Location notes This segment required when the location of health care service is different than that carried in 2010AA Billing Provider. 1. NM101 Entity Identifier Code: Service Location NM102 Entity Type Qualifier: Non-Person Entity 2 3. NM103 Service Facility Name 4. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Service Facility Location NPI is submitted in NM NM109 Laboratory or Facility Primary Identifier 10-digit National Provider Identifier (NPI). 6. REF Service Facility Location Secondary Identification Use when provider is not NPI enumerated or unknown. This segment is not validated for MIPS bill EDI formatting. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Service Facility Secondary ID 7-digit LNI provider account number. Leading zeros may be included but are not required. G2 97

98 LOOP ID 2310F REFERRING PROVIDER NAME 2310F REFERRING PROVIDER NM1*DN TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 349 NM1 Referring Provider Name Situational 350 NM101 Entity Identifier Code DN [R] R 350 NM102 Entity Type Qualifier 1 [R] R 350 NM103 Referring Provider Last Name ADAMS R 350 NM104 Referring Provider First Name SAMUEL S 350 NM105 Referring Provider Middle Name S 351 NM108 Identification Code Qualifier XX [R] S 351 NM109 Identification Code S 334 REF Referring Provider Secondary ID Situational 334 REF01 Reference ID Qualifier G2 [R] R 335 REF02 Referring Provider Secondary Reference ID R Segment Count Example EDI Data Institutional NM1*DN*1* ADAMS*SAMUEL****XX* ~ LNI Provider Account Number NM1*DN*1* ADAMS*SAMUEL~ REF*G2*12345~ NPI + LNI Provider Account Number NM1*DN*1* ADAMS*SAMUEL****XX* ~ REF*G2*12345~ 2310F Referring Provider Name notes: The Referring Provider is the provider who sends the patient to another provider for services. Required on outpatient claims when the Referring Provider is different than the Attending Provider. 1. NM101 Entity Identifier Code: Referring Provider DN 2. NM102 Entity Type Qualifier: Person 2 3. NM103 Referring Provider Last Name 4. NM104 Referring Provider First Name 5. NM105 Referring Provider Middle Initial 6. NM108 Identification Code Qualifier: CMS National Provider Identifier XX Required when the Referring Provider s NPI is submitted in NM NM109 Referring Provider Identifier 10-digit National Provider Identifier (NPI). 8. REF Referring Provider Secondary Identification Use when provider is not NPI enumerated or unknown. This segment is not validated for MIPS bill EDI formatting. May be included as an additional ID to the NPI submitted in NM109 of this loop. REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Referring Provider Secondary ID 7-digit LNI provider account number. Leading zeros may be included but are not required. G2 98

99 LOOP ID 2400 SERVICE LINE NUMBER TR3 PAGE # Segment/Field ID 2400 SERVICE LINE - LX FIELD NAME Sample Data, TR3 Required Value [R] and Department Required Value [DRV] Seg/Field USAGE 423 Service Line Number (max. 99 occurrences for LX MIPS bill) Required 423 LX01 Service Line Number 1 R 424 SV2 Institutional Service Line Required 424 SV201 Service Line Revenue Code 0420 R 425 SV202 Composite Medical Procedure Identifier Situational 425 SV202-1 Product/Service ID Qualifier: HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes ER - Jurisdiction Specific Procedure and Supply Codes (LNI Local Codes) HC [R] or ER [DRV for local codes] R 426 SV202-2 Procedure Code R 426 SV202-3 Procedure Code Modifier 1 S 426 SV202-4 Procedure Code Modifier 2 S 427 SV202-5 Procedure Code Modifier 3 S 427 SV202-6 Procedure Code Modifier 4 S 427 SV203 Line Item Charge Amount R 428 SV204 Unit or Basis for Measurement Code UN R 428 SV205 Units 3 R 428 SV207 Line Item Non-Covered Charge Amount S 433 DTP Date - Service Date Situational 434 DTP01 Date Qualifier 472 [R] R 434 DTP02 Date Format RD8 R 434 DTP03 Date of Service R 435 REF Line Item Control Number Situational 435 REF01 Reference Identification Qualifier 6R [R] R 436 REF02 Line Item control Number R LX Service Line Number (max. 99 occurrences) Required LX01 Service Line Number 2 through 99 SV2 Institutional Service Line Required SV201 Revenue Code 0420 SV202 Composite Medical Procedure Identifier Situational Product/Service ID Qualifier: HC - Health Care Financing Administration Common SV202-1 Procedural Coding System (HCPCS) Codes ER - Jurisdiction Specific Procedure and Supply Codes (LNI Local Codes) HC [R] or ER [DRV for local codes] SV202-2 Procedure Code SV202-3 Procedure Code Modifier 1 GP SV202-4 Procedure Code Modifier 2 SV202-5 Procedure Code Modifier 3 SV202-6 Procedure Code Modifier 4 SV203 Line Item Charge Amount SV204 Unit or Basis for Measurement Code UN SV205 Service Unit Count 3 SV206 Service Line Rate SV207 Line Item Non-Covered Charge Amount DTP Service Date Situational DTP01 Date Qualifier 472 [R] DTP02 Date Format RD8 DTP03 Date of Service REF Line Item Control Number Situational REF01 Reference Identification Qualifier 6R [R] R REF02 Line Item control Number R 99

100 Segment Count 38 LX*1~ 39 SV2*0420*HC:97530:GP*117*UN*3~ 40 DTP*472*RD8* ~ 41 LX*2~ 42 SV2*0420*HC:97530:GP*117*UN*3~ 43 DTP*472*RD8* ~ 44 LX*3~ 45 SV2*0420*HC:97530:GP*117*UN*3~ 46 DTP*472*RD8* ~ 47 LX*4~ 48 SV2*0420*HC:97530:GP*117*UN*3~ 49 DTP*472*RD8* ~ Example EDI Data Institutional Service Line notes 1. MIPS processing will support up to and including ninety-nine (99) lines of service for 837 Institutional billing. LX01 Service Line Number 1 The Service Line LX segment must begin with one (1) And is incremented by one for each additional service line billed. MIPS Maximum Service Line Numbers is ninety-nine (99). If the number of Service Lines submitted is greater than 99 Then bill formats with EDI formatting error H09 See EDI Formatting Errors pages SV2 Institutional Service Line SV201 Service Line Revenue Code 3. SV202 Composite Medical Procedure SV202-1 Product/Service ID Qualifier Use code HC when billing HCPCS codes Health Care Financing Administration Common Procedural Coding system (HCPCS) The AMA s CPT codes are level 1 HCPCS codes and are reported with code HC. HC or ER Use code ER when billing LNI Local Codes - Jurisdiction Specific Procedure and Supply Codes Workers Compensation Specific Procedure and Supply Codes Note: Clearinghouse trading partners are required to accept LNI local codes when billed with Product/Service ID Qualifier ER. 4. SV202-2 Procedure Code Service or Product code provided. 5. SV202-3 through SV202-6 Procedure Modifiers 1 through 4 For information on billing Procedure Code Modifiers visit: o Fee Schedules at 6. SV203 Line Item Charge Amount Sum Total of all Service Line Charges Must balance to the Total Claim Charge Amount(s) in 2300 CLM SV204 Unit or Basis for Measurement Code: Unit UN 8. SV205 Service Unit Count Enter Units or Days as whole numbers. Do not use fractions or decimals. 100

101 2400 Service Line notes continued 9. SV207 Line Item Non-Covered Charge Amount 10. Date Service Date DTP01 Date/Time Qualifier: Service 472 DTP02 Date Time Format Qualifier: CCYYMMDD or CCYYMMDD-CCYYMMDD D8 or RD8 DTP03 Service Date(s) 11. REF Line Item Control Number REF01 Reference Identification Qualifier: Provider Control Number REF02 Line Item Control Number 6R Provided at the discretion of the submitter. Must be unique within a Patient Control Number CLM01. The department will support up to 30 characters of the Line Item Control Number. If submitted, the Line Item Control Number will be returned in the following transactions: o 835 (5010/4010) 2110 REF*6R REF02 o 277 Notification (5010) REF*FJ REF02 101

102 837 Institutional Sample Billing Data NPI Provider ID This sample EDI data represents sample billing for professional services and includes the use of the Provider s NPI as the primary provider identifier within all applicable areas of the transaction. SEG No. ISA*00*...*00*...*ZZ* *30* *110930*1800*U*00501* *1*P*:~ GS*HC* * * *1800*101*X*005010X223A2~ 1 ST*837* *005010X223A2~ 2 BHT*0019*00*1234* *1800*CH~ 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 6 HL*1**20*1~ 7 PRV*BI*PXC*282N00000X~ 8 NM1*85*2*COMMUNITY HOSPITAL*****XX* ~ 9 N3*123 MAIN ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected] 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ 20 NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ 22 CLM* PUBLICJQ-00100*468*13:A:1*Y**Y*********Y~ 23 DTP*434*RD8* ~ 24 DTP*435*DT* ~ 25 CL1*3*1*30~ 26 REF*G1* ~ 27 REF*D9*VANTN012345~ 28 REF*EA*MEDRECNUM001~ 29 NTE*ADD*ADDITIONAL REMARKS~ 30 HI*BK:724.1*BJ:724.1*BN:E821.0~ 31 HI*BH:04:D8: ~ 32 NM1*71*1*LINCOLN*ABRAHAM*H***XX* ~ 33 PRV*AT*ZZ* X~ 34 NM1*77*2* FOREST GROVE CLINIC***XX* ~ 35 N3*500 FOREST GROVE~ 36 N4*OLYMPIA*WA*98501~ 37 NM1*DN*1* ADAMS*SAMUEL****XX* ~ 38 LX*1~ 39 SV2*0420*HC:97530:GP*117*UN*3~ 40 DTP*472*RD8* ~ 41 LX*2~ 42 SV2*0420*HC:97530:GP*117*UN*3~ 43 DTP*472*RD8* ~ 44 LX*3~ 45 SV2*0420*HC:97530:GP*117*UN*3~ 46 DTP*472*RD8* ~ 47 LX*4~ 48 SV2*0420*HC:97530:GP*117*UN*3~ 49 DTP*472*RD8* ~ 50 SE*50* ~ 51 GE*1*101~ 52 IEA*1* ~ The Sample EDI Data Shown below is Parsed by Segment for readability purposes and does not represent the Continuous Data format used when uploading the file through Provider Express Billing (PEB) 102

103 Institutional 837 Health Care Claim Sample Billing Data LNI Provider ID This sample EDI data represents sample billing for professional services and includes the use of the Provider s LNI Provider Account Number as the primary provider identifier within all applicable areas of the transaction. SEG No. ISA*00*...*00*...*ZZ* *30* *110930*1800*U*00501* *1*P*:~ GS*HC* * * *1800*101*X*005010X223A2~ 1 ST*837* *005010X223A2~ 2 BHT*0019*00*1234* *1800*CH~ 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 6 HL*1**20*1~ 7 PRV*BI*PXC*282N00000X~ 8 NM1*85*2*COMMUNITY HOSPITAL~ 9 N3*123 MAIN ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected] 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ 20 NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ 22 REF*G2*12345~ 23 CLM* PUBLICJQ-00100*468*13:A:1*Y**Y*********Y~ 24 DTP*434*RD8* ~ 25 DTP*435*DT* ~ 26 CL1*3*1*30~ 27 REF*G1* ~ 28 REF*D9*VANTN012345~ 29 REF*EA*MEDRECNUM001~ 30 NTE*ADD*ADDITIONAL REMARKS~ 31 HI*BK:724.1*BJ:724.1*BN:E821.0~ 32 HI*BH:04:D8: ~ 33 NM1*71*1*LINCOLN*ABRAHAM*H~ 34 PRV*AT*ZZ* X~ 35 REF*G2*12345~ 36 NM1*77*2* FOREST GROVE CLINIC~ 37 N3*500 FOREST GROVE~ 38 N4*OLYMPIA*WA*98501~ 39 REF*G2*12345~ 40 NM1*DN*1* ADAMS*SAMUEL~ 41 REF*G2* LX*1~ 43 SV2*0420*HC:97530:GP*117*UN*3~ 44 DTP*472*RD8* ~ 45 LX*2~ 46 SV2*0420*HC:97530:GP*117*UN*3~ 47 DTP*472*RD8* ~ 48 LX*3~ 49 SV2*0420*HC:97530:GP*117*UN*3~ 50 DTP*472*RD8* ~ 51 LX*4~ 52 SV2*0420*HC:97530:GP*117*UN*3~ 53 DTP*472*RD8* ~ 54 SE*54* ~ GE*1*101~ IEA*1* ~ The Sample EDI Data Shown below is Parsed by Segment for readability purposes and does not represent the Continuous Data format used when uploading the file through Provider Express Billing (PEB) 103

104 837 Institutional Sample Billing Data NPI + LNI Provider ID This sample EDI data represents sample billing for Institutional services and includes the use of the Provider s NPI as the primary provider identifier and the LNI Provider Account Number as the secondary provider identifier within all applicable areas of the transaction. SEG No. ISA*00*...*00*...*ZZ* *30* *110930*1800*U*00501* *1*P*:~ GS*HC* * * *1800*101*X*005010X223A2~ 1 ST*837* *005010X223A2~ 2 BHT*0019*00*1234* *1800*CH~ 3 NM1*41*2*AMERICAN BILLING SERVICES*****46* ~ 4 PER*IC*BEN FRANKLIN*TE* *EM*[email protected]~ 5 NM1*40*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****46* ~ 6 HL*1**20*1~ 7 PRV*BI*PXC*282N00000X~ 8 NM1*85*2*COMMUNITY HOSPITAL*****XX* ~ 9 N3*123 MAIN ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI* ~ 12 PER*IC*DOLLY MADISON*TE* *EM*[email protected] 13 HL*2*1*22*0~ 14 SBR*P*18*A123456******WC~ 15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~ 17 N4*OLYMPIA*WA*98555~ 18 DMG*D8* *M~ 19 REF*SY* ~ 20 NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI* ~ 21 N4*OLYMPIA*WA*98504~ 22 REF*G2*12345~ 23 CLM* PUBLICJQ-00100*468*13:A:1*Y**Y*********Y~ 24 DTP*434*RD8* ~ 25 DTP*435*DT* ~ 26 CL1*3*1*30~ 27 REF*G1* ~ 28 REF*D9*VANTN012345~ 29 REF*EA*MEDRECNUM001~ 30 NTE*ADD*ADDITIONAL REMARKS~ 31 HI*BK:724.1*BJ:724.1*BN:E821.0~ 32 HI*BH:04:D8: ~ 33 NM1*71*1*LINCOLN*ABRAHAM*H***XX* ~ 34 PRV*AT*ZZ* X~ 35 REF*G2*12345~ 36 NM1*77*2* FOREST GROVE CLINIC***XX* ~ 37 N3*500 FOREST GROVE~ 38 N4*OLYMPIA*WA*98501~ 39 REF*G2*12345~ 40 NM1*DN*1* ADAMS*SAMUEL****XX* ~ 41 REF*G2* LX*1~ 43 SV2*0420*HC:97530:GP*117*UN*3~ 44 DTP*472*RD8* ~ 45 LX*2~ 46 SV2*0420*HC:97530:GP*117*UN*3~ 47 DTP*472*RD8* ~ 48 LX*3~ 49 SV2*0420*HC:97530:GP*117*UN*3~ 50 DTP*472*RD8* ~ 51 LX*4~ 52 SV2*0420*HC:97530:GP*117*UN*3~ 53 DTP*472*RD8* ~ 54 SE*54* ~ GE*1*101~ IEA*1* ~ The Sample EDI Data Shown below is Parsed by Segment for readability purposes and does not represent the Continuous Data format used when uploading the file through Provider Express Billing (PEB) 104

105 ACKNOWLEDGMENTS, RESPONSES AND REPORTS This section describes the outbound files created by LNI s Medical Information Payment System (MIPS) and posted to the Provider Express Billing (PEB) website for the following EDI transactions: Responses TA1 Interchange Acknowledgment 999 Implementation Acknowledgement 824 Application Advice Notices 277 Health Care Claim Notification 835 Health Care Claim Payment/Advice Interchange Control and Functional Group Header & Trailer The Interchange Control Header and Trailer (ISA/IEA) and Functional Group Header and Trailer (GS/GE) share common data elements and data values within the outbound EDI transactions and are described in the following sections. ISA Envelope The ISA envelope provides information that identifies the sender, receiver, and identifying information of the file such as type of data, the date and time sent, tracking number, etc. The Interchange Control Header (ISA) is a fixed record length segment and all positions within each of the data elements must be filled. The purpose of the ISA is to start and identify an interchange of zero or more functional groups and interchange-related control segments. The first element separator (* asterisk), ISA position 4, defines the data element separator to be used throughout the entire interchange. The segment terminator (~ tilde), ISA position 106, immediately following the component separator (ISA16, position 105) defines the segment terminator to be used throughout the entire interchange. The following ISA information and example applies to all EDI outbound transactions provided by Washington State Department of Labor and Industries. 105

106 Interchange Control Header (ISA) The Interchange ISA/IEA envelope returned by LNI to the Submitter will contain standard and/or identical data values for all acknowledgments and Notifications to 837 submissions processed by the department. The ISA/IEA information that follows applies to the following outbound transactions: 999 Implementation Acknowledgement 824 Application Advice 277 Notification 835 Remittance Advice INTERCHANGE CONTROL HEADER (ISA) Sample Data, TR3 Required TR3 Segment/Field Seg/Field Size FIELD NAME Value [R] and Department PAGE # ID USAGE Min/Max Returned Value [DRV] C.3 ISA Interchange Control Header Required 106/106 ISA01 Authorization Information Qualifier 00 [R] [DRV] R 2/2 ISA02 Authorization Information. R 10/10 ISA03 Security Information Qualifier 00 [R] [DRV] R 2/2 ISA04 Security Information. R 10/10 ISA05 ISA06 Interchange ID Qualifier (Sender) 30 Interchange Sender ID: Washington State Department of Labor and Industries Federal Tax Identification Number [DRV] R 2/2 R 15/15 ISA07 Interchange ID Qualifier (Receiver) ZZ [DRV] R 2/2 ISA08 Interchange Receiver ID: Your National Provider Identifier (NPI) or your Washington State Department of Labor and R 15/15 Industries assigned 7-digit provider account number authorized for electronic submission or ISA09 Interchange Date R 6/6 ISA10 Interchange Time 1800 R 4/4 ISA11 Repetition Separator: Caret ^ R 1/1 ISA12 Interchange Control Version Number [R] R 5/5 ISA13 Interchange Control Number R 9/9 ISA14 Acknowledgement Requested 1 [DRV] R 1/1 ISA15 Usage Indicator P or T R 1/1 ISA16 Component Element Separator: Colon : R 1/1 Segment Terminator: Tilde ~ 1/1 Segment Example EDI Data for TA1, 999, 824, 277 and 835 Count ISA*00*...*00*...*30* *ZZ* *100501*1800*^*00501* *0*P*:~ The. in the above example represent character position within a field. In an actual transmission the. within the above ISA example would be replaced with spaces. ISA Interchange Control Header information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.3 ISA Interchange Control Header of the Implementation Guides (TR3 s). 106

107 ISA - Interchange Control Header notes Submitters may expect the following ISA/IEA Header/Trailer values in LNI s outbound transactions. 1. ISA01 Authorization Information Qualifier: No Authorization Information Present ISA02 Authorization Information: Spaces inserted into this data element Spaces 3. ISA03 Security Information Qualifier: No Security Information Present ISA04 Security Information: Spaces inserted into this data element Spaces 5. ISA05 Interchange Sender ID Qualifier: U.S. Federal Tax Identification Number ISA06 Interchange Sender ID: LNI Federal Tax ID ISA07 Interchange Receiver ID Qualifier: Mutually Defined ZZ 8. ISA08 Interchange Receiver ID 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) Clearinghouse or Provider s Submitter ID that is authorized for EDI through PEB) 9. ISA09 Interchange Date: formatted as YYMMDD 10. ISA10 Interchange Time: formatted as HHMM Where HH = Hours (00-23) and MM = Minutes (00-59). 11. ISA11 Repetition Separator: Caret ^ 12. ISA12 Interchange Control Version Number: ISA/IEA envelope version ISA13 Interchange Control Number ISA14 Acknowledgement Requested ISA15 Interchange Usage Indicator P or T P returned for 837 submissions received in Production T returned for 837 submissions received in Test 16. ISA16 Component Element Separator: Colon : 17. Segment Terminator: Tilde ~ 107

108 Interchange Control Trailer (IEA) The Interchange Control Trailer (IEA) is used to end an interchange of zero or more functional groups, interchange-related control segments, and is part of the ISA envelope. TR3 PAGE # Segment/Field ID INTERCHANGE CONTROL TRAILER (IEA) Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Seg/Field USAGE C.10 IEA Interchange Control Trailer Required Size Min/Max IEA01 Number of Included Functional Groups 1 R 1/5 IEA02 Interchange Control Number R 9/9 Segment Count IEA*1* ~ Example EDI Data IEA Interchange Control Trailer information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.10 IEA Interchange Control Trailer of the 837 Implementation Guides (TR3 s). ISA Interchange Control Trailer notes 1. IEA01 Number of Included Segments 0 or 1 Total number of functional groups (GS/GE segment sets) included in the Interchange TA1 Acknowledgment returns value of 0 as there are no functional groups to report 999, 824, 277, and 835 Notifications return value of 1 functional group reported 3. IEA02 Interchange Control Number Value is identical to ISA13 Interchange Control Number 108

109 Functional Group Header (GS) The Functional Group Header/Trailer returned by LNI will contain standard and/or identical data values for all acknowledgments to 837 submissions processed by the department. The GS/GE information that follows applies to the following outbound transactions: 999 Implementation Acknowledgement 824 Application Advice 277 Notification 835 Payment Advice FUNCTIONAL GROUP HEADER (GS) Sample Data, TR3 Required Segment/Field Seg/Field FIELD NAME Value [R] and Department ID USAGE Required Value [DRV] C.7 GS Functional Group Header Required GS01 Functional Identifier Code: See table for values [R] R 2/2 Application Sender Code: [DRV] GS02 Washington State Department of Labor and R 2/15 Industries Federal Tax Identification Number GS03 Application Receiver Code: or Your National Provider Identifier or your Washington State Department of Labor and Industries assigned 7-digit provider account R 2/15 number authorized for electronic submission. This will match the Sender ID supplied in the 837 GS02. GS04 Functional Group Creation Date: format CCYYMMDD R 8/8 GS Functional Group Creation Time: format HHMM R 4/8 GS06 Group Control Number 1 R 1/9 GS07 X [R] Responsible Agency Code R 1/2 GS08 Version/Release/Industry Identifier Code X2.. [R] R 1/12 TR3 PAGE # Size Min/Max TR3 PAGE # Appendix C X231 (999) TR3 PAGE # Appendix C X186 (824) TR3 PAGE # Appendix C X214 (277) TR3 PAGE # Appendix C X221 (835) Example EDI Data 999 Implementation Acknowledgement GS*FA* * * *1800*1*X*001010X231A1~ Example EDI Data 824 Application Advice GS*AG* * * *1800*1*X*004010X161~ Example EDI Data 277 Notification GS*HN* * * *1800*1*X*001010X214~ Example EDI Data 835 Payment Advice GS*HP* * * *1800*1*X*001010X221A1~ 109

110 GS Functional Group Header notes 1. GS01 Functional Identifier Code see table 2-character Functional Identifier Code assigned to each X12 transaction X12 Transaction Value Definition 999 FA Implementation Acknowledgement 824 AG Application Advice 277 HN Health Care Claim Status Notification 835 HP Health Care Claim Payment/Advice 2. GS02 Application Sender Code: LNI Federal Tax ID GS03 Application Receiver Id 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) Submitter ID authorized for EDI and registered with PEB. 4. GS04 Date: Functional Group creation date format is CCYYMMDD 5. GS05 Time: Functional Group creation time format is HHMM Where HH = Hours (00-23) and MM = Minutes (00-59). 6. GS06 Group Control Number 1 7. GS07 Responsible Agency Code: Accredited Standards Committee X12 X 8. GS08 Version/Release Industry Identifier Code: see table Version of transaction sets within ISA/IEA envelope X12 Transaction Value Definition X231A1 Implementation Acknowledgement X161 Application Advice X214 Health Care Claim Status Notification X221A1 Health Care Claim Payment/Advice 110

111 Functional Group Trailer (GE) The purpose of the Functional Group Trailer (GE) is to end the functional group and to provide control information. TR3 PAGE # Segment/Field ID FUNCTIONAL GROUP TRAILER (GE) Sample Data, TR3 Required FIELD NAME Value [R] and Department Returned Value [DRV] Seg/Field USAGE C.9 GS Functional Group Trailer Required Size Min/Max GE01 Number of Transaction Sets included 1 [DRV] R 1/6 GE02 Group Control Number 1 [DRV] R 2/15 Segment Count GE*1*1~ Example EDI Data GE Functional Group Trailer information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.9 GE Functional Group Trailer of the 837 Implementation Guides (TR3 s). GE Functional Group Trailer notes 1. GE01 Number of Transaction Sets included 1 Total number of Transaction Sets (ST/SE segment sets) included in the Interchange 2. GE02 Group Control Number: positive unsigned number 1 Value is identical to the GS06 Group Control Number 111

112 TA1 Interchange Acknowledgment Labor and Industries TA1Interchange acknowledgement, acknowledges the receipt of the 837 Interchange ISA/IEA envelope. If the 837 Interchange was received correctly, the TA1 reflects the valid interchange, regardless of the validity of the contents of the transaction sets (ST/SE) within the Interchange. LNI will return a TA1 Interchange Acknowledgment to the submitter of the 837 submission when: Correctly requested by the submitter as described below, or The Interchange ISA/IEA envelope is rejected. Available to submitter via PEB Retrieve Acknowledgments function. TR3 PAGE # Segment/Field ID ISA 837 Interchange Control Header (ISA) Requirements for TA1 Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Interchange Control Header ISA05 Interchange ID Qualifier (Sender): Mutually Defined ZZ [R] [DRV] ISA06 Interchange Sender ID: or Your National Provider Identifier (NPI) or your Washington State Department of Labor and Industries assigned 7-digit provider account number authorized for electronic submission. This Sender ID must match the Sender ID supplied in the GS02 field. ISA07 Interchange ID Qualifier (Receiver): U.S. 30 [R] [DRV] Federal Tax Identification Number (TIN) ISA08 Interchange Receiver ID: [DRV] Washington State Department of Labor and Industries Federal Tax Identification Number ISA14 Acknowledgement Requested: 1 - Requested 1 Seg/Field USAGE Required R R R R Size Min/Max 2/2 15/15 2/2 15/15 R 1/1 837 Interchange Acknowledgment Requirements for LNI TA1 response notes 1. ISA05 Interchange Sender ID Qualifier: Mutually defined ZZ 2. ISA06 Interchange Sender ID: 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI). Clearinghouse or Provider s Submitter ID that is authorized for EDI through PEB. Must match the GS02 Sender ID. 3. ISA07 Interchange Receiver ID Qualifier: U.S. Federal Tax Identification Number (TIN) ISA08 Interchange Receiver ID: U.S. Federal Tax Identification Number (TIN) Washington State Department of Labor and Industries Federal Tax ID. 5. ISA09 TA1 Acknowledgement Requested: Yes 1 112

113 Interchange Acknowledgement (TA1) Interchange Acknowledgement TA1 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE TA1 Interchange Acknowledgment Required 78/C.10 TA101 Interchange Control Number R 78/C.10 TA102 Interchange Date (YYMMDD) R 78/C.10 TA103 Interchange Time (HHMM) 1800 R 78/C.10 TA104 Interchange Acknowledgment Code [A, E, or R] A R 78/C.11 TA105 Interchange Note Code 000 R Interchange Acknowledgement notes 1. TA101 Interchange Control Number [837-ISA13] Value received in the submitted 837 ISA13 Interchange Control Number 2. TA102 Interchange Date [837-ISA09] Value received in the submitted 837 ISA09 Interchange Date 3. TA103 Interchange Time [837-ISA10] Value received in the submitted 837 ISA10 Interchange Time 4. TA104 Interchange Acknowledgement Code(s) see table Status code indicating the receipt status of the 837 Interchange ISA/IEA envelope received The following code(s) specify the status of processing the interchange ISA/IEA envelope. Code Definition A The Transmitted Interchange Control Structure Header and Trailer Have Been Received and Have No Errors. E The Transmitted Interchange Control Structure Header and Trailer Have Been Received and Are Accepted But Errors Are Noted. This Means the Sender Must Not Resend This Data. P Partially Accepted. At least one Transaction Set was Rejected. R The Transmitted Interchange Control Structure Header and Trailer are Rejected Because of Errors. ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X230, Version 5, Release 1 C.10 C.11 This table information is intended for reference and convenience use only 113

114 5. TA105 Interchange Note Code(s) see table Status code indicating the receipt status of the 837 Interchange (ISA) received The following Error code(s) specify the error(s) found processing the interchange ISA/IEA envelope. Code Definition 000 No error 001 The Interchange Control Number in the Header and Trailer Do Not Match. The Value From the Header is Used in the Acknowledgment. 002 This Standard as Noted in the Control Standards Identifier is Not Supported. 003 This Version of the Controls is Not Supported 004 The Segment Terminator is Invalid 005 Invalid Interchange ID Qualifier for Sender 006 Invalid Interchange Sender ID 007 Invalid Interchange ID Qualifier for Receiver 008 Invalid Interchange Receiver ID 009 Unknown Interchange Receiver ID 010 Invalid Authorization Information Qualifier Value 011 Invalid Authorization Information Value 012 Invalid Security Information Qualifier Value 013 Invalid Security Information Value 014 Invalid Interchange Date Value 015 Invalid Interchange Time Value 016 Invalid Interchange Standards Identifier Value 017 Invalid Interchange Version ID Value 018 Invalid Interchange Control Number Value 019 Invalid Acknowledgment Requested Value 020 Invalid Test Indicator Value 021 Invalid Number of Included Groups Value 022 Invalid Control Structure 023 Improper (Premature) End-of-File (Transmission) 024 Invalid Interchange Content (e.g., Invalid GS Segment) 025 Duplicate Interchange Control Number 026 Invalid Data Element Separator 027 Invalid Component Element Separator 028 Invalid Delivery Date in Deferred Delivery Request 029 Invalid Delivery Time in Deferred Delivery Request 030 Invalid Delivery Time Code in Deferred Delivery Request 031 Invalid Grade of Service Code ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X230, Version 5, Release 1 C.10 C.11 This table information is intended for reference and convenience use only Segment Count Example EDI Data TA1 ISA*00*...*00*...*30* *ZZ* *110930*1800*^*00501* *1*P*:~ TA1* *110930*1800*A*000*~ (Accepted) TA1* *110930*1800*R*024*~ (Rejected) TA1* *110930*1800*E*024*~ (Accepted with Errors) IEA*1* ~ 114

115 ASC X12C X231A1 999 IMPLEMENTATION ACKNOWLEDGMENT Labor and Industries 999 Implementation acknowledgment, acknowledges the acceptance or rejection of the EDI format/syntax of each Functional Group and associated Transaction Sets received in the submitter s 837 Interchange submission. If the submitter is using their NPI as their primary identifier and LNI has it on file, this will be returned within the 999 response. The EDI layout and sample data provides an example of the expected 999 response from LNI and is for reference only. Failure to follow the 837 ISA and GS requirements below will result in the department rejecting your submission and LNI s ability to generate the correct routing for the 999 and therefore, no 999 response will be generated and available to the submitter of the 837 Interchange. 837 ISA Interchange Control Header requirements for 999 acknowledgment TR3 PAGE # Segment/Field ID ISA ISA Interchange Control Header (ISA) Requirements for 999 Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Interchange Control Header Interchange Sender ID: Your National Provider Identifier (NPI) or your Washington State Department of Labor and Industries assigned 7-digit provider account number authorized for electronic submission. This Sender ID must match the Sender ID supplied in the 837 GS02 field or Seg/Field USAGE Required R Size Min/Max 15/ GS Functional Group requirements for LNI 999 acknowledgment TR3 PAGE # Segment/Field ID 837 Functional Group Header (GS) Requirements for 999 Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Seg/Field USAGE GS Functional Group Header Required Application Sender Code: Your National Provider Identifier (NPI) or your Washington State Department of Labor and GS02 Industries assigned 7-digit provider account number authorized for electronic submission and registered with Provider Express Billing (PEB). This Sender ID must match the Sender ID supplied in the 837 ISA06 field or [DRV] R Application Receiver Code: GS03 Washington State Department of Labor and Industries Federal Tax Identification Number [DRV] R Size Min/Max 2/15 2/15 115

116 Functional Group Header (GS) The 999 GS Functional Group Header from LNI returned to the submitter is used to indicate the beginning of a functional group and to provide control information. TR3 PAGE # Segment/Field ID FUNCTIONAL GROUP HEADER (GS) Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Seg/Field USAGE Size Min/Max GS Functional Group Header Required C.12 GS01 Functional Identifier Code: FA [R] R 2/2 C.12 Application Sender Code: LNI Federal Tax ID GS [DRV] R 2/15 C.12 Application Receiver Code: GS03 Your National Provider Identifier or your Washington State Department of Labor and Industries assigned 7-digit provider account R 2/15 number authorized for electronic submission. This will match the Sender ID supplied in the 837 GS or C.13 GS04 Functional Group Creation Date: R 8/8 C.13 GS05 Functional Group Creation Time: 1800 R 4/8 C.13 GS06 Group Control Number 1 [DRV] R 1/9 C.13 GS07 Responsible Agency Code X [R] R 1/2 C.13 GS08 Version/Release/Industry Identifier Code X231A1 [R] R 1/12 Segment Count Example EDI Data GS*FA* * * *1800*1*X*005010X231A1~ GS Functional Group Header information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.7 GS Functional Group Header of the 999 Implementation Guide (TR3 s) GS Functional Group Header notes 1. GS01 Functional Identifier Code: Implementation Acknowledgement FA 2. GS02 Application Sender Code: LNI Federal Tax ID GS03 Application Receiver Id [837-GS02] 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) Submitter ID authorized for EDI and registered with PEB Value received in 837 GS02 Application Sender Code 4. GS04 Functional Group Creation Date: formatted as CCYYMMDD GS05 Functional Group Creation Time: formatted as HHMM 1800 Where HH = Hours (00-23) and MM = Minutes (00-59) 6. GS06 Group Control Number 1 7. GS07 Responsible Agency Code: Accredited Standards Committee X12 X 8. GS08 Version/Release Industry Identifier Code X231A1 116

117 Functional Group Trailer (GE) The purpose of the Functional Group Trailer (GE) is to end the functional group and to provide control information. TR3 PAGE # Segment/Field ID 999 FUNCTIONAL GROUP TRAILER (GE) Sample Data, TR3 Required FIELD NAME Value [R] and Department Required Value [DRV] Seg/Field USAGE Size Min/Max GS Functional Group Header Required C.15 GE01 Number of Transaction Sets included 1 R 2/2 C.15 GE02 Group Control Number 1 [DRV] R 2/15 Segment Count GE*1*1~ Example EDI Data GE Functional Group Trailer information is available in Appendix C, EDI Control Directory; C.1 Control Segments; C.15 GE Functional Group Trailer of the 999 Implementation Guide (TR3 s) GE Functional Group Trailer notes: 1. GE01 Number of Transaction Sets Included => 1 Total number of Transaction Sets included in the 837 file submission this 999 is responding to. 2. GE02 Group Control Number: 1 This value is the same value as the GS06 Group Control Number. 117

118 ST Transaction Set Header Implementation Acknowledgement 999 TRANSACTION SET HEADER (ST) IMPLEMENTATION ACKNOWLEDGEMENT 999 TR3 Segment/Field Sample Data, TR3 Required Value [R] Seg/Field FIELD NAME PAGE # ID and Department Required Value [DRV] USAGE 21 ST Transaction Set Header Required 21 ST01 Transaction Set Identifier Code 999 [R] R 21 ST02 Transaction Set Control Number 0001 [DRV] R 22 ST03 Implementation Convention Reference X231A1 [R] R 23 AK1 Functional Group Response Header Required 23 AK101 Functional Identifier Code HC [DRV] R 23 AK102 Group Control Number [DRV] R 24 AK103 Version/Release/Industry Identifier Code X222A1 R 25 AK2 Transaction Set Response Header Situational 25 AK201 Transaction Set Identifier Code: Health Care Claim 837 [DRV] R 26 AK202 Transaction Set Control Number R 26 AK203 Implementation Convention Reference X222A1 S 27 IK3 IK3 Error Identification Situational 27 IK301 Segment ID Code i.e., SBR, NM1, etc. R 27 IK302 Segment Position in Transaction Set (data count position) R 28 IK303 Loop ID Code S 28 IK304 Segment Syntax Error Code R 29 CTX Segment Context Situational 29 CTX01-1 Context Name (Tag) SITUATIONAL TRIGGER [R] R 29 CTX02 Segment ID Code R 29 CTX03 Segment Position in Transaction Set R 30 CTX04 Loop Identifier Code S 30 CTX05-1 Element Position in Segment S 31 CTX06-1 Data Element Reference Number S 34 IK4 Implementation Data Element Note Situational 34 IK401 Position in Segment 34 IK401-1 Element Position in Segment R 34 IK401-2 Component Data Element Position in Composite S 35 IK402 Data Element Reference Number S 35 IK403 Implementation Data Element Syntax Error Code R 35 IK404 Copy of Bad Data Element S 36 CTX Element Context Situational 36 CTX01-1 Context Name (Tag) SITUATIONAL TRIGGER [R] R 36 CTX02 Segment ID Code R 36 CTX03 Segment Position in Transaction Set R 37 CTX04 Loop Identifier Code S 37 CTX05-1 Element Position in Segment S 38 CTX06-1 Data Element Reference Number S 39 IK5 Transaction Set Response Trailer Required 39 IK501 Transaction Set Acknowledgment Code A R 40 IK502 Implementation Transaction Set syntax Error Code S 42 AK9 Functional Group Response Trailer Required 42 AK901 Functional Group Acknowledge Code A R 43 AK902 Number of Transaction Sets Included 1 R 43 AK903 Number of Received Transaction Sets 1 R 43 AK904 Number of Accepted Transaction Sets 1 R 43 AK905 Functional Group Syntax Error Code S 44 AK906-AK909 Functional Group Syntax Error Code S 45 SE Transaction Set Trailer Required 45 SE01 Number of Included Segments R 45 SE02 Transaction Set Control Number R 118

119 999 Acknowledgment of Accepted 837 file submission Segment Count Example EDI Data ISA*00* *00* *30* *ZZ* *110930*1800*^*00501* *1*P*:~ GS*FA* * * *1800*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC*001234*005010X222A1~ AK2*837* *005010X222A1~ IK5*A~ AK9*A*1*1*1~ SE*6*0001~ GE*1*1~ IEA*1* ~ 999 Acknowledgment of Rejected 837 file submission Segment Count See 824 Example EDI Data ISA*00* *00* *30* *ZZ* *110930*1800*^*00501* *1*P*:~ GS*FA* * * *1800*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC*2*005010X222A1~ AK2*837* *005010X222A1~ IK3*CLM*22*2300*8~ IK4*2*782*I12*389.55~ CTX*SITUATIONAL TRIGGER*CLM*22*2300*2*782~ IK5*R*5~ AK9*R*1*1*0~ SE*13*0001~ 824 Notification associated to 999 Acknowledgment of Rejected 837 file submission Segment Count Example EDI Data 824 (4010) ISA*00* *00* *30* *ZZ* *110930*1800*U*00401* *1*P*:~ GS*AG* * * *1800*1*X*004010X161~ ST*824*0001~ BGN*11* * *1800** **U~ N1*40*824 RECEIVER*46*RECEIVER ETIN~ N1*41*824 SUBMITTER*FI* ~ OTI*TR*TN*NA*** *1800*2* *837*005010X222A1~ TED*024**CLM*22*2**389.55~ NTE*ZZZ*CLM ~ RED* CLM02 = SUM(2400 SV102)**94**ZZ*E024~ SE*9*0001~ GE*1*1~ IEA*1* ~ 119

120 999 Implementation Acknowledgement notes The 999 acknowledges the acceptance or rejection status of the transaction set(s) within a functional group of the Interchange submission. If a transaction set is reported as rejected (IK5*R) an 824 Application Advice may also be generated to report error conditions found in the Interchange. Remember to use both the 999 and 824 together when identifying error conditions causing rejection of the Interchange submission. 1. ST Transaction Set Header The ST segment indicates the beginning of the 999 transaction set Provides a control number Indicates the version standard used to create the 999 transaction a. ST01 Transaction Set Identifier Code: Implementation Acknowledgement 999 b. ST02 Transaction Set Control Number 0001 c. ST03 Implementation Convention Reference X231A1 2. AK1 Functional Group Response Header The AK1segment describes the 837 functional group this 999 response is acknowledging a. AK1-AK101 Functional Identifier Code: Healthcare Claim HC Value received in the submitted 837-GS01 Functional Identifier Code b. AK1-AK102 Group Control Number [837-GS06] Value received in the submitted 837-GS06 Group Control Number c. AK1-AK103 Version/Release/Industry Identifier Code [837-GS08] Value received in the submitted 837-GS08 Version/Release/Industry Identifier Code X222A1 = Professional 837 Health Care Claim X223A1 = Institutional 837 Health Care Claim 3. AK2 Transaction Set Response Header Used to start the acknowledgement of each transaction set received within a functional group of the 837 submission. a. AK2-AK201 Transaction Set Identifier Code: Health Care Claim 837 Value received in the submitted 837-ST01Transaction Set Identifier b. AK2-AK202 Transaction Set Control Number Value [837-ST02] Value received in the submitted 837-ST02 Transaction Set Control Number c. AK2-AK203 Implementation Convention Reference [837-ST03] Value received in the submitted 837-ST03 Implementation Guide Version Name X222A1 = Professional 837 Health Care Claim X223A1 = Institutional 837 Health Care Claim 120

121 4. IK3 Error Identification The IK3 segment is returned when implementation errors are found in a data segment Identifies the location of the data segment in error If no implementation errors are found, this segment is not present in the 999 a. IK301 Segment ID Code This value identifies the data segment that is in error, i.e. SBR, NM1, DMG, etc. b. IK302 Segment Position in Transaction Set This value is the numerical count of the data segment s position within the transaction set Position count from the start (beginning) of the transaction set ST segment c. IK303 Loop Identifier Code This value is the loop ID of the data segment that is in error, i.e. 2000B, 2010AB, 2310B, etc. d. IK304 Implementation Segment Syntax Error Code Implementation error code found based on the syntax editing of the data segment. IK304 Implementation Segment Syntax Error Codes Code Definition 1 Unrecognized segment ID 2 Unexpected segment 3 Required segment missing 4 Loop Occurs Over Maximum Times 5 Segment Exceeds Maximum Use 6 Segment Not in Defined Transaction Set 7 Segment Not in Proper Sequence 8 Segment Has Data Element Errors I4 Implementation Not Used segment present I6 Implementation Dependent segment missing I7 Implementation Loop Occurs under minimum times I8 Implementation Segment Below minimum use I9 Implementation Dependent Not Used segment present ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X231, Version 5, Release 1 Page 28 This table information is intended for reference and convenience use only 121

122 5. CTX Segment Context The CTX segment identifies the data that triggered the error identified in the IK3/IK4 loop caused by a situational requirement. If the CTX segment is exists, a corresponding 824 Application Advice is generated reporting the error that triggered the situational requirement event. a. CTX01-1 Context Name SITUATIONAL TRIGGER b. CTX02 Segment ID Code This is the segment ID of the data segment in error c. CTX03Segment Position in Transaction Set The numerical count position of this data segment from the start of the transaction set: The transaction set header (ST) is count position 1 d. CTX04 Loop Identifier Code The loop ID number given on the transaction set e. CTX05-1 Element Position in Segment The relative position of the simple data element or composite data structure in error within a segment, count beginning with 1 for the position immediately following the segment ID f. CTX06-1 Data Element Reference Number Reference number of the Data Element in error 122

123 6. IK4 Implementation Data element Note The IK4 segment is used to report implementation errors in a data element or composite data structure and to identify the location of the data element in error. a. IK401-1 Element Position in Segment b. IK401-2 Component Data Element Position in Composite c. IK402 Data Element Reference Number d. IK403 Implementation Data Element Syntax Error Code see table This value is the code indicating the implementation error found after syntax edits of a data element. IK403 Implementation Data Element Syntax Error Codes Code Definition 1 Required Data Element Missing 2 Conditional Required Data Element Missing 3 Too Many Data Elements 4 Data Element Too Short 5 Data Element Too Long 6 Invalid Character in Data Element 7 Invalid Code Value 8 Invalid Date 9 Invalid Time 10 Exclusion Condition Violated 12 Too Many Repetitions 13 Too Many Components I10 Implementation Not Used Data Element Present I11 Implementation Too Few Repetitions I12 Implementation Pattern Match Failure I13 Implementation Dependent Not Used Data Element Present I6 Code Value Not Used in Implementation I9 Implementation Dependent Data Element Missing ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X231, Version 5, Release 1 Page 35 This table information is intended for reference and convenience use only 123

124 7. CTX Element Context The CTX segment identifies the data that triggered the error identified in the IK3/IK4 loop caused by a situational requirement. If the CTX segment is exists, a corresponding 824 Application Advice is generated reporting the error that triggered the situational requirement event. a. CTX01-1 Context Name SITUATIONAL TRIGGER b. CTX02 Segment ID Code This is the segment ID of the data segment in error c. CTX03Segment Position in Transaction Set The numerical count position of this data segment from the start of the transaction set: The transaction set header (ST) is count position 1 d. CTX04 Loop Identifier Code The loop ID number given on the transaction set e. CTX05-1 Element Position in Segment The relative position of the simple data element or composite data structure in error within a segment, count beginning with 1 for the position immediately following the segment ID f. CTX06-1 Data Element Reference Number Reference number of the Data Element in error 124

125 8. IK5 Transaction Set Response Trailer The IK5 segment acknowledges the acceptance or rejection of the transaction set and reports implementation errors. a. IK501Transaction Set Acknowledgement Code see table This value is the code indicating the accepted or rejected condition of the transaction set based on syntax editing. IK501 Transaction Set Acknowledgment Codes Code Definition A Accepted Accepted But Errors Were Noted. The Transaction Set indicated in the AK2 loop contained E errors, but was forwarded for further processing. Rejected. The Transaction Set indicated in the AK2 loop contained errors, and was NOT R forwarded for further processing. The Transaction Set will need to be corrected and resubmitted for processing. ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X231, Version 5, Release 1 Page 39 This table information is intended for reference and convenience use only b. IK502 Implementation Transaction Set Syntax Error Code see table This value is a code indicating the implementation error found based on the syntax editing of the Transaction Set. A code value will be present only when IK501 = E (Accepted with errors) or R (Rejected). IK502 Implementation Transaction Set Syntax Error Codes Code Definition 1 Transaction Set Not Supported 2 Transaction Set Trailer Missing 3 Transaction Set Control Number in Header and Trailer Do Not Match 4 Number of Included Segments Does Not Match Actual Count 5 One or More Segments in Error 6 Missing or Invalid Transaction Set Identifier 7 Missing or Invalid Transaction Set Control Number 8 Authentication Key Name Unknown 9 Encryption Key Name Unknown 10 Requested Service (Authentication or Encrypted) Not Available 11 Unknown Security Recipient 12 Incorrect Message Length (Encryption Only) 13 Message Authentication Code Failed 15 Unknown Security Originator 16 Syntax Error in Decrypted Text 17 Security Not Supported 18 Transaction Set not in Functional Group 19 Invalid Transaction Set Implementation Convention Reference 23 Transaction Set Control Number Not Unique within the Functional Group 24 S3E Security End Segment Missing for S3S Security Start Segment 25 S3S Security Start Segment Missing for S3E Security End Segment 26 S4E Security End Segment Missing for S4S Security Start Segment 27 S4S Security Start Segment Missing for S4E Security End Segment I6 Implementation Convention Not Supported ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X231, Version 5, Release 1 Page 40 This table information is intended for reference and convenience use only 125

126 c. IK503 IK506 Implementation Transaction Set Syntax Error Code(s) This value is a code indicating the implementation error found based on the syntax editing of the transaction set. This code value supplements the code value in IK502 and is present if there are additional error codes to report. Code values reported here is the same code values defined in the table above for IK AK9 Functional Group Response Trailer The AK9 segment acknowledges the acceptance or rejection of the functional group(s) within the Interchange. Reports the number of included transaction set(s) reported in the 837 GE01 Functional Group Trailer Reports the number of accepted transaction set(s) Reports the number of received transaction set(s) a. AK901 Functional Group Acknowledgement Code see table This value is a code indicating the accepted or rejected condition of the functional group based on syntax editing. IK901 Functional Group Acknowledgment Codes Code Definition Accepted. This code value is present when there are no AK2 loops or all IK501 values = A A (accepted). Accepted But Errors Were Noted. The Functional Group indicated in this 999 contained errors, E but was forwarded for further processing. Rejected. The Functional Group indicated in this 999 contained errors, and was NOT forwarded R for further processing. The Functional Group will need to be corrected and resubmitted for processing. ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X231, Version 5, Release 1 Page 42 This table information is intended for reference and convenience use only b. AK902 Number of Transaction Sets Included [837-GE01] Total number of transaction sets included in the functional group of the Interchange c. AK903 Number of Received Transaction Sets Total number of transaction sets received in the functional group of the Interchange d. AK904 Number of Accepted Transaction Sets The number of transaction sets Accepted processing the functional group of the Interchange 126

127 e. AK905 Functional Group Syntax Error Code see table This value is a code indicating the error found based on the syntax editing of the functional group header and/or trailer AK905 Functional Group Syntax Error Codes Code Definition 1 Functional Group Not Supported 2 Functional Group Version Not Supported 3 Functional Group Trailer Missing 4 Group Control Number in the Functional Group Header and Trailer Do Not Agree 5 Number of Included Transaction Sets Does Not Match Actual Count 6 Group Control Number Violates Syntax 10 Authentication Key Name Unknown 11 Encryption Key Name Unknown 12 Requested Service (Authentication or Encryption) Not Available 13 Unknown Security Recipient 14 Unknown Security Originator 15 Syntax Error in Decrypted Text 16 Security Not Supported 17 Incorrect Message Length (Encryption Only) 18 Message Authentication Code Failed 19 Functional Group Control Number not Unique within Interchange 23 S3E Security End Segment Missing for S3S Security Start Segment 24 S3S Security Start Segment Missing for S3E Security End Segment 25 S4E Security End Segment Missing for S4S Security Start Segment 27 S4S Security Start Segment Missing for S4E Security End Segment 26 Implementation Convention Not Supported ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X231, Version 5, Release 1 Page 43 This table information is intended for reference and convenience use only f. AK906 AK909 Functional Group Syntax Error Code(s) This value is a code indicating the implementation error found based on the syntax editing of the functional group header and/or trailer. Supplements the code value in AK905 and is present if there are additional error codes to report Code values reported here is the same code values defined in the table above for AK SE Transaction Set Trailer The SE segment indicates the termination of the 999 transaction set a. SE01 Number of Included Segments This value is the Total number of segments included in this 999 acknowledgment b. SE02 Transaction Set Control Number 0001 This value is the same value as the ST01 Transaction Set Control Number 127

128 824 Application Advice ASC X12N X161 The EDI layout and sample data for the 824 Application Advice is for reference only. This layout includes all Loops and Segments that could be included in an 824 Advice and is used to report application errors not reported in the standard 999/997 Acknowledgement returned for an 837 submission. The 999/997 Functional Acknowledgement will report the acceptance or rejection of each transaction set within the 837 Interchange. LNI processing supports X161 format for both 5010 and submissions. The 824 Application Advice will be generated to report error events for Situational Requirements in 837 (5010) submissions where the 999 indicates rejection of a transaction set (IK5=R) and the CTX Trigger segment is present. The 824 Application Advice will also be generated for application level errors in 837 (4010) submissions that are not reported in the 997 where the 997 indicates rejection of the transaction set (AK5=R) and no AK3/AK4 error segment is included in the 997 to report the error condition(s) causing rejection. When applicable, the 824 Application Advice will be posted to Provider Express Billing (PEB) and be available for download to the Submitter of the 837. PEB File naming convention: EDI 824 Application Advice txt Where equals the Submitter ID authorized for electronic file submission and/or retrieval. 128

129 Transaction Set Header (ST) The purpose of the Transaction Set Header (ST) is to indicate the start of a transaction set and to assign a control number. TR3 PAGE # Segment/Field ID TRANSACTION SET HEADER (ST) FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE ST Transaction Set Header Required ST01 Transaction Set Identifier Code 824 [R] R ST02 Transaction Set Control Number 0001 R BGN Beginning Segment Required BGN01 Transaction Set Purpose Code 11 [R] R BGN02 Transaction Set Identifier Code R BGN03 Transaction Set Creation Date R BGN04 Transaction Set Creation Time HHMM 1800 R Referenced Interchange Control Number: Source 837- BGN06 S ISA13/IEA BGN08 Action Code: U - Reject U R Segment Count 1 ST*824*0001*005010X186~ 2 BGN*11*001122* *0600** **U~ Example EDI Data 824 ST Transaction Set Header notes: 1. ST01 Transaction Set Identifier Code: Application Advice ST02 Transaction Set Control Number ST03 Implementation Convention Reference ID X BGN01 Transaction Set Purpose Code: Response BGN02 Transaction Set Identifier Code [837-ST02] This value is the value of 837 ST02 Transaction Set Control Number 6. BGN03 Transaction Set Creation Date: formatted as CCYYMMDD This value is the Date this 824 was generated for the 837 submission received 7. BGN04 Transaction Set Creation Time: formatted as HHMM This value is the Time this 824 was generated for the 837 submission received Where HH = Hours (00-23) and MM = Minutes (00-59) 8. BGN06 Reference Interchange Control Number [837-ISA13] 9. BGN08 Action Code: Reject U The entire transaction set is rejected. 129

130 1000A Receiver Name This segment identifies the Receiver of the 824 transaction set. 1000B RECEIVER NAME NM1*40 TR3 PAGE # Segment/Field ID FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE N1 Submitter Name Required N101 Entity Identifier Code: Receiver 40 [R] R N102 Receiver Name: 824 RECEIVER [DRV] R Identification Code Qualifier: Electronic Transmitter N103 R Identification Number (ETIN) 46 [DRV] N104 Identification Code: ETIN RECEIVER ETIN [DRV] R Segment Count N1*40*824 RECEIVER*46*RECEIVER ETIN~ Example EDI Data A Receiver Name notes: 1. N101 Entity Identifier Code: 40 Receiver 2. N102 Receiver Name: RECEIVER NAME Default value 3. N103 Identification Code Qualifier: 46 Electronic Transmitter Identification Number (ETIN) 4. N104 Receiver Identifier: RECEIVER ETIN Default value 130

131 1000B Submitter Name This segment identifies the Submitter of the 824 transaction set. TR3 PAGE # Segment/Field ID 1000A SUBMITTER NAME NM1*41 FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE N1 Submitter Name Required N101 Entity Identifier Code: Submitter 41 [R] R N102 Submitter Name: 824 SUBMITTER [DRV] R N103 Identification Code Qualifier: Federal TIN FI [DRV] R N104 Identification Code: LNI Federal TIN [DRV] R Segment Count N1*41*824 SUBMITTER*FI* ~ Example EDI Data B Submitter Name notes: 1. N101 Entity Identifier Code: 41 Submitter 2. N102 Submitter Name: 824 SUBMITTER Default value 3. N103 Identification Code Qualifier: FI Federal Taxpayer s Identification Number 4. N104 Submitter Identifier: LNI Federal Tax ID Number 131

132 2000 Original Transaction Identification This loop is used to identify the edited transaction set and the level at which the results of the edits are reported, and to indicate the rejected edit results. TR3 PAGE # SEG./ FIELD ID 2000 ORIGINAL TRANSACTION IDENTIFICATION - OTI FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] USAGE 38 OTI Original Transaction Identification Required 39 OTI01 Application Acknowledgement Code TR R 41 OTI02 Reference Identification Qualifier TN R 41 OTI03 Edit Level Reference Identifier NA R 41 OTI06 Functional Group Creation Date S 42 OTI07 Functional Group Creation Time 1800 S 42 OTI08 Functional Group Control Number 1 S 42 OTI09 Transaction Set Control Number S 42 OTI10 Transaction Set Identifier Code 837 R 43 OTI11 Version/Release/Industry Identifier Code [837-GS08] S Segment Count OTI*TR*TN*NA*** *1800*1*00112*837*005010X222A1~ Example EDI Data Original Transaction Identification notes: 1. OTI01 Application Acknowledgement Code: Transaction Set Rejected see table LNI EDI validation will typically return one of the following codes: Code Definition TR Transaction Set Rejected TE Transaction Set Accepted with Error TP Transaction Set Partial Accept/Reject. ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12C/005010X186, Version 5, Release 1 Page 40 This table information is intended for reference and convenience use only 2. OTI02 Reference Identification Qualifier: Transaction Reference Number TN Required when OTI01 = TR, TE, or TP 3. OTI03 Edit Level Reference Identifier: Not Applicable NA Value will always be NA. 4. OTI06 Functional Group Creation Date: formatted as CCYYMMDD [837-GS04] This value is the 837 GS04 Functional Group Creation Date 5. OTI07 Functional Group Creation Time: formatted as HHMM [837-GS05] This value is the 837 GS05 Functional Group Creation Time 6. OTI08 Functional Group Control Number [837-GS06] This value is the 837 GS06 Functional Group Control Number 7. OTI09 Transaction Set Control Number [837-ST02] This value is the 837 ST02 Transaction Set Control Number 8. OTI10 Transaction Set Identifier Code: Health Care Claim 837 This code identifies the type of transaction set submitted the 824 is reporting on If OTI10 equals 837 BGN06 Reference Identification equals 837 BHT03 Originator Application Transaction Identifier 132

133 9. OTI11 Version/Release/Industry Identifier Code [837-GS08] This value is the 837 GS08 Version/Release/Industry Identifier Code X222A1 Health Care Claim Professional X223A1 Health Care Claim Institutional X098A1 Health Care Claim Professional X096A1 Health Care Claim Institutional

134 2100 Technical Error Description - Error or Informational Message Location This loop is used to report errors or warnings about the data referenced in the OTI loop. Errors indicate rejection of all or part of the data referenced in the Original Transaction Identification (OTI) loop. TR3 PAGE # 2100 TED - ERROR OR INFORMATIONAL MESSAGE LOCATION Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME ID Department Returned Value [DRV] USAGE TED Technical Error Description Situational TED01 Application Error Condition Code 024 [R] R TED03 Segment ID Code CLM S TED04 Segment Position in Transaction Set 22 S TED05-1 Element Position in Segment 2 S NTE Note Situational NTE01 ZZZ [DRV] R NTE02 CLM R RED Error or Informational Message (Related Data) Required RED01 Error Description CLM02 = SUM (2400 SV203) R RED03 Agency Qualifier Code: 94 [R] R RED05 Code List Qualifier Code: Insurance Business Process ZZ [R] R RED06 Industry Code: Insurance Business Process Application Error Code E024 S Segment Count TED*024**CLM*22*2~ NTE*ZZZ* CLM ~ RED* CLM02 = SUM (2400 SV203) **94**ZZ*E050~ Example EDI Data Technical Error Description notes: Required when OTI01 Application Acknowledgement Code equal TR, TE, or TP 1. TED01 Application Error Condition Code: Other Unlisted Reason TED03 Segment ID Code This value identifies the segment ID that is in error 3. TED04 Segment Position in Transaction Set The numerical count position of this data segment from the start of the transaction set 4. TED05-1 Element Position in Segment Relative position of the data element in error within the segment 5. RED01 Error Description NA Free-form description used to clarify error code in RED06 Per 5010 IG, No description is needed. Element is required. Use NA 6. RED03 Agency Qualifier Code: Code Assigned by Destination Organization of the RED05 Application Error Code Qualifier Code: ZZ Insurance Business Process Application Error Code 8. RED06 IBP Application Error Code: Insurance Business Process Application Error Code IBP application error codes are standard codes used for reporting of data content errors Codes beginning with E indicate Error and codes beginning with W indicate Warning Codes are available from the Washington Publishing Company (WPC) web site: See WPC Code Lists, Insurance Business Process Application Error Codes 134

135 Transaction Set Trailer (SE) The purpose of the Transaction Set Trailer (SE) is to indicate the end of the transaction set and provide a count of the transmitted segments (including the beginning (ST) and ending (SE) segments) TR3 PAGE # Segment/Field ID TRANSACTION SET TRAILER FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 73 SE Transaction Trailer Required 73 SE01 Number of Included Segments 28 R 73 SE02 Transaction Set Control Number 0001 R Segment Count SE*28*0001~ Example EDI Data 824 SE Transaction Set Trailer notes: 1. SE01 Number of included segments This count is the total number of segments within the transaction set. Count includes the ST and SE segments. 2. SE02 Transaction Set Control Number This value is identical to the value in the ST02 Transaction Set Control Header 135

136 277 HEALTH CARE CLAIM ACKNOWLEDGEMENT ASC X12N X214 The purpose of this companion guide is to provide users of the 277 Health Care Claim Acknowledgement with information on LNI s use of the 277 for the following: Health Care Claim Acknowledgement (Notification)005010X214 Health Care Payer Unsolicited Claim Status (Pended Notification) X070 Health Care Claim Acknowledgment (Notification) LNI will produce the 277 Notification as a secondary response acknowledgement to a submitter s 837 Professional and Institutional file submission(s), and acknowledges the acceptance of individual bills formatted into LNI s Medical Information Payment System (MIPS) for processing prior to adjudication. This 277 Notification (5010) will: Acknowledge and identify each bill formatted into LNI s Medical Information Payment System MIPS. Identify bills with EDI formatting errors resulting in auto-denial and rejected from MIPS adjudication. o Report EDI formatting error via 2200D STC segment o Report the Explanation of Benefits (EOB) text of the EDI formatting error in STC12 Provide Summary Information to the Receiver/Submitter of all bills received at the COB. o Total Accepted/Rejected Quantity Number of bills accepted into MIPS for adjudication. Number of bills rejected from MIPS adjudication due to EDI formatting errors. o Total Accepted/Rejected Amount Total dollar amount of all submitted charges for bills accepted into adjudication. Total dollar amount of all submitted charges for bills auto-denied and rejected from adjudication. Generated overnight from the nightly adjudication cycle. Monday through Friday and posted to Provider Express Billing (PEB) for the Submitter of the 837 Interchange Proper use of this 277 will: Allow provider to correct bills with EDI formatting errors and re-submit billing prior to payment cycle cut-off. Reduce turn-around time in reporting bills with EDI formatting errors to the provider on their remittance advice. 136

137 Health Care Payer Unsolicited Claim Status (Pended Notification) LNI will produce the 277 Pended Notification (3070 format) that identifies all bills that are still in process in the department s Medical Information and Payment System (MIPS) at the time of the department s payment cycle. This 277 Pended Notification will: Report all bills still in process (not finalized) at the time of the payment cycle. Supplement the information reported in the 835 Payment/Advice. Report either the National Provider Identifier (NPI), or the LNI provider account number, whichever the provider is using as their primary identifier and the department has on file. Routed to the designated recipient receiving the 835 Payment/Advice. Posted to Provider Express Billing (PEB) during the payment cycle. Status Information (STC) Segment Usage The department will use the Status Information Segment to communicate bill status information in regards to the bill formatted into MIPS for processing. 137

138 Transaction Set Header (ST) The purpose of the Transaction Set Header (ST) is to indicate the start of a transaction set and to assign a control number. TRANSACTION SET HEADER (ST) TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field PAGE # ID FIELD NAME Department Returned Value [DRV] USAGE 32 ST Transaction Set Header Required 32 ST01 Transaction Set Identifier Code 277 [R] R 32 ST02 Transaction Set Control Number [DRV] R 32 ST03 Version, Release, or Industry Identifier X214 [R] R 33 BHT Beginning of Hierarchical Transaction Required 33 BHT01 Hierarchical Structure Code 0085 [R] R 33 BHT02 Transaction Set Purpose Code 08 [R] R 33 BHT03 Reference Identification X [DRV] R 33 BHT04 Transaction Set Creation Date R 34 BHT05 Transaction Set Creation Time 2300 R 34 BHT06 Transaction Type Code TH [R] R Segment Example EDI Data 277 Count 1 ST*277* *005010X214~ 2 BHT*0085*08* X * *2300*TH~ Transaction Set Header notes 1. ST01 Transaction Set Identifier Code: Health Care Information Status Notification ST02 Transaction Set Control Number ST03 Version, Release, or Industry Identifier: X BHT01 Hierarchical Structure Code: 0085 Information Source, Information Receiver, Provider of Service, Patient 5. BHT02 Transaction Set Purpose Code: Status BHT03 Reference Identification: Inventory File Number 24-digit identification number concatenated as: o EDI format and Version Number: position 1 through Notification (Nightly Batch cycle) X Pended Notification (Payment Cycle) X070 o Submitter ID registered with PEB 7-digit Submitter ID (LNI Provider Account Number) Position 14 through 20 OR 10-digit Submitter ID (National Provider Identifier) Position 14through 23 o Sequence Number: BHT04 Transaction Set Creation Date: formatted as CCYYMMDD 8. BHT05 Transaction Set Creation Time: formatted as HHMM Where HH = Hours (00-23) and MM = Minutes (00-59). 138

139 9. BHT06 Transaction Type Code: 5010 Receipt Acknowledgement Advice (Nightly cycle) TH 3070 Pended Claims Notification (Payment cycle) NO 139

140 INFORMATION SOURCE DETAIL 2000A Information Source Level 2000A INFORMATION SOURCE LEVEL TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field PAGE # ID FIELD NAME Department Returned Value [DRV] USAGE 35 HL Information Source Level Required 35 HL01 Hierarchical ID Number 1 R 36 HL03 Hierarchical Level Code 20 [R] R 36 HL04 Hierarchical Child Code 1 [R] R Segment Count 3 HL*1**20*1~ Example EDI Data A Information Source HL notes 1. HL01 Hierarchical ID Number 1 Begins with 1 and incremented by 1 each time used. 2. HL03 Hierarchical Level Code: Information Source HL04 Hierarchical Child Code: 1 Additional Subordinate HL Data segments in this HL structure 2100A Information Source Name 2100A INFORMATION SOURCE NAME NM1*PR (Payer) TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 37 NM1 Information Source Name Required 38 NM101 Entity Identifier Code PR [DRV] R 38 NM102 Entity Type Qualifier: 2 [R] R 38 NM103 WA ST DEPT OF LABOR AND Information Source Name INDUSTRIES [DRV] R 38 NM108 Identification Code Qualifier FI [DRV] R 39 NM109 Information source Identifier [DRV] R Segment Example EDI Data 277 Count 4 NM1*PR*2*WA ST DEPT OF LABOR AND INDUSTRIES*****FI* ~ 2100A Information Source Name notes 1. NM101 Entity Identifier Code: Payer PR 2. NM102 Entity Type Qualifier: Non-Person Entity 2 3. NM103Information Source Name WA ST DEPT OF LABOR AND INDUSTRIES 4. NM108 Identification Code Qualifier: Federal Taxpayer s Identification Number FI 5. NM109 Information Source Identifier

141 2200A Transmission Receipt Control Identifier TR3 PAGE # Segment/Field ID 2200A TRANSMISSION RECEIPT CONTROL IDENTIFIER FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 40 TRN Transmission Receipt Control Identifier Required 40 TRN01 Trace Type Code 1 [R] R 40 TRN02 Reference Identification [DRV] R 41 DTP Information Source Receipt Date Required 41 DTP01 Date/Time Qualifier 050 [R] R 41 DTP02 Date Time Period Format Qualifier D8 [R] R 41 DTP03 Information source Receipt Date [DRV] R 42 DTP Information Source Process Date Required 42 DTP01 Date/Time Qualifier 009 [R] R 42 DTP02 Date Time Period Format Qualifier D8 [R] R 43 DTP03 Information Source Process Date [DRV] R Segment Count 5 TRN*1* ~ 6 DTP*050*D8* ~ 7 DTP*009*D8* ~ Example EDI Data A Transmission Receipt Control Identifier notes 1. TRN01 Trace Type Code: Current Transaction Trace Numbers 1 2. TRN02 Information Source Application Trace Identifier 13-digit identification number concatenated as: o Current date formatted as CCYYMMDD: Position 1 through 8. 20YYMMDD o 5-digit Sequence Number: Positions 9 through DTP Information Source Receipt Date: 277 Notification creation date DTP01 Date/Time Qualifier: Received 050 DTP02 Date Time Period Format Qualifier: formatted as CCYYMMDD D8 DTP03 Information Source Receipt Date 4. DTP Information source Process Date: 837 transaction file processing date DTP01 Date/Time Qualifier: Process 009 DTP02 Date Time Period Format Qualifier: formatted as CCYYMMDD D8 DTP03 Information Source Process Date 141

142 INFORMATION RECEIVER DETAIL 2000B Information Receiver Level This level defines the Provider or Clearinghouse receiving the 277 Acknowledgement. TR3 PAGE # Segment/Field ID 2000B INFORMATION RECEIVER LEVEL FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 44 HL Information Receiver Level Required 44 HL01 Hierarchical ID Number 2 R 44 HL02 Hierarchical Parent ID Number 1 R 45 HL03 Hierarchical Level Code: Information Receiver 21 [R] R 45 HL04 Hierarchical Child Code 1 [DRV] R Segment Count 8 HL*2*1*21*1~ Example EDI Data B Information Receiver HL notes 1. HL01 Hierarchical ID Number 2 Begins with 1 and incremented by 1 each time used. 2. HL02 Hierarchical Parent ID Number 1 3. HL03 Hierarchical Level Code: Information Receiver HL04 Hierarchical Child Code: 1 0 No Subordinate HL Segment in this HL structure. Used when STC03 = U (rejected) 1 - Additional Subordinate HL Data segments in this HL structure. Used when STC03 = WQ (Accepted) 142

143 2100B Information Receiver Name TR3 PAGE # Segment/Field ID 2100B INFORMATION RECEIVER NAME NM1*41 FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 46 NM1 Information Receiver Name Required 47 NM101 Entity Identifier Code 41 [R] R 47 NM102 Entity Type Qualifier 2 [DRV] R 47 NM103 Information Receiver Name Community Clearinghouse R 47 NM104 Information Receiver First Name. S 47 NM105 Information Receiver Middle Name. S 48 NM108 Identification Code Qualifier 46 [R] R 48 NM109 Identification Code or R Segment Example EDI Data 277 Count 9 NM1*41*2*COMMUNITY CLEARINGHOUSE*****46* ~ 2100A Information Source Name notes 1. NM101 Entity Identifier Code: Submitter NM102 Entity Type Qualifier: Non-Person Entity 2 3. NM103Information Source Receiver Name Clearinghouse or Provider name receiving the NM104 Information Receiver First Name Spaces Required when NM102 = 1 (Person) 5. NM105 Information Receiver Middle Name Spaces Required when NM102 = 1 (Person) and if available 6. NM108 Identification Code Qualifier: Electronic Transmitter Identification Number (ETIN) NM109 Information Receiver Primary Identifier 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) This is the Submitter ID authorized for EDI with Provider Express Billing (PEB) 143

144 2200B Information Receiver Application Trace Identifier TR3 PAGE # SEG./ FIELD ID 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] USAGE 49 TRN Information Receiver Application Trace Identifier Required 49 TRN01 Trace Type Code 2 [R] R 49 TRN02 Claim Transaction Batch Number Submitter ID + Julian Date [DRV] R 50 STC Information Receiver Status Information Required 50 STC01 Health Care Claim Status R 50 STC01-1 Health Care Claim Status Category Code A1 R 51 STC01-2 Health Care Claim Status Code 20 R 51 STC02 Status Information Effective Date R 52 STC03 Action Code WQ [DRV] R 52 STC04 Total Submitted Charges R 55 QTY Total Accepted Quantity Situational 55 QTY01 Quantity Qualifier 90 [R] R 55 QTY02 Total Accepted Quantity R 56 QTY Total Rejected Quantity Situational 56 QTY01 Quantity Qualifier AA [R] R 56 QTY02 Total Rejected Quantity R 57 AMT Total Accepted Amount Situational 57 AMT01 Amount Qualifier Code YU [R] R 57 AMT02 Total Accepted Amount R 58 AMT Total Rejected Amount Situational 58 AMT01 Amount Qualifier Code YY [R] R 58 AMT02 Total Rejected Amount R Segment Count Example EDI Data 277 Received file submission(s) containing 10 bills for Total Charges of $2000. No bills contained EDI formatting errors. 10 TRN*2* ~ 11 STC*A1*20* *WQ*2000~ 12 QTY*90*10~ 13 AMT*YU*2000~ Received file submission(s) containing 10 bills for Total Charges of $2000. All bills contained EDI formatting errors. TRN*2* ~ STC*F2*122* *WQ*2000~ QTY*AA*10~ AMT*YY*2000~ Received file submission(s) containing 10 bills for Total Charges of $2000. Four (4) bills contained EDI formatting errors. TRN*2* ~ STC*A1*20* *WQ*1200~ STC*F2*122* *WQ*800~ QTY*90*6~ QTY*AA*4~ AMT*YU*1200~ AMT*YY*800~ 144

145 2200B Information Receiver Application Trace Identifier notes 1. TRN01 Trace Type Code: Referenced Transaction Trace Numbers 2 : 2. TRN02 Claim Transaction Batch Number LNI generated number consisting of Submitter ID and Julian Date. 3. STC01 Health Care Claim Status Reporting considerations: a. A submitter may submit multiple 837 file submissions throughout the business day prior to LNI s nightly adjudication cycle. b. The same submitter may submit both Professional and Institutional 837 file submissions during the business day for processing into LNI s nightly adjudication cycle. c. LNI will generate a single 277 Notification from the nightly adjudication cycle as a secondary acknowledgement of bills received from the submitter and formatted into the MIPS for adjudication. d. At this level, LNI will return the STC Health Care Claim Status to report the following to the submitter: All bills accepted into MIPS adjudication that will be processed through the MIPS adjudication system. All bills accepted into MIPS that are identified as Auto-Denied due to EDI formatting errors and rejected from processing through the MIPS adjudication system. STC01-1 Health Care Claim Status Category Code: A2 or F2 Code A2 returned to indicate bill status as: Acknowledgment/Acceptance into adjudication system The claim/encounter has been accepted into the adjudication system (WPC Claim Status Category Code). Code F2 returned to indicate bill status as: Finalized/Denial The claim/line has been denied (WPC Claim Status Category Code). STC01-2 Health Care Claim Status Code 20 or 122 When STC01-1 equal A2 Value will be 20 Accepted for processing (WPC Claim Status Code). When STC01-1 equal F2, Value will be 122 Missing/invalid data prevents payer from processing claim (WPC Claim Status Code). LNI will continue to use CSC 122 and will consider using CSC 21 in the future. Note: Claim Status Code 122 was stopped on 01/01/2008 and replaced by Claim Status Code 21. Claim Status Code 21 Missing or invalid information. At least one other status code is required to identify the missing or invalid information. CSC 122 is more applicable at this level of the STC detail. The Health Care Claim Status Category Codes and Health Care Claim Status Codes are maintained by and available from the Washington Publishing Company

146 2200B Information Receiver Application Trace Identifier notes continued 4. STC02 Status Information Effective Date: format CCYYMMDD 5. STC03 Action Code WQ Code WQ Accept. Used to indicate the bills in this STC segment are accepted into MIPS for processing. 6. STC04 Total Submitted Charges This is the sum total of all 837-CLM02 Claim Charges received. When STC01-1 equal A2 Value is the sum total of all 837-CLM02 Claim Charges of the bills accepted into MIPS for adjudication processing. When STC01-1 equal F2 Value is the sum total of all 837-CLM02 Claim Charges of the bills Auto-Denied due to EDI formatting errors that are rejected from MIPS adjudication processing. 7. QTY Quantity Information Segment (Accepted and/or Rejected) In conjunction with the STC Health Care Claim Status segment, this segment is used to report: The total number of bills accepted into MIPS adjudication processing for all files received from the submitter. The total number of bills rejected from MIPS adjudication processing due to EDI formatting errors, for all files received from the submitter. QTY - Total Accepted Quantity When STC01-1 equal A2 QTY01 Quantity Qualifier: Acknowledged Quantity 90 QTY02 Total Accepted Quantity: o Value is the Total number (count) of all bills accepted into MIPS adjudication processing. QTY - Total Rejected Quantity When STC01-2 equal F2 QTY01 Quantity Qualifier: Unacknowledged Quantity AA QTY02 Total Rejected Quantity: o Value is the Total number (count) of all bills rejected from MIPS adjudication processing due to EDI formatting errors. 146

147 2200B Information Receiver Application Trace Identifier notes continued 8. AMT Amount Information Segment (Accepted and/or Rejected) In conjunction with the STC Health Care Claim Status segment, this segment will be used is used to report: The total dollar amount of bills accepted into MIPS adjudication processing for all files received from the submitter. The total dollar amount of bills rejected from MIPS adjudication processing due to EDI formatting errors, for all files received from the submitter. AMT - Total Accepted Amount When STC01-1 equal A2 AMT01 Amount Qualifier Code: In Process YU AMT02 Total Accepted Amount o Value is the Total dollar amount of all 837-CLM02 Claim Charges for all bills accepted into MIPS adjudication processing for all files received from the submitter. AMT - Total Rejected Amount When STC01-2 equal F2 AMT01 Amount Qualifier Code: Returned YY AMT02 Total Rejected Amount o Value is the Total dollar amount of all 837-CLM02 Claim Charges for all bills rejected from MIPS adjudication processing for all files received from the submitter. 147

148 BILLING PROVIDER OF SERVICE DETAIL 2000C Billing Provider of Service Level 2000C BILLING PROVIDER OF SERVICE LEVEL TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 59 HL Provider of Service Situational 59 HL01 Hierarchical ID Number 3 R 59 HL02 Hierarchical Parent ID Number 2 R 60 HL03 Hierarchical Level Code: Provider of Service 19 [R] R 60 HL04 Hierarchical Child Code 1 R Segment Count 14 HL*3*2*19*1~ Example EDI Data C Billing Provider of Service Level HL notes 1. HL01 Hierarchical ID Number 3 Begins with 1 and incremented by 1 each time used. 2. HL02 Hierarchical Parent ID Number 2 3. HL03 Hierarchical Level Code: Provider of Service HL04 Hierarchical Child Code: 1 0 No Subordinate HL Segment in this HL structure. 1 - Additional Subordinate HL Data segments in this HL structure. 148

149 2100C Billing Provider Name Information in 2100C is derived from the submitted AA Billing Provider Name Loop. TR3 PAGE # Segment/Field ID 2100C BILLING PROVIDER NAME NM1*85 FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 61 NM1 Billing Provider Name Required 61 NM101 Entity Identifier Code 85 [R] R 61 NM102 Entity Type Qualifier 2 R 62 NM103 Provider Last or Organization Name Community Hospital R 62 NM104 Provider First Name. 62 NM105 Provider Middle Name. S 62 NM108 Identification Code Qualifier FI or XX R 62 NM109 Identification Code R S Segment Count Example EDI Data NM1*85*2*COMMUNITY HOSPITAL*****FI* ~ 2100C Billing Provider Name notes 1. NM101 Entity Identifier Code: Billing Provider NM102 Entity Type Qualifier: 1 or 2 Person (individual) 1. Non-Person Entity (organization) NM103 Provider Last or Organization Name This value is the value received in the submitted AA-NM103 Billing Provider Last Name. 4. NM104 Provider First Name This value is the value received in the submitted AA-NM104 Billing Provider First Name. Required when NM102 = 1 (Person) and if present in AA-NM104. May be spaces. 5. NM105 Provider Middle Name This value is the value received in the submitted AA-NM105 Billing Provider Middle Name. Required when NM102 = 1 and if present in AA-NM105. May be spaces. 6. NM108 Identification Code Qualifier FI or XX FI Used for Federal Taxpayer s Identification Number XX Used for CMS National Provider Identifier (NPI) 7. NM109 Identification Code If NM108 equals FI then NM109 contains the Billing Provider s Federal Tax ID If NM108 equals XX then NM109 contains the Billing Provider s National Provider Identifier NPI. 149

150 2200C Provider of Service Information Trace Identifier TR3 PAGE # Segment/Field ID 2200C PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 64 TRN Provider of Service Information Trace Identifier Situational 64 TRN01 Trace Type Code 1 [R] R 64 TRN02 Provider of Service Information Trace Identifier 0 R 65 STC Billing Provider Status Information Situational 65 STC01 Health Care Claim Status R 65 STC01-1 Health Care Claim Status Category Code A2 R 66 STC01-2 Health Care Claim Status Code 20 R 66 STC03 Action Code WQ or U [R] R 67 STC04 Total Submitted Charge for Unit Work R 70 REF Provider Secondary Identifier Situational 71 REF01 Reference Identification Qualifier G2 [DRV] R 71 REF02 Billing Provider Additional Identifier R 71 QTY Total Accepted Quantity Situational 71 QTY01 Quantity Qualifier QA [R] R 71 QTY02 Total Accepted Quantity R 72 QTY Total Rejected Quantity Situational 72 QTY01 Quantity Qualifier QC [R] R 72 QTY02 Total Rejected Quantity R 73 AMT Total Accepted Amount Situational 73 AMT01 Amount Qualifier Code YU [R] R 73 AMT02 Total Accepted Amount R 74 AMT Total Rejected Amount Situational 74 AMT01 Amount Qualifier Code YY [R] R 74 AMT02 Total Rejected Amount R Segment Count Example EDI Data 277 Received 10 bills for Billing Provider with Total Charges of $2000. No bills contained EDI formatting errors. 16 TRN*2*0~ 17 STC*A2*20**WQ*2000~ 18 REF*G2* QTY*QA*10~ 20 AMT*YU*2000~ Received 10 bills for Billing Provider with Total Charges of $2000. All bills contained EDI formatting errors. TRN*2*0~ STC*F2*122**WQ*2000~ REF*G2* QTY*QC*10~ AMT*YY*2000~ Received 10 bills for Billing Provider with Total Charges of $2000. Four (4) bills contained EDI formatting errors. TRN*2* ~ STC*A1*20**WQ*1200~ STC*F2*122**WQ*800~ REF*G2* QTY*QA*6~ QTY*QC*4~ AMT*YU*1200~ AMT*YY*800~ 150

151 2200C Provider of Service Information Trace Identifier notes: 1. TRN01 Trace Type Code: Current Transaction Trace Numbers 1 2. TRN02 Provider of Service Information Trace Number 0 Default value of zero used. 3. STC01 Health Care Claim Status At this level, LNI will return the STC Health Care Claim Status segment to report on bills accepted/rejected for the Billing Provider indentified in loop 2100C. Total number of bills received and accepted for MIPS adjudication. The sum total of total charges received for the accepted bills. Total number of bills received and rejected from MIPS adjudication and identified as Auto-Denied due to EDI formatting errors. The sum total of total charges received for the Billing Provider s rejected bills. STC01-1 Health Care Claim Status Category Code A2 or F2 Code A2 returned to indicate bill status as: Accepted Acknowledgment/Acceptance into adjudication system The claim/encounter has been accepted into the adjudication system (WPC Claim Status Category Code). Code F2 returned to indicate bill status as: Rejected due to EDI formatting error Finalized/Denial The claim/line has been denied (WPC Claim Status Category Code). STC01-2 Health Care Claim Status Code 20 or 122 When STC01-1 equal A2 Value will be 20 Accepted for processing (WPC Claim Status Code). When STC01-1 equal F2, Value will be 122 Missing/invalid data prevents payer from processing claim (WPC Claim Status Code). LNI will continue to use CSC 122 and will consider using CSC 21 in the future. Note: Claim Status Code 122 was stopped on 01/01/2008 and replaced by Claim Status Code 21. Claim Status Code 21 Missing or invalid information. At least one other status code is required to identify the missing or invalid information. CSC 122 is more applicable at this level of the STC detail. The Health Care Claim Status Category Codes and Status Codes are maintained by and available from the Washington Publishing Company STC03 Action Code WQ or U Code WQ Accept. Used to indicate the bills in this STC segment are accepted into MIPS for adjudication processing. Code U Reject. Used to indicate the bills in this STC segment are Auto-Denied due to EDI formatting errors and will not be included into MIPS adjudication processing. 5. STC04 Total Submitted Charges for Unit Work Sum total of all CLM02 total charges being acknowledged for the identified Billing Provider in loop 2100C. 151

152 2200C Provider of Service Information Trace Identifier notes: 6. REF Provider Secondary Identifier REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Billing Provider Additional Identifier 7-digit LNI provider account number associated to Billing Provider in loop 2100C. G2 7. QTY Quantity Information Segment (Accepted or Rejected) LNI will use this segment to report the total number of bills received and accepted/ rejected for/from MIPS adjudication for the Billing Provider in loop 2100C. QTY - Total Accepted Quantity QTY01 Quantity Qualifier: Quantity Approved (accepted) QTY02 Total Accepted Quantity Number of bills accepted into MIPS adjudication. QTY - Total Rejected Quantity QTY01 Quantity Qualifier: Quantity Disapproved (rejected) QTY02 Total Rejected Quantity Number of bills rejected from MIPS adjudication. QA QC 8. AMT Amount Information Segment (Accepted or Rejected) LNI will use this segment to report the total dollar amount of the bills accepted/rejected for/from MIPS adjudication for the Billing Provider in loop 2100C. AMT - Total Accepted Amount AMT01 Amount Qualifier Code: In Process AMT02 Total Accepted Amount Total dollar amount of all 837-CLM02 Claim Charges for accepted bills. AMT - Total Rejected Amount AMT01 Amount Qualifier Code: Returned AMT02 Total Rejected Amount Total dollar amount of all 837-CLM02 Claim Charges for rejected bills. YU YY 152

153 PATIENT DETAIL 2000D HL Patient Level This level identifies the injured worker patient data received in the 837 transaction receiving health care services TR3 PAGE # Segment/Field ID FIELD NAME 2100D PATIENT LEVEL Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 75 HL Patient Level Situational 75 HL01 Hierarchical ID Number 4 R 75 HL02 Hierarchical Parent ID Number 3 R 76 HL03 Hierarchical Level Code: Patient PT [R] R Segment Count 21 HL*4*3*PT~ Example EDI Data D Patient Level HL notes: 1. HL01 Hierarchical ID Number 4 Begins with 1 and incremented by 1 each time used. 2. HL02 Hierarchical Parent ID Number 3 3. HL03 Hierarchical Level Code: Patient PT 2100D Patient Name 2100D PATIENT NAME NM1*QC TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 77 NM1 Patient Name Required 77 NM101 Entity Identifier Code QC [R] R 77 NM102 Entity Type Qualifier 1 [R] R 77 NM103 Patient Last Name Public R 78 NM104 Patient First Name (Required when submitted in 837) John S 78 NM105 Patient Middle Name/Initial (Required when submitted in 837) Q S 78 NM108 Identification Code Qualifier MI [DRV] R 78 NM109 Patient Identification Number A R Segment Count 22 NM1*QC*1*PUBLIC*JOHN*Q***MI*A123456~ Example EDI Data

154 2100D Patient Name notes: 1. NM101 Entity Identifier Code: Patient QC 2. NM102 Entity Type Qualifier: Person 1 3. NM103 Patient Last Name NM103 contains the value received in the BA-NM103 Subscriber Last Name. NM103 contains UNKNOWN when Last Name submitted as UNKNOWN or when 4. NM104 Patient First Name NM104 contains the value received in the BA-NM104 Subscriber First Name. 5. NM105 Patient Middle Initial NM105 contains the value received in the BA-NM105 Subscriber Middle Name. 6. NM108 Identification Code Qualifier: Member Identification Number MI 7. NM109 Patient Identification Number NM109 contains the formatted LNI Claim ID BA NM109/2000B SBR03 NM109 is Blank/Missing when the bill formats with an invalid/missing Claim ID EDI formatting error H05: INVALID/MISSING WORKERS COMPENSATION CLAIM NUMBER Returned in 2200D STC

155 2200D Claim Status Tracking Number TR3 PAGE # Segment/Field ID 2200D CLAIM STATUS TRACKING NUMBER FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 79 TRN Claim Status Tracking Number Required 79 TRN01 Trace Type Code 2 [R] R 79 TRN02 PUBLICJQ Patient Control Number [DRV] [ CLM01] R 80 STC Claim Level Status Information Required 80 STC01-1 Health Care Claim Status Category Code: P0-Pending; A2-Accepted A2 R 81 STC01-2 Health Care Claim Status Code: Accepted for processing 20 R 82 STC02 Status Information Effective Date (CCYYMMDD) R 82 STC03 Status Information Action Code: U (Reject) WQ (Accept) WQ or U [R] R 82 STC04 Total Charges Submitted: CLM R 84 STC12 Free-Form Message Text: LNI usage reporting EDI formatting errors EOB text. S 85 REF Payer s Claim Control Number Situational 85 REF01 Reference Identification Qualifier: Payer s Claim Number 1K [R] R 85 REF02 Reference Identification: ICN LNI assigned Internal Control Number [DRV] R 86 Claim Identifier Number for Clearinghouse and Other REF Transmission Intermediaries Situational 86 REF01 Reference Identification Qualifier: Claim number D9 [R] R 86 REF02 Reference Identification: Value Added Network Trace Number (2300 REF*D9) VANTN001 R 87 Institutional Bill Type Identification: Inpatient or REF Outpatient bills only Situational 87 REF01 Reference Identification Qualifier: Billing Type BLT [R] R 87 REF02 Reference Identification: 111-Inpatient; 131-Outpatient 111 R 89 DTP Claim Level Service Date Situational 89 DTP01 Date/Time Qualifier: Service 472 [R] R 89 DTP02 Date Time Period Format Qualifier RD8 or D8 R 89 DTP03 Date Time Period (date range CCYYMMDD- CCYYMMDD) or date CCYYMMDD Segment Count Example EDI Data 277 Bill Accepted into MIPS adjudication with no EDI formatting error 23 TRN*2*PUBLICJQ-00100~ 24 STC*A2:20* *WQ*100~ 25 REF*1K* ~ 26 REF*D9*VANTN001~ 27 REF*BLT*111~ 28 DTP*472*RD8* ~ Bill Rejected from MIPS adjudication due to EDI formatting error. Bill is Auto-denied TRN*2*PUBLICJQ-00100~ STC*F2:122* *U*100********INVALID NPI BILLING PROVIDER NUMBER~ REF*1K* ~ REF*D9*VANTN001~ REF*BLT*111~ DTP*472*RD8* ~ or R 155

156 2200D Claim Status Tracking Number notes: 1. TRN01 Trace Type Code: Referenced Transaction Trace Numbers 2 2. TRN02 Patient Control Number Value received in the CLM01 Patient Account Number. LNI will return the first 20 characters of the CLM01 Patient Account Number. 3. STC01 Health Care Claim Status (Claim Level Status Information) STC01-1 Health Care Claim Status Category Code Code used to indicate the general category of the status o Accepted, rejected, additional information requested, etc. o Code is then further detailed in Claim Status Code STC02. STC01-2 Health Care Claim Status Code Code used to convey the status of an entire bill or specific service line. Health Care Claim Status Category Codes and Status Codes are maintained by and available from the Washington Publishing Company STC02 Status Information Effective Date: formatted as CCYYMMDD 5. STC03 Status Information Action Code WQ or U LNI will use this code to convey the status of the bill WQ Accepted: Indicates the bill is accepted into MIPS adjudication processing. U Reject: Indicates the bill is rejected from MIPS adjudication due to EDI formatting error(s) resulting in Auto-denial and returned to the provider with EOB H00/Hxx on the provider s remittance advice. 6. STC04 Total Claim Charge Amount Value received in the CLM02 Total Claim Charge. 7. STC12 Free Form Message Text This is the Explanation of Benefits (EOB) text explaining the reason for the EDI formatting error on the formatted bill. See EDI Formatting Errors section for description of possible EOB error text returned in this element. Bills containing EDI formatting errors are Auto-denied. EOB H00/Hxx. Bills containing EDI formatting errors may be corrected and resubmitted at any time. 8. REF Payer Claim Control Number REF01 Reference Identification Qualifier: Payer s Claim Number 1K REF02 Payer Claim Control Number 17-digit Internal Control number (ICN) assigned to the bill. The ICN is used to track the bill through adjudication in MIPS and is returned on the provider s remittance advice. 9. REF Claim Identifier Number for Clearinghouse and Other Transmission Intermediaries Submitted at the discretion of the submitter REF01 Reference Identification Qualifier: Claim Number D9 REF02 Clearinghouse Trace Number Submitter s value added network trace number as received in the CLM/REF*D9. If not sent by the Submitter then this segment is not present in the

157 2200D Claim Status Tracking Number notes continued: 10. REF Institutional Bill Type Identification (Institutional bills only) REF01 Reference Identification Qualifier: Billing Type REF02 Bill Type Identifier 111 (Inpatient) 131 (Outpatient) BLT REF02 contains the Institutional Bill Type received in the 837 Institutional 2300-CLM. This value is a concatenation of the values received in: CLM05-1 (Facility type Code) CLM05-3 (Claim Frequency Code) 11. DTP Claim Level Service Date DTP01 Date Time Qualifier: Service 472 DTP02 Date Time Period Format Qualifier D8 Date is formatted as CCYYMMDD RD8 Date is formatted as a range of CCYYMMDD-CCYYMMDD DTP03 Claim Service Period D8 or RD8 Date of Service(s) For Professional 837 bills, this information is derived from the earliest service level dates received in 2400 DTP to the latest service level date. For Institutional 837 bills, this information is derived from the statement period date received in 2300 DTP

158 Transaction Set Trailer (SE) The purpose of the Transaction Set Trailer (SE) is to indicate the end of the transaction set and provide a count of the transmitted segments (including the beginning (ST) and ending (SE) segments). TRANSACTION SET TRAILER (SE) TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field PAGE # ID FIELD NAME Department Returned Value [DRV] USAGE 102 SE Transaction Set Trailer Required 102 SE01 Number of Included Segments 28 R 102 SE02 Transaction Set Control Number 0001 R Segment Count 29 SE*29*0001~ Example EDI Data 277 SE Transaction Set Trailer notes: 1. SE01 Number of Included Segments This value is the total number of segments within the transaction set including the ST and SE segments. 2. SE02 Transaction Set Control Number This value must be identical to the value in the Transaction Set control Header ST

159 277 Health Care Claim Acknowledgment Receipt Advice SEG No. 277 Notification ISA*00*...*00*...*30* *ZZ* *110930*2300*^*00501* *0*P*:~ GS*HN* * * *2300*1*X*005010X214~ 1 ST*277* *005010X214~ 2 BHT*0085*08* X * *2300*TH~ 3 HL*1**20*1~ 4 NM1*PR*2*WA ST DEPT OF LABOR AND INDUSTRIES*****FI* ~ 5 TRN*1* ~ 6 DTP*050*D8* ~ 7 DTP*009*D8* ~ 8 HL*2*1*21*1~ 9 NM1*41*2*COMMUNITY CLEARINGHOUSE*****46* ~ 10 TRN*2* ~ 11 STC*A1*20* *WQ*2000~ 12 QTY*90*10~ 13 AMT*YU*2000~ 14 HL*3*2*19*1~ 15 NM1*85*2*COMMUNITY HOSPITAL*****FI* ~ 16 TRN*2*0~ 17 STC*A2*20**WQ*2000~ 18 REF*G2* QTY*QA*10~ 20 AMT*YU*2000~ 21 HL*4*3*PT~ 22 NM1*QC*1*PUBLIC*JOHN*Q***MI*A123456~ 23 TRN*2*PUBLICJQ-00100~ 24 STC*A2:20* *WQ*100~ 25 REF*1K* ~ 26 REF*D9*VANTN001~ 27 REF*BLT*111~ 28 DTP*472*RD8* ~ 29 SE*29*0001~ GE*1*101~ IEA*1* ~ 159

160 835 Health Care Claim Payment/Advice Companion Guide ASC X12N X221A1 The following EDI layout and sample data for the 835 Payment/Advice is for reference only. This layout includes all Loops and Segments that could be included in an 835 Remittance from the Washington State Department of Labor and Industries, depending on the finalized billing transactions. This sample data provides an example of the expected data from Labor and Industries, but is not all-inclusive. The Department operates a two-week payment cycle for provider warrants and remittance advice. The warrant and a hardcopy of the remittance advice will be sent to the designated payee in addition to any electronic remittance advice information. A schedule of the payment cycle is available at: The 835 Remittance Advice will be made available to the provider or its designated recipient every two-weeks on the Provider Express Billing (PEB) website. The 835 Remittance Advice will provide a list of all finalized bills (paid/denied) for the current payment cycle. This will include bills submitted through other mediums such as paper or Direct Entry billing. Please note: 835 s indicating Notification Only (BPR01=H) implies there is no warrant sent with the hardcopy remittance advice. 835 s indicating Remittance Advice (BPR01=I) will include the warrant number that is being sent with the hardcopy remittance advice. Standard and Pharmacy 835 Payment/Advice The Department generates a standard 835 Payment/Advice for medical providers and a Pharmacy 835 Payment/Advice for pharmacy providers. Although common data exists between the standard and pharmacy 835 Payment/Advice, the 2100 Claim Payment and 2110 Service Payment information loops will contain specific information for those provider types receiving the 835 Payment/Advice. The 2100 Claim Payment and 2110 Service Payment loops are specifically described for the standard and pharmacy 835 Payment/Advice within this companion guide. 277 Unsolicited Claim Status Notification (Pended Claim Listing) In addition to the 835 Payment/Advice generated to designated recipients, the Department will also generate a 277 Unsolicited Claim Status Notification (3070) of ALL bills pending at the time of the payment cycle. Refer to the Companion Guide section ASC X12N X214 Health Care Claim Acknowledgement 277 for detail information. 160

161 NPI as Primary Identifier When a provider has indicated an NPI as their primary identifier, the header Receiver Identification loop will display the NPI as the primary identifier; this will match the identifier provided in the ISA08 data element of the Interchange Control Header. The GS03 of the Functional Group Header will similarly include the NPI if it is the designated primary identifier. Note: if the provider has designated a clearinghouse recipient for the 835 RA and the 277u, the clearinghouse s LNI assigned provider number will appear in these positions. The Payee Identification Loop will contain either the NPI or LNI provider number as the primary identifier, and the Federal Tax ID will continue to be reported in the REF segment. The Claim Payment Loop includes references for the Service Provider and Rendering Provider identifiers, the NPI will be reported in the NM1 segment (Service Provider) based on the bill information; and the Reference segment for Rendering Provider will include the corresponding LNI provider numbers in all cases. This will be supplied as information only. The department generates the 835 as an electronic remittance advice and notification only, not for an electronic payment. Warrant payments will be mailed along with hardcopy remittance advice to all designated payees. Designated payees may also view a PDF version of the hardcopy remittance advice. The 835 will be available to the designated recipient on the 2-week payment cycle. It will provide a list of all finalized bills (paid and denied) for the provider within the current payment cycle. The 277u Pended Notice will provide a complete list of all bills pending at the time of payment. The primary identifier for the payee provider must be either the National Provider Identifier (NPI), or the LNI Provider Account number, dependent upon the provider s primary identifier indication. 161

162 835 Transaction Set Header (ST) The purpose of the Transaction Set Header (ST) is to indicate the start of a transaction set and to assign a control number. The following Transaction Set Header information applies to both the Standard and Pharmacy 835 Payment/Advice. TRANSACTION SET HEADER (ST) TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 68 ST Transaction Set Header Required 68 ST01 Transaction Set Identifier Code 835 [R] R 68 ST02 Transaction Set Control Number R 69 BPR Financial Information Required 70 BPR01 Transaction Handling Code I or H [DRV] R 71 BPR02 Total Actual Provider Payment Amount R 71 BPR03 Credit or Debit Flag Code C or D [R] R 72 BPR04 Payment Method Code CHK OR NON [DRV] R 76 BPR16 Check Issue or EFT Effective Date R 77 TRN Reassociation Trace Number Required 77 TRN01 Trace Type Code 1 [R] R 77 TRN02 Check or EFT Trace Number R 78 TRN03 Payer Identifier [DRV] R 82 REF Receiver Identification Situational 82 REF01 Receiver Identification Qualifier EV [DRV] R 82 REF02 Receiver Identification or R 85 DTM Production Date Situational 85 DTM01 Date/Time Qualifier 405 [DRV] R 86 DTM02 Production Date R Segment Count 1 ST*835*0001~ 2 BPR*I* *C*CHK*********** ~ 3 TRN*1*123456* ~ 4 REF*EV* ~ 5 DTM*405* ~ Example EDI Data

163 Transaction Set (ST) notes: 1. ST01 Transaction Set Identifier Code: Health Care Payment/Advice BPR01 Transaction Handling Code H or I H Notification Only. No payment amount (warrant) issued to payee. BPR02 Total Actual Provider Payment Amount equal 0 (zero). I Remittance Information Only. Payment amount (warrant) issued to payee. BPR02 Total Actual Provider Payment Amount greater than 0 (zero). 3. BPR02 Total Actual Provider Payment Amount (Total Warrant Payment Amount) 4. BPR03 Credit or Debit Flag Code: C or D C Credit Total Warrant Payment Amount issued to payee is a payment. D Debit Total Warrant Payment Amount issued to payee is returned as a payment to LNI. 5. BPR04 Payment Method Code: Check or non-payment CHK or NON CHK Check A check (warrant) issued to the payee for the Total Warrant Payment Amount. NON Non Payment Data No check (warrant) issued to the payee. 6. BPR16 Check Issue or EFT Effective Date (Warrant Payment Date): Date the warrant payment is issued to the payee - formatted as CCYYMMDD 7. TRN01 Trace Type Code: Current transaction Trace Numbers 1 8. TRN02 Check or EFT Trace Number (Warrant Number) If BPR04 equals CHK This is the Warrant Number issued for the payment. IF BPR04 equals NON This is the Remittance Advice (RA) Number of the payment cycle. 9. TRN03 Payer Identifier LNI Federal Tax ID number preceded by the number one (1). 10. REF Receiver Identification REF01 Reference Identification Qualifier: Receiver Identification Number EV REF02 Receiver Identification: Submitter ID LNI Provider ID or NPI authorized to receive 835 Payment Advice. 11. DTM Production Date DTM01 Date/Time Qualifier: Production 405 DTM02 Production Date (Billing Cycle End Date): formatted as CCYYMMDD 163

164 1000A Payer Identification The following Payer Identification information applies to both the Standard and Pharmacy 835 Payment/Advice. 1000A PAYER IDENTIFICATION NM1*PR TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 87 N1 Payer Identification Required 87 N101 Entity Identifier Code: Payer PR [R] R 87 N102 WA ST DEPT OF LABOR AND Payer Name INDUSTRIES [DRV] R 89 N3 Payer Address Required 89 N301 Payer Address P O BOX [DRV] R 90 N4 Payer City, State, Zip Code Required 91 N401 City OLYMPIA [DRV] R 92 N402 State WA [DRV] R 93 N403 Zip Code [DRV] R 94 PER Payer Business Contact Information Situational 95 PER01 Contact Function Code CX [R] R 95 PER02 Payer Contact Name PROVIDER HOTLINE [DRV] S 95 PER03 Communication Number Qualifier TE [R] S 95 PER04 Communication Number [DRV] S 97 PER Payer Technical Contact Information Required 97 PER01 Contact Function Code BL [R] R 98 PER02 Payer Contact Name ELECTRONIC BILLING UNIT [DRV] S 98 PER03 Communication Number Qualifier TE [R] S 98 PER04 Communication Number [DRV] S 98 PER05 Communication Number Qualifier EM [R] S 99 PER06 Communication Number [email protected] [DRV] S 100 PER Payer Web Site Information Situational 100 PER01 Contact Function Code IC [R] R 101 PER03 Communication Number Qualifier UR [R] R 101 PER04 Communication Number [DRV] S Segment Example EDI Data 835 Count 6 N1*PR*WA ST DEPT OF LABOR AND INDUSTRIES~ 7 N3*P O BOX 44263~ 8 N4*OLYMPIA*WA* ~ 9 PER*CX*PROVIDER HOTLINE*TE* ~ 10 PER*BL*ELECTRONIC BILLING UNIT*TE* *EM*[email protected]~ 11 PER*IC**UR* ~ 164

165 1000A Payer Identification notes: 1. N101 Entity Identifier Code: Payer PR 2. N102 Payer Name WA ST DEPT OF LABOR & INDUSTRIES 3. N301 Payer Address P O BOX N401 Payer City OLYMPIA 5. N402 Payer State Code WA 6. N403 Payer Zip Code PER Payer Business Contact Information This segment provides contact information for the provider regarding questions on bill payment or denial, provider bulletins and updates, Medical Aid Rules and Fee schedules and applicable sections of the Washington Administrative Code (WAC) or Revised Code of Washington (RCW). PER01 Contact Function Code: Payers Claim Office CX PER02 Payer Contact Name PROVIDER HOTLINE PER03 Communication Number Qualifier: Telephone TE PER04 Payer Contact Communication Number Value PER Payer Technical Contact Information This segment provides contact information for clearinghouses and providers to contact the department s Electronic Billing Unit regarding electronic billing, EDI formats, EDI formatting errors and related electronic billing issues. PER01 Contact Function Code: Technical Department BL PER02 Payer Technical Contact Name ELECTRONIC BILLING UNIT PER03 Communication Number Qualifier: Telephone TE PER04 Payer Contact Communication Number Value PER03 Communication Number Qualifier: EM PER04 Payer Technical Contact Communication Number Value [email protected] 9. PER Payer Web Site Information This segment provides the department s web site address for Medical Providers including information regarding fee schedules, billing codes and LNI payment policies. PER01 Contact Function Code: Information Contact PER03 Communication Number Qualifier: URL PER04 Payer Contact Communication Number IC UR 165

166 1000B Payee Identification The following Payee Identification information applies to both the Standard and Pharmacy 835 Payment/Advice. 1000B PAYEE IDENTIFICATION N1*PE TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 102 N1 Payee Identification Required 102 N101 Entity Identifier Code PE [R] R 102 N102 Payee Name COMMUNITY HOSPITAL R 103 N103 Identification Code Qualifier FI or XX [R] R 103 N104 Payee Identification Code R 104 N3 Payee Address Situational 104 N301 Payee Address 123 WEST ST R 105 N4 Payee City, State, Zip Code Required 105 N401 Payee City Name OLYMPIA R 106 N402 Payee State Code WA S 106 N403 Payee Zip Code S 107 REF Payee Additional Identification Situational 107 REF01 Reference Identification Qualifier PQ [DRV] R 108 REF02 Reference Identification: 7-character LNI Provider Account Number or 10-digit Federal Tax ID or R Segment Count 12 N1*PE*COMMUNITY HOSPITAL*XX* ~ 13 N3*123 WEST ST~ 14 N4*OLYMPIA*WA*98500~ 15 REF*PQ* ~ Example EDI Data B Payee Identification notes: 1. N101 Entity Identifier Code: Payee PE 2. N102 Payee Name MIPS Payee Provider Name 3. N103 Identification Code Qualifier FI or XX If N103 equals FI Then N104 is the payee s Federal Tax ID If N103 equals XX Then N104 is the payee s National Provider Identifier (NPI) 4. N104 Payee Identification Code Payee s Federal Tax ID (N103 = FI) National Provider Identifier (NPI) (N103 = XX) 166

167 1000B Payee Identification notes continued 5. N301 Payee Address MIPS Provider Master Page 2 Billing Address or Location Address 6. N401 Payee City Name MIPS Provider Master Page 2 Billing Address or Location Address 7. N402 Payee State Code MIPS Provider Master Page 2 Billing Address or Location Address 8. N403 Payee Zip Code MIPS Provider Master Page 2 Billing Address or Location Address 9. REF Payee Additional Identification segment REF01 Reference Identification Qualifier: Payee Identification PQ REF02 Payee Provider Identification LNI Provider Account Number 167

168 2000 Header Number The following Header Number information applies to both the Standard and Pharmacy 835 Payment/Advice. TR3 PAGE # Segment/Field ID 2000 Header Number - LX FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 111 LX Header Number Situational Assigned Number (identifying sequence number of bill 111 LX01 R level segments) 1 Segment Count 16 LX*1~ Example EDI Data Header Number notes: 1. LX01 Assigned Number: Identifies a particular set of bill level adjustments 1 LX01 begins with one (1) and is incremented by one (1) for each set of bill information. 168

169 Standard 835 Payment/Advice 2100 Claim Payment & 2110 Service Payment 2100 Claim Payment Information The following Claim Payment information applies specifically to the Standard 835 Payment/Advice Claim Payment Information CLP (Standard 835) TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 123 CLP Claim Payment Information Required 123 CLP01 Patient Control Number PUBLICJQ R 124 CLP02 Claim Status Code 1 or 4 or 22 [DRV] R 125 CLP03 Total Claim Charge Amount R 125 CLP04 Claim Payment Amount R 125 CLP05 Patient Responsibility Amount 0 S 126 CLP06 Claim Filing Indicator Code WC [DRV] R 127 CLP07 Payer Claim Control Number R 128 CLP11 Diagnosis Related Group (DRG) Code S 128 CLP12 Diagnosis Related Group (DRG) Weight S 129 CAS Claim Adjustment Situational 131 CAS01 Claim Adjustment Group Code CO R 131 CAS02 Claim Adjustment Reason Code 42 R 132 CAS03 Adjustment Amount R 132 CAS04 Adjustment Quantity S 137 NM1 Patient Name Required 137 NM101 Entity Identifier Code QC [R] R 138 NM102 Entity Type Qualifier 1 [R] R 138 NM103 Patient Last Name PUBLIC S 138 NM104 Patient First Name JOHN S 138 NM105 Patient Middle Q S 139 NM108 Identification Code Qualifier MI [DRV] S 139 NM109 Patient Identifier H S 146 NM1 Service Provider Name Situational 147 NM101 Entity Identifier Code: Rendering Provider 82 [R] R 147 NM102 Entity Type Qualifier: 1-Person; 2-Non-person 1 or 2 R 147 NM103 Last Name or Organization WASHINGTON S 147 NM104 First Name GEORGE S 148 NM105 Middle Name S 148 NM108 Identification Code Qualifier: Provider Commercial Number (PC) or NPI (XX) PC or XX [DRV] R 149 NM109 Identification Code: 7-character LNI Provider Account Number or 10-digit National Provider Identifier or R 159 MIA Inpatient Adjudication Information Situational 160 MIA01 Quantity: Covered Days or Visits Count R 160 MIA02 Quantity: PPS Outlier Amount S 161 MIA04 DRG Amount S 161 MIA05 Reference Identification: Remark Code/EOB S 166 Outpatient Adjudication Information: Used for all MOA services except Inpatient. Situational 166 MOA01 Percent: Reimbursement Rate S 167 MOA02 Monetary Amount: HCPCS Payable Amount S 167 MOA03 Reference Identification: Remark Code/EOB S 169 REF Other Claim Related Identification Situational 169 REF01 Reference Identification Qualifier EA R 170 REF02 Other Claim Related Identifier R 169

170 171 REF Rendering Provider Identification Situational 171 REF01 Reference Identification Qualifier G2 [DRV] R 172 REF02 Rendering Provider Secondary Identifier R 173 DTM Statement From or To Date Situational 174 DTM01 Date Time Qualifier 232 [DRV] R 174 DTM02 Claim Date R 173 DTM Statement From or To Date Situational 174 DTM01 Date Time Qualifier 233 [DRV] R 174 DTM02 Claim Date R 182 AMT Claim Supplemental Information Situational 183 AMT01 Amount Qualifier Code: Outlier Amount ZZ R 183 AMT02 Monetary Amount S Segment Count Example EDI Data CLP*PUBLICJQ-00100*1*500*450*0*WC* ~ 18 CAS*CO*42*50~ 19 NM1*QC*1*PUBLIC*JOHN*Q***MI*H010101~ 20 NM1*82*1*WASHINGTON*GEORGE***XX* ~ 21 MOA**450~ 22 REF*EA*MEDRECNUM001~ 23 REF*G2* ~ 24 DTM*232* ~ 25 DTM*233* ~ 170

171 2100 Claim Payment Information notes: 1. CLP01 Patient Control Number: Patient Account Number Based on Bill Medium type ICN 7 value received in CLM01 Patient Account Number ICN 5 value received in Box 26 Patient Account No. of the Direct Entry online bill form ICN 3 value received in EMC format - Record Type C1, Field 10, Patient Account Number ICN 0 value received in Box 26 Patient s Account No. of the CMS-1500 paper form (1 st digit position of LNI Internal Control Number - CLP07) 2. CLP02 Claim Status Code: Finalized Bill Status 1 or 4 or 22 1 Processed as Primary. Bill paid (full or partial payment). 4 Denied. (Bill denied, no payment issued) 22 Reversal of Previous Payment (adjustment) 3. CLP03 Total Claim Charge Amount Based on Bill Medium type ICN 7 value received in CLM02 Total Claim Charge ICN 5 value received in Box 28 Total Charge of the Direct Entry online bill form ICN 3 value received in EMC format - Record Type T2, Field 6, Total Charges ICN 0 value received in Box 28 total charge of the CMS-1500 paper form (1 st digit position of LNI Internal Control Number - CLP07) 4. CLP04 Claim Payment Amount: Total amount the Department paid on this bill MIPS bill AMT-PD 5. CLP05 Patient Responsibility Amount 0 (zero) Patient s responsibility is always zero for Washington State workers compensation billing. 6. CLP06 Claim Filing Indicator Code : WC Workers Compensation Health Claim 7. CLP07 Payer Claim Control Number: 17-digit LNI Internal Control Number (ICN) The first position of the ICN identifies the medium type of the submitted bill to LNI. 7 = HIPAA EDI 837 Professional or Institutional bill 5 = Direct Entry bill (effective 6/23/2009) 4 = Credits/Adjustments bill 3 = Proprietary EMC format bill 0 = Paper bill 8. CLP11 Diagnosis Related Group (DRG) Code Returned on Institutional bills when adjudicated using DRG. 9. CLP12 Quantity Diagnosis Related Group (DRG) Weight Returned on Institutional bills when adjudicated using DRG. 171

172 2100 Claim Payment Information notes continued 10. CAS Segment Claim Adjustment Segments will be used to report claim level (bill level) adjustments. Used when the Claim Payment Amount CLP04 is different than the Total Claim Charge Amount CLP03. The information in CAS01 and CAS02 is derived from the HIPAA EOB cross-reference associated to LNI s assigned EOB (Explanation of Benefits) codes returned for the bill on the payee s remittance advice. CAS01 Claim Adjustment Group Code Descriptions are defined in the 835 Implementation Guide (TR3) CO Contractual Obligations OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility CR Correction and Reversal used when CLP02=22 (4010A1) o Note: Code CR not available in 5010A1 format CAS02 Claim Adjustment Reason Code Defined by the Washington Publishing Company (WPC). Codes are mapped and cross-referenced to LNI s EOB (Explanation of Benefits) codes CAS03 Adjustment Amount Difference between Claim Payment Amount CLP04 and Total claim Charge CLP03 CAS04 Adjustment Quantity 11. NM1 Patient Name Segment NM101 Entity Identifier Code: Patient QC NM102 Entity Type Qualifier: Person 1 NM103 Patient Last Name Claimant s Last name or UNKNOWN 2010BA NM103 Subscriber Last name NM104 Patient First Name Claimant s First name or UNKNOWN 2010BA NM104 Subscriber First Name NM105 Patient Middle Name Claimant s Middle name/initial Null - If the claimant s middle name/initial is not on file or unknown 172

173 2100 Claim Payment Information notes continued NM108 Identification Code Qualifier: Member Identification Number NM109 Patient Identifier 7-digit LNI Claim Number or UNKNOWN 2010BA NM109 or 2000B SBR03 MI If NM109 Patient Identifier equal UNKNOWN AND the 1 st digit of the ICN begins with 7 (CLP07) Then the LNI Claim ID received in the BA-NM109 and/or 2000B-SBR03 is invalid. The MIPS bill is formatted and denied with EDI formatting error: EOB H05 INVALID/MISSING WORKERS COMPENSATION CLAIM NUMBER OR If NM109 Patient Identifier equal UNKNOWN AND the 1 st digit of the ICN begins with 0 (CLP07) Then the LNI Claim ID provided in Box 11 Insured s Policy Group or FECA Number of the CMS-1500 Health Insurance Claim Form is missing or invalid and no valid Claim ID was found in Box 1a. Insured s ID Number. The MIPS bill is formatted and denied with: EOB 989 DENIED. CLAIM NUMBER MISSING. RESUBMIT NEW BILL WITH CLAIM NUMBER. 12. NM1 Service Provider segment This segment identifies the rendering provider of service. NM101 Entity Identifier Code: Rendering Provider 82 NM102 Entity Type Qualifier: Person or Non-Person Entity 1 or 2 1 Person 2 Non-Person Entity NM103 Rendering Provider Last Name NM104 Rendering Provider First Name NM108 Identification Code Qualifier: PC Provider Commercial Number XX - National Provider Identifier (NPI) NM109 Rendering Provider Identifier 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) o 7-digit LNI Provider Account Number when NM108 equal PC o 10-digit National Provider Identifier (NPI) when NM108 equal XX PC 173

174 2100 Claim Payment Information notes continued 13. MIA Inpatient Adjudication Information segment Required for 837 Institutional Inpatient bills. Not applicable to the Pharmacy 835 Remittance Advice. MIA01 Covered Days or Visits Count: 0 Always 0 (zero) MIA02 PPS Operating Outlier Amount 0 MIA04 Claim DRG Amount MIA05 Claim Payment Remark Code Remittance Advice Remark Codes defined by the Washington Publishing Company (WPC). Mapped and cross-referenced to LNI s assigned EOB (Explanation of Benefits) codes. 14. MOA Outpatient Adjudication Information segment Required for 837 Institutional outpatient bills. Not applicable to the Pharmacy 835 Remittance Advice. MOA01 Reimbursement Rate: percentage expressed as a decimal MOA02 Claim HCPCS Payable Amount MOA03 Claim Payment Remark Code Remittance Advice Remark Codes defined by the Washington Publishing Company (WPC). Mapped and cross-referenced to LNI s assigned EOB (Explanation of Benefits) codes. 15. REF Other Claim Related Identification segment(s) a. Medical Record Identification Number Returned if received in 837 bill transaction CLM 2300 REF*EA*REF02 REF01 Reference Identification Qualifier: Medical Record Number REF02 Other Claim Related Identifier EA b. Original Reference Number Returned on finalized request for adjustment (Replacement and Void) bills. Identifies the bill being adjusted. Value received in CLM REF*F8 REF02 REF01 Reference Identification Qualifier: Original Reference Number REF02 Other Claim Related Identifier 17-digit Internal Control Number (ICN) F8 16. REF Rendering Provider Identification REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Rendering Provider Secondary Identifier 7-digit LNI provider account number G2 174

175 2100 Claim Payment Information notes continued 17. DTM Statement From or To Date segment DTM01 Date Time Qualifier: Statement Period Start date 232 DTM02 Claim Date: formatted as CCYYMMDD Beginning Date of Service DTM01 Date Time Qualifier: Statement Period End date 233 DTM02 Claim Date: formatted as CCYYMMDD Ending Date of Service 18. AMT Claim Supplemental Information segment Note: Qualifier ZZ returned in 4010A1 format. ZZ is not available/valid for 5010 format. Replace ZZ with?? AMT01 Amount Qualifier Code: Mutually Defined (4010A1 format) AMT02 Outlier Amount ZZ 175

176 2110 Service Payment Information The following Service Payment information applies specifically to the Standard 835 Payment/Advice. TR3 PAGE # Segment/Field ID 2110 Service Payment Information SVC (Standard 835) FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE 186 Service Payment Information: Used for all services SVC except Inpatient Situational Service ID Qualifier: HC-HCPCS; 187 SVC01-1 NU-Revenue Codes R AD-American Dental, ER-Local Codes HC or NU or ER 188 SVC01-2 Product/Service ID: Adjudicated Procedure Code R 188 SVC01-3 Procedure Modifier 25 S 189 SVC01-4 Procedure Modifier S 189 SVC01-5 Procedure Modifier S 189 SVC01-6 Procedure Modifier S 189 SVC02 Line Item Charge Amount R 190 SVC03 Line Item Allowed Amount R 190 SVC04 Product/Service ID: Revenue Code S 190 SVC05 Quantity: Units of Service Paid 5 S 194 DTM Service Date Situational 195 DTM01 Date/Time Qualifier: Date of Service 472 [DRV] R 195 DTM02 Date: CCYYMMDD Service Date R 196 CAS Service Adjustment Situational 198 CAS01 Claim Adjustment Group Code R 198 CAS02 Claim Adjustment Reason Code R 199 CAS03 Adjustment Amount R 199 CAS04 Adjustment Quantity S 206 REF Line Item Control Number Situational Reference Identification Qualifier: Provider Control 206 REF01 R Number 6R [R] 206 REF02 Reference Identification (line item #) 01 R 215 LQ Health Care Remark Code Situational 215 LQ01 Code List Qualifier Code HE R 216 LQ02 Remark Code R Segment Count 17 SVC*HC:99050:25*500*450**5~ 18 DTM*472* ~ 19 CAS*CO*97*50~ 20 REF*6R*01~ Example EDI Data

177 2110 Service Payment Information notes: 1. SVC01-1 Service Id Qualifier: Qualifies the product/service in SVC01-2 HC or NU or ER HC - HCPCS Codes, CPT codes, LNI local codes HC is returned when the service contains procedure code or Procedure code and Revenue code NU - National Uniform Billing Committee (NUBC) Revenue Codes NU is returned when the service contains only Revenue code ER - Jurisdiction Specific Procedure and Supply Codes (LNI Local Codes) ER is returned when the service contains LNI Local billing codes Note: ZZ never returned/implemented on LNI Local codes. 2. SV01-2 Product/Service ID: Adjudicated Procedure/Revenue Code 3. SVC01-3 Procedure modifier (1) SVC01-4 Procedure modifier (2) SVC01-5 Procedure Modifier (3) SVC01-6 Procedure Modifier (4) Up to four (4) modifiers are returned when present with billed service 4. SV02 Line Item Charge Amount: Service Line billed amount 5. SV03 Line Item Allowed Amount: Service Line paid amount 6. SV04 NUBC Revenue Code 7. SV05 Quantity: Unit of Service Paid 8. DTM Service Date DTM01 Date/Time Qualifier: Service Date, single date of service 472 DTM02 Service Date: formatted as CCYYMMDD 9. CAS Service Adjustment Segment CAS Segments will be used to report claim adjustments at the service line level when the Claim Payment Amount is different than the Total Claim Charge Amount. The information in CAS01 and CAS02 is derived from a HIPAA EOB cross-reference associated to LNI s assigned EOB (Explanation of Benefits) codes returned on the bill. CAS01 Claim Adjustment Group Code Claim Adjustment Group Codes descriptions are defined in the 835 Implementation Guide (TR3). CO Contractual Obligations OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility CR Correction and Reversal used when CLP02 = 22 (Reversal of Previous Payment adjustment) o Valid for format o Invalid for format CAS02 Claim Adjustment Reason Code Defined by the Washington Publishing Company (WPC). Codes are mapped and cross-referenced to LNI s EOB (Explanation of Benefits) codes 177

178 2110 Service Payment Information notes: CAS03 Adjustment Amount Difference between SVC03 Line Item Allowed Amount and SVC02 Line Item Charge Amount. CAS04 Adjustment Quantity 10. REF Line Item Control Number LNI returns a sequential line item control number for each line of service on the bill LNI does not return the Line Item Control Number received in the REF*6R REF02 at this time. REF01 Reference Identification Qualifier: Provider Control Number REF02 Line Item Control Number Sequential line number for each line of service 6R Value 11. LQ Health Care Remark Codes The Claim Payment Remark Codes (Remittance Advice Remark Codes) are returned on Paid bills (CLP02=1) for services other than pharmacy prescription drugs and provide information about remittance processing or supplemental information for an adjustment already described by a Claim Adjustment Reason Code in a CAS Claim Adjustment Segment. Remittance Advice Remark Codes are available from the Washington Publishing Company (WPC). LQ01 Code List Qualifier Code: Claim Payment Remark Codes LQ02 Remark Code HE 178

179 Pharmacy 835 Payment/Advice 2100 Claim Payment & 2110 Service Payment 2100 Claim Payment Information The following Claim Payment information applies specifically to the Pharmacy 835 Payment/Advice Claim Payment Information CLP (Pharmacy 835) TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 123 CLP Claim Payment Information Required 123 CLP01 Patient Control Number PUBLICJQ R 124 CLP02 Claim Status Code 1 or 4 or 22 [DRV] R 125 CLP03 Total Claim Charge Amount 50 R 125 CLP04 Claim Payment Amount 31 R 125 CLP05 Patient Responsibility Amount 0 S 126 CLP06 Claim Filing Indicator Code WC [DRV] R 127 CLP07 Payer Claim Control Number R 137 NM1 Patient Name Required 137 NM101 Entity Identifier Code QC [R] R 138 NM102 Entity Type Qualifier 1 [R] R 138 NM103 Patient Last Name PUBLIC S 138 NM104 Patient First Name JOHN S 138 NM105 Patient Middle Q S 139 NM108 Identification Code Qualifier MI [DRV] S 139 NM109 Patient Identifier H S 146 NM1 Service Provider Name Situational 147 NM101 Entity Identifier Code 82 [R] R 147 NM102 Entity Type Qualifier 2 R 147 NM103 Last Name or Organization STOP-N-GO PHARMACY S 148 NM108 Identification Code Qualifier PC or XX [DRV] R 149 NM109 Rendering Provider Identifier or R 171 REF Rendering Provider Identification Situational 171 REF01 Reference Identification Qualifier G2 [DRV] R 172 REF02 Rendering Provider Secondary Identifier R Segment Count CLP* *1*200*150.75*0*WC* ~ NM1*QC*1*PUBLIC*JOHN*Q***MI*H010101~ NM1*82*2*STOP-N-GO PHARMACY***PC* ~ REF*G2* ~ Example EDI Data Pharmacy

180 2100 Claim Payment Information for Pharmacy 835 notes: 1. CLP01 Patient Control Number: Patient Account Number This value is the NCPDP Prescription/Service Reference Number (Rx-No) MPOS reference: NCPDP version 5.1/D.0, Claim Segment - Data Element 402-D2 2. CLP02 Claim Status Code: Finalized Bill Status 1 or 4 or 22 1 Processed as Primary. Bill paid (full or partial payment). 4 Denied. (Bill denied, no payment issued) 22 Reversal of Previous Payment 3. CLP03 Total Claim Charge Amount This value is the NCPDP Gross Amount Due. MPOS reference: NCPDP version 5.1/D.0, Pricing Segment - Data Element 430-DU 4. CLP04 Claim Payment Amount: Total amount the Department paid on this bill This value is the NCPDP Total Amount Paid MPOS reference: NCPDP version 5.1/D.0, Data Element 509-F9 5. CLP05 Patient Responsibility Amount 0 (zero) Patient s responsibility is always zero for Washington State workers compensation billing. 6. CLP06 Claim Filing Indicator Code : WC Workers Compensation Health Claim 7. CLP07 Payer Claim Control Number: 17-digit LNI Internal Control Number (ICN) The first position of the ICN identifies the medium type of the submitted bill to LNI. 6 = Pharmacy Point of Service bill (MPOS) 0 = Paper bill 8. NM1 Patient Name segment NM101 Entity Identifier Code: Patient QC NM102 Entity Type Qualifier: Person 1 NM103 Patient Last Name If NM103 Patient Last Name equal UNKNOWN The LNI Claim ID is not on file with the department or a name conflict existed at the time of bill processing. MPOS reference: NCPDP version 5.1/D.0, Insurance Segment - Data Element 313-CD NM104 Patient First Name If NM104 Patient First Name equal UNKNOWN The LNI Claim ID is not on file with the department or a name conflict existed at the time of bill processing. MPOS reference: NCPDP version 5.1/D.0, Insurance Segment - Data Element 312-CC NM105 Patient Middle Name NM108 Identification Code Qualifier: Member Identification Number MI 180

181 2100 Claim Payment Information for Pharmacy 835 notes continued NM109 Patient Identifier: 7-digit LNI Claim Number 7-character LNI Claim Number This value is the NCPDP Cardholder ID If the LNI Claim ID is invalid or not on file, the bill is denied and returned with: EOB 280 Claim ID Billed is Not Active. NCPDP Rejection Code: 52 Non-Match Cardholder ID MPOS reference: NCPDP version 5.1/D.0, Insurance Segment - Data Element 302-C2 9. NM1 Service Provider segment This segment is used to identify the pharmacy provider of service. NM101 Entity Identifier Code: 82 Rendering Provider NM102 Entity Type Qualifier: 2 Non-person entity NM103 Rendering Provider Last or Organization Name Pharmacy name NM108 Identification Code Qualifier: PC Provider Commercial Number XX - National Provider Identifier (NPI) NM109 Rendering Provider Identifier 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) o 7-digit LNI Provider Account Number when NM108 equal PC o 10-digit National Provider Identifier (NPI) when NM108 equal XX PC 10. REF Rendering Provider Identification segment REF01 Reference Identification Qualifier: Provider Commercial Number REF02 Rendering Provider Secondary Identifier: o 7-digit LNI provider account number G2 181

182 2110 Service Payment Information (Only one occurrence per CLP) The following Service Payment information applies specifically to the Pharmacy 835 Payment/Advice. TR3 PAGE # Segment/Field ID 2110 Service Payment Information SVC (Pharmacy 835) FIELD NAME Sample Data, TR3 Required Value [R] and Department Returned Value [DRV] Seg/Field USAGE Service Payment Information: Used for all services 186 Situational SVC except Inpatient 187 SVC01-1 Product or Service ID Qualifier N4 or HC or ER R 188 SVC01-2 Product or Service ID R 189 SVC02 Line Item Charge Amount 50 R 190 SVC03 Line Item Allowed Amount 31 R 190 SVC05 Quantity 14 S 194 DTM Service Date Situational 195 DTM01 Date/Time Qualifier: Date of Service 472 [DRV] R 195 DTM02 Prescription Fill Date R 196 CAS Service Adjustment Situational 198 CAS01 Claim Adjustment Group Code R 198 CAS02 Claim Adjustment Reason Code R 199 CAS03 Adjustment Amount R 199 CAS04 Adjustment Quantity S 215 LQ Health Care Remark Code Situational 215 LQ01 Code List Qualifier Code: RX NCPDP Reject/Payment codes RX [DRV] R 216 LQ02 Industry Code R Segment Count SVC*HC:99050:25*500*450**5~ DTM*472* ~ Example EDI Data

183 2110 Service Payment Information for Pharmacy 835 notes 1. SVC01-1 Service Id Qualifier: Qualifies the product/service in SVC01-2 N4 or HC or ER N4 National Drug Code (NDC) format N4 returned to report NDC Drug code associated to prescription service billed HC - HCPCS Codes, CPT codes HC is returned when the service contains procedure codes ER - Jurisdiction Specific Procedure and Supply Codes (LNI Local Codes) ER is returned when the service contains LNI Local billing codes Note: ZZ never returned/implemented on LNI Local codes. 2. SV01-2 Product/Service ID: 11-digit National Drug Code (NDC) excluding dashes when SVC01-1 equals N4 Procedure code or LNI Local code 3. SV02 Line Item Charge Amount: NCPDP Gross Amount Due 430-DU MPOS reference: NCPDP version 5.1/D.0, Claim Segment - Data Element 407-D7 4. SV03 Line Item Allowed Amount: NCPDP Total Amount Paid 509-F9 MPOS reference: NCPDP version 5.1/D.0, Data Element 509-F9 5. SV05 Quantity: Unit of Service Paid: NCPDP Quantity Dispensed 442-E7 MPOS reference: NCPDP version 5.1/D.0, Claim Segment - Data Element 407-D7 6. DTM Service Date DTM01 Date/Time Qualifier: 472 Service Date, single date of service DTM02 Service Date: Prescription Fill Date formatted as CCYYMMDD 7. CAS Service Adjustment Segment CAS Segments will be used to report claim adjustments at the service line level when the Claim Payment Amount is different than the Total Claim Charge Amount. The information in CAS01 and CAS02 is derived from a HIPAA EOB cross-reference associated to LNI s assigned EOB (Explanation of Benefits) codes returned on the bill. CAS01 Claim Adjustment Group Code Claim Adjustment Group Codes descriptions are defined in the 835 Implementation Guide (TR3). CO Contractual Obligations OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility CR Correction and Reversal used when CLP02 = 22 (Reversal of Previous Payment adjustment) o Valid for format o Invalid for format CAS02 Claim Adjustment Reason Code Defined by the Washington Publishing Company (WPC). Codes are mapped and cross-referenced to LNI s EOB (Explanation of Benefits) codes 183

184 2110 Service Payment Information notes: CAS03 Adjustment Amount Difference between SVC03 Line Item Allowed Amount and SVC02 Line Item Charge Amount. CAS04 Adjustment Quantity 8. LQ Health Care Remark Codes LQ01 Code List Qualifier Code: NCPDP Reject/Payment Codes RX LQ02 Remark Code: NCPDP Rejection Code The NCPDP Rejection Codes are returned in the Pharmacy 835 when the bill is denied (CLP02=4). 184

185 Provider Adjustment (for Provider Gross Adjustments only) The following Provider Adjustment information applies to both the Standard and Pharmacy 835 Payment/Advice. Provider Level Adjustment - PLB TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field PAGE # ID FIELD NAME Department Returned Value [DRV] USAGE 217 PLB Provider Adjustment Situational 218 PLB01 Provider Identifier or R 218 PLB02 Date: CCYYMMDD R 219 PLB03-1 Adjustment Reason Code ZZ R 222 PLB03-2 Provider Adjustment Identifier S 223 PLB R Segment Count PLB* * *ZZ: *118.07~ Example EDI Data 835 Provider Adjustment notes: The PLB segment is returned for a Provider Level Adjustment that is not specific to a particular claim or service to the amount of the actual payment to the Payee. The PLB segment is reported as the last segment for the payee provider within the transaction set immediately prior to the Transaction Set Trailer (SE) segment. 1. PLB01 Provider Identifier: Payee provider account number for this adjustment 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI) 2. PLB02 Fiscal Period Date: Value is the last day of the provider s fiscal year the adjustment applies to Formatted as CCYYMMDD 3. PLB03 Adjustment Identifier PLB03-1 Adjustment Reason Code: A1 LNI returns code ZZ (Mutually Defined) o ZZ used to report hemophilia clotting factor A1 LNI will return code?? o 5010A1 Code ZZ is removed. o Use code HM Hemophilia Clotting Factor Supplement to replace ZZ? PLB03-2 Provider Adjustment Identifier: 17-digit LNI Internal Control Number (ICN) for the reported adjustment 4. Provider Adjustment Amount: Dollar amount returned from the provider to LNI 185

186 Transaction Set Trailer (SE) The purpose of the Transaction Set Trailer (SE) is to indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) The following Transaction Set Header information applies to both the Standard and Pharmacy 835 Payment/Advice. Transaction Set Trailer (SE) TR3 Segment/Field Sample Data, TR3 Required Value [R] and Seg/Field FIELD NAME PAGE # ID Department Returned Value [DRV] USAGE 228 SE Transaction Trailer Required 228 SE01 Number of Included Segments 19 R 228 SE02 Transaction Set Control Number 0001 R Segment Count 28 SE*19*0001~ Example EDI Data 835 SE Transaction Set Trailer notes: 1. SE01 Number of included segments is the total number of segments within the transaction set including the ST and SE segments. 2. SE02 Transaction Set Control Number Must be identical to Transaction Set control Header ST

187 Standard 835 Payment Advice SEG No. Standard 835 Payment Advice ISA*00*...*00*...*30* *ZZ* *111005*2300*^*00501* *0*P*:~ GS*HN* * * *2300*1*X*005010X221A1~ 1 ST*835* ~ 2 BPR*I* *C*CHK*********** ~ 3 TRN*1*123456U* ~ 4 REF*EV* ~ 5 DTM*405* ~ 6 NM1*PR*2*WA ST DEPT OF LABOR AND INDUSTRIES~ 7 N3*PO BOX 44263~ 8 N4*OLYMPIA*WA* ~ 9 PER*CX*PROVIDER HOTLINE*TE* ~ 10 PER*BL*ELECTRONIC BILLING UNIT*TE* *EM*[email protected]~ 11 PER*IC**UR* ~ 12 N1*PE*COMMUNITY HOSPITAL*XX* ~ 13 N3*123 WEST ST~ 14 N4*OLYMPIA*WA*98500~ 15 REF*PQ* LX*1~ 17 CLP*PUBLICJQ-00100*1*500*450*0*WC* ~ 18 CAS*CO*42*50~ 19 NM1*QC*1*PUBLIC*JOHN*Q***MI*H010101~ 20 NM1*82*1*WASHINGTON*GEORGE***XX* ~ 21 REF*EA*MEDRECNUM001~ 22 REF*G2* ~ 23 DTM*232* ~ 24 DTM*233* ~ 25 SVC*HC:99050:25*500*450**5~ 26 DTM*472* ~ 27 CAS*CO*97*50~ 28 REF*6R*01~ 29 PLB* * *ZZ: *118.07~ 30 SE*30* ~ GE*1*101~ IEA*1* ~ 187

188 Pharmacy 835 Payment Advice SEG No. Pharmacy 835 Payment Advice ISA*00*...*00*...*30* *ZZ* *111005*2300*^*00501* *0*P*:~ GS*HN* * * *2300*1*X*005010X221A1~ 1 ST*835* ~ 2 BPR*I* *C*CHK*********** ~ 3 TRN*1*123456U* ~ 4 REF*EV* ~ 5 DTM*405* ~ 6 NM1*PR*2*WA ST DEPT OF LABOR AND INDUSTRIES~ 7 N3*PO BOX 44263~ 8 N4*OLYMPIA*WA* ~ 9 PER*CX*PROVIDER HOTLINE*TE* ~ 10 PER*BL*ELECTRONIC BILLING UNIT*TE* *EM*[email protected]~ 11 PER*IC**UR* ~ 12 N1*PE* STOP-N-GO PHARMACY*XX* ~ 13 N3*123 WEST ST~ 14 N4*OLYMPIA*WA*98500~ 15 REF*PQ* LX*1~ 17 CLP* PUBLICJQ-00100*1*200*150.75*0*WC* ~ 18 CAS*CO*42*50~ 19 NM1*QC*1*PUBLIC*JOHN*Q***MI*H010101~ 20 NM1*82*2*STOP-N-GO PHARMACY***PC* ~ 21 REF*G2* ~ 22 SVC*N4: *51*30**60~ 23 DTM*472* ~ 24 CAS*CO*W1*21~ 25 SE*26* ~ GE*1*101~ IEA*1* ~ 188

189 Appendix EDI Formatting Errors Place of Service Codes 5010 Change Summary Version Chart 189

190 EDI Formatting Errors Bills submitted with missing or invalid Department Required Values [DRV] as indicated in this companion guide for 837 transactions will result in the bill formatting into LNI s Medical Information Payment System MIPS with an EDI formatting Error condition. Bills with EDI formatting errors are auto-denied and rejected from adjudication processing. Reported back to the submitter in the 277 Notification (5010) and 277 Unsolicited (3070). o Department s EOB text associated to the EDI formatting error is returned in -2200D-STC12. o Claim Status Category Codes, Claim Status Codes, Action Codes, and Entity Codes associated to EOB returned as applicable. Reported back to the Provider on their Remittance Advice. Department EOB s are cross-walked to best fit HIPAA EOB codes for recipients of 835 Payment Advice. Code references: Washington Publishing Company o Claim Status Category Codes (CSCC) o Claim Status Codes (CSC) o Claim Adjustment Reason Codes (CARC) o Remittance Advice Remark Codes (RARC) Code references: Implementation Guides 835/277 (TR3s) o Claim Adjustment Group Code (CAS01) o Action Code (STC03) o Entity Code (STC10-3) EOBs and Code values listed below and returned in the 835/277 for LNI bill processing is subject to change/revision without notice and provided here for reference use only. EOB1 H00 EDI Formatting Error: This Billing is Denied/Rejected The Second EOB Details the Error. Reason EDI formatting error. This EOB is applicable to the provider s remittance advice and is NOT returned on the EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CO A1 MA 130 CSCC ST01-1 CSC STC01-2 AC STC03 CSCC STC10-1 CSCC STC10-1 EC STC

191 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H01 INVALID WORKERS' COMPENSATION PAY-TO PROVIDER NUMBER Reason Not applicable AB REF*X5 REF02: The value received in REF02 is NOT a valid LNI provider account number. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N77 F F U 5010-NA A A U - current H02 MISSING WORKERS' COMPENSATION BILLING PROVIDER NUMBER Reason AA/2010BB REF*G2 REF02: Billing Provider received with non NPI primary identifier. Billing Provider Secondary ID REF*G2 segment/qualifier is missing. Reason AA REF*X5 REF02: Billing Provider received with primary identifier of 24/34 (NM108) and EIN/SSN (NM109). Secondary ID REF*X5 segment and/or qualifier is missing. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N77 F2 21 U/15 F /3070U A A U - current H03 INVALID WORKERS' COMPENSATION BILLING PROVIDER NUMBER Reason AA/2010BB REF*G2 REF02: The value received in REF02 in NOT a valid LNI provider account number. Reason AA REF*X5 REF02: The value received in REF02 is NOT a valid LNI provider account number. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N77 F2 21 U/15 F /3070U A A U - current 191

192 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H04 SUBMITTED TRANSACTION IS NOT IDENTIFIED AS A WORKERS' COMPENSATION BILLING Reason 5010/ B SBR09 Claim filing Indicator is NOT WC (workers compensation) 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO 31, 109 none F2 21 U/15 F /3070U F F U - current H05 INVALID/MISSING WORKERS' COMPENSATION CLAIM NUMBER (SUBSCRIBER IDENTIFICATION). Reason 5010/ B SBR02 Patient Relationship to Insured is NOT 18 (Self) OR/AND 2010BA NM109 Subscriber Primary ID OR 2000B SBR03 Subscriber Group or Policy Number is not a valid LNI Claim Number/Claim ID. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CO 31,140 MA 130 CSCC ST01-1 CSC STC01-2 AC STC03 CSCC STC10-1 CSCC STC10-1 EC STC10-3 F2 21 U/15 F2 162 QC 5010/3070U F F2 162 QC 3070U - current H06 INVALID TRANSACTION TYPE CODE (MUST BE CHARGEABLE) Reason 5010/ ST Header BHT06 Claim or Encounter Identifier is NOT CH (Chargeable) 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CO A1 MA 130 CSCC ST01-1 CSC STC01-2 AC STC03 CSCC STC10-1 CSCC STC10-1 EC STC10-3 F2 21 U/15 F /3070U F F U - current 192

193 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H07 INVALID TRANSACTION TYPE IDENTIFICATION (IDENTIFIED AS DRAFT/PILOT). Reason ST Header REF-REF02 Transmission Type Identification is invalid. Not applicable to format. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CO A1 MA 130 CSCC ST01-1 CSC STC01-2 AC STC03 CSCC STC10-1 CSCC STC10-1 EC STC10-3 H08 INVALID CLAIM FREQUENCY TYPE CODE (6-CORRECTED NOT ALLOWED). INVALID CLAIM FREQUENCY TYPE CODE (ADJUSTMENT/REPLACEMENT/VOID NOT ALLOWED). Reason 5010/ CLM CLM05-3 Claim Frequency Code is not 1 (Original) or 7 (Replacement) or 8 (Void). Applicable to billing submitted on or after 9/1/2011. Reason CLM CLM05-3 Claim Frequency Code is not 1 (Original). Applicable to billing submitted previous to 9/1/ EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CO A1 MA 130 CSCC ST01-1 CSC STC01-2 AC STC03 CSCC STC10-1 CSCC STC10-1 EC STC10-3 F2 21 U/15 F /3070U F2 21 U/15 F /3070U F F U - current Note: CSCC STC returned on 837 Institutional bills with H08 H09 LINE ITEM MAXIMUM EXCEEDED. INSTITUTIONAL BILL SERVICE LINE LIMIT IS 99 SERVICE LINES. Reason 5010/ Institutional LX LX01 Service Line Greater Than 99. MIPS supports up to and including, 99 lines of service for Institutional billing. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 none F2 21 U F2 F /3070U F U - current 193

194 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H10 Reason MISSING WORKERS' COMPENSATION PAY-TO PROVIDER NUMBER AB REF*X5 REF02: Pay-to Provider received with primary identifier of 24/34 (NM108) and EIN/SSN (NM109). Pay-to Provider Secondary ID REF*X5 segment/qualifier is missing. Not applicable to format. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N77 F F U 5010-NA A2 122 NA 3070U - current H11 MISSING WORKERS' COMPENSATION RENDERING PROVIDER NUMBER Reason B REF*G2 REF02: Rendering Provider received with non NPI primary identifier AND Rendering Provider Secondary ID REF*G2 segment/qualifier is missing. Reason B REF*X5 REF02: Rendering Provider received with primary identifier of 24/34 (NM108) and EIN/SSN (NM109) AND Rendering Provider Secondary ID REF*X5 segment and/or qualifier is missing. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N77 F2 21 U F /3070U A2 122 NA 3070U - current H12 INVALID WORKERS' COMPENSATION RENDERING PROVIDER NUMBER Reason B REF*G2 REF02: The value received in REF02 is NOT a valid LNI provider account number. Reason B REF*X5 REF02: The value received in REF02 is NOT a valid LNI provider account number. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N77 F2 21 U F /3070U A2 122 NA 3070U - current 194

195 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H21 THE PAYEE PROVIDER'S NPI IS EITHER INVALID OR IS NOT REGISTERED. CALL PROVIDER ACCOUNTS AT Reason AB NM109 Pay-to Provider Identifier: The NPI received in NM109 is INVALID or NOT ON FILE, or ON FILE but NOT cross-walked to an LNI provider account number in MIPS. Not applicable to format. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N280 F F U A2 122 NA 3070U - current H22 INVALID NPI BILLING PROVIDER NUMBER. THE SUBMITTED NPI IS NOT ON FILE OR IS NOT ASSOCIATED TO AN LNI PROVIDER NUMBER. Reason AA NM109 Billing Provider Identifier: Billing Provider received with NPI as primary provider identifier and no 2010BB Billing Provider Secondary ID REF*G2. NPI received in NM109 is INVALID or NOT ON FILE, or ON FILE but NOT crosswalked to an LNI provider account number in MIPS. Reason AA NM109 Billing Provider Identifier: Billing Provider received with NPI as primary provider identifier and no 2010AA Billing Provider Secondary ID REF*X5. NPI received in NM109 is INVALID or NOT ON FILE, or ON FILE but NOT crosswalked to an LNI provider account number in MIPS. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO 16 N77 F2 21 U/15 F /3070U A2 122 NA 3070U - current H23 THE SERVICE PROVIDER'S NPI IS INVALID OR IS NOT REGISTERED. CALL PROVIDER ACCOUNTS AT Reason B NM109 Rendering Provider Identifier: Rendering Provider received with NPI as primary provider identifier and no 2310B Rendering Provider Secondary ID REF*G2. NPI received in NM109 is INVALID or NOT ON FILE, or ON FILE but NOT cross-walked to an LNI provider account number in MIPS. Reason B NM109 Rendering Provider Identifier: Rendering Provider received with NPI as primary provider identifier and no 2310B Rendering Provider Secondary ID REF*X5. NPI received in NM109 is INVALID or NOT ON FILE, or ON FILE but NOT cross-walked to an LNI provider account number in MIPS. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code GC CARC RARC CSCC CSC AC CSCC CSCC EC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO 16 N290 F2 21 U/15 F /3070U A2 122 NA 3070U - current 195

196 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H31 ICN (INTERNAL CONTROL NUMBER) SUBMITTED ON REQUEST FOR ELECTRONIC ADJUSTMENT NOT FOUND IN PAYER'S SYSTEM OR IS INVALID. CORRECT AND RESUBMIT. Reason 5010/ CLM REF*F8 REF02 Payer Claim Control Number (ICN Internal Control Number) submitted for adjustment request is NOT found in MIPS or is invalid as submitted. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 M47 F2 21 U/15 F /3070U H32 CLAIM NUMBER SUBMITTED ON REQUEST FOR ELECTRONIC ADJUSTMENT DOES NOT MATCH THE CLAIM NUMBER FOUND ON THE ICN OF THE BILL TO BE ADJUSTED. Reason 5010/ BA NM109 or 2000B SBR03 LNI Claim ID submitted on adjustment request does not match the Claim ID found on the bill to be adjusted (ICN). 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 MA61 F2 21 U/15 F2 162 IL 5010/3070U H33 RENDERING PROVIDER SUBMITTED ON REQUEST FOR ELECTRONIC ADJUSTMENT DOES NOT MATCH THE RENDERING PROVIDER FOUND ON THE ICN OF THE BILL TO BE ADJUSTED. Reason 2310B NM1-NM109 (NPI) or REF*G2/X5 REF02 or 2010AA NM1-NM109 or REF*G2/X5 REF02 submitted on adjustment request does not match the rendering provider found on the bill to be adjusted (ICN). 835 EOB XREF GC CARC RARC CO A CSCC ST Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSC STC01-2 AC STC03 CSCC STC10-1 CSCC STC10-1 EC STC10-3 F2 21 U/15 F /3070U 196

197 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H34 ICN (INTERNAL CONTROL NUMBER) SUBMITTED FOR REQUEST FOR ELECTRONIC ADJUSTMENT IS ALREADY IN PROCESS AND WILL APPEAR ON A FUTURE REMITTANCE ADVICE. Reason The Internal Control Number (ICN) submitted on adjustment request was found to be already in process duplicate request for adjustment to original ICN 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1, 18 N522 F2 21 U/15 F /3070U H35 ICN (INTERNAL CONTROL NUMBER) SUBMITTED FOR ELECTRONIC ADJUSTMENT HAS ALREADY BEEN ADJUSTED/CREDITED. ORIGINAL ICN ADJUSTMENT/CREDIT ALLOWED ONCE Reason The Internal Control Number (ICN) submitted on adjustment request was previously processed as an adjustment/void. Original ICN may be adjusted / /voided only once. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1, 18 N522 F2 21 U/15 F /3070U H36 ICN (INTERNAL CONTROL NUMBER) SUBMITTED FOR ELECTRONIC ADJUSTMENT PREVIOUSLY PROCESSED AS A CREDIT (VOID). RESUBMIT NEW BILL IF CREDIT WAS IN ERROR. Reason The Internal Control Number (ICN) submitted on adjustment request was previously processed as a credit (void). Voided ICN may not be adjusted. Submission of new bill is required. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N522 F2 21 U/15 F /3070U 197

198 EOB2 EOB TEXT RETUNED IN D STC12 AND PROVIDER REMITTANCE ADVICE H37 Not Applicable ICN (INTERNAL CONTROL NUMBER) SUBMITTED ON REQUEST FOR ELECTRONIC ADJUSTMENT ALLOWED FOR ORIGINAL ICN RECEIVED IN HIPAA 837 FORMAT (ICN 7). Reason The Internal control Number (ICN) submitted on adjustment request must be for original bill submitted in HIPAA 837 format (ICN begins with 7 ). Electronic adjustment not allowed for bills submitted in proprietary format (ICN 3 ) or paper bills (ICN 0 ). 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 M47 F2 21 U/15 F /3070U H38 ELECTRONIC ADJUSTMENT TRANSACTION SUBMITTED IS MISSING REQUIRED PAYER CLAIM CONTROL NUMBER (ICN) SEGMENT 2300 REF*F8 Reason Transaction submitted as electronic adjustment request CLM05-3 = 7 (Replacement) or 8 (Void) AND required Payer Claim Control Number (ICN) segment 2300 REF*F8 is missing from the transaction. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 M47 F2 21 U/15 F /3070U H39 ICN (INTERNAL CONTROL NUMBER) SUBMITTED FOR ELECTRONIC ADJUSTMENT VOID IS FOR DENIED BILL. VOID NOT ALLOWED ON DENIED BILL. Reason The Internal Control Number (ICN) submitted on adjustment request for Void is to a fully denied bill (no payment). Fully denied bills cannot be voided. 835 EOB XREF 277 Claim Status Category Code, Claim Status Code, Action Code, Entity Code CSCC CSC AC CSCC CSCC EC GC CARC RARC ST01-1 STC01-2 STC03 STC10-1 STC10-1 STC10-3 CO A1 N142 F2 21 U/15 F2 5010/3070U 198

199 Legend CSCC Code F2 A2 A6 A7 277 Notification Claim Status Category Codes (CSCC) Returned in STC01-1 and STC10-1 Description Finalized/Denial-The claim/line has been denied. Acknowledgement/Acceptance into adjudication system-the claim/encounter has been accepted into the adjudication system Acknowledgement/Rejected for Missing Information - The claim/encounter is missing the information specified in the Status details and has been Acknowledgement/Rejected for Invalid Information - The claim/encounter has invalid information as specified in the Status details and has been rejected. Bill formatted into MIPS with EDI formatting error auto-denied Discontinued - applicable to 3070 Unsolicited prior 7/1/2011 Discontinued - applicable to 3070 Unsolicited prior 7/1/2011 Discontinued - applicable to 3070 Unsolicited prior 7/1/2011 LNI will return CSCC F2 on all bills formatted into MIPS with an EDI formatting error. Bills with EDI formatting errors are auto-denied and rejected from adjudication processing. CSCC s A2, A6, and A7 are no longer returned in the 277 Notification (3070) Unsolicited. 277 Notification Claim status Codes (CSC) Returned in STC01-2 and STC10-2 CSC Code Description Missing or invalid information. Note: At least one other status code is required to identify the missing or invalid information. Missing/invalid data prevents payer from processing claim. (Use CSC Code 21). Stopped: 01/01/2008 Replaces CSC 122 Usage of this code stopped 01/01/2008. Replaced by CSC Claim was processed as adjustment to previous claim. EOBs: H34, H35, H Claim submitted to incorrect payer. EOBs: H Service line number greater than maximum allowable for payer. EOBs: H Entity's id number. Note: This code requires use of an Entity Code. 162 Entity's health insurance claim number (HICN). Note: This code requires use of an Entity Code. 228 Type of bill for UB claim EOBs: H01, H02, H03, H10, H11, H12, H33 EOBs: H05 Removed on EOBs: H08. Replaced with CSC Payer Assigned Claim Control Number EOBs: H31, H Entity not eligible for encounter submission. Note: This code requires use of an Removed on EOBs: H06. Replaced with Entity Code. CSC Claim Frequency Code EOBs: H08. Replaces CSCC Claim or Encounter Identifier EOBs: H06. Replaces CSCC Entity's National Provider Identifier (NPI). Note: This code requires use of an Entity Code. EOBs: H21, H22, H23 LNI will return Claim Status Codes (CSC) as applicable to detail the error causing the EDI formatting error. 199

200 277 Notification Action Codes (AC) & Entity Codes (EC) Returned in STC03 and STC10-3 Action Code U/15 Reject / Correct and resubmit claim 5010/3070 values Entity Code 87 Pay-to Provider 85 Billing Provider 82 Rendering Provider IL Insured or Subscriber QC Patient CSCC 153, 562 Returned on EOBs: H01, H10, H21 Reference to AB Pay-to Provider information. CSCC 153 Returned on EOBs: H02, H03, H22 Reference to AA Billing Provider information CSCC 153 Returned on EOBs: H11, H12, H23, H33 Reference to B Rendering Provider information CSCC 162 Returned on EOBs: H32 Reference to BA Subscriber information CSCC 162 Returned on EOBs: H05 Reference to BA Subscriber NM109 or 2000B SBR03 information 835 Payment Advice CAS Segment Claim Adjustment Group Code, Claim Adjustment Reason Code, Remittance Advice Remark Code CAS01 Claim Adjustment Group Code CO Contractual Obligations CAS02 Claim Adjustment Reason Codes A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 16 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) 18 Duplicate Claim/Service 31 Patient cannot be identified as our insured 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 140 Patient/Insured health identification number and name do not match. LQ Segment N77 N152 N280 N290 M47 MA61 MA130 Remittance Advice Remark Codes Missing/incomplete/invalid designated provider number. Missing/Incomplete/Invalid replacement claim information. Missing/incomplete/invalid pay-to provider primary identifier. Missing/incomplete/invalid rendering provider primary identifier. Missing/incomplete/invalid internal or document control number. Missing/incomplete/invalid social security number or health insurance claim number. Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. 200

201 Place of Service Codes The Place of Service codes used for reporting where health care services were provided is maintained by the Centers for Medicare & Medicaid Services (CMS). The following list of Place of Service Codes is provided for convenience of reference and effective as of November 1, Please visit the CMS website at for updated information. POS Code Place of Service Name Place of Service Description 01 Pharmacy A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients. 02 Unassigned 03 School A facility whose primary purpose is education. 04 Homeless Shelter A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). 05 Indian Health Service Free-standing Facility 06 Indian Health Service Provider-based Facility 07 Tribal 638 Free-standing Facility 08 Tribal 638 Provider-based Facility 09 Prison/ Correctional Facility A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders. 10 Unassigned 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. 12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence. 13 Assisted Living Facility Congregate residential facility with self-contained living units providing assessment of each resident s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. 14 Group Home A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration). 15 Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services. 16 Temporary Lodging A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code. 17 Walk-in Retail Health Clinic A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services. (This code is available for use immediately with a final effective date of May 1, 2010) Unassigned 20 Urgent Care Facility Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. 21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of 201

202 physicians to patients admitted for a variety of medical conditions. 22 Outpatient Hospital A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. 23 Emergency Room Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. 24 Ambulatory Surgical Center A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis. 25 Birthing Center A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants. 26 Military Treatment Facility A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF) Unassigned 31 Skilled Nursing Facility A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. 32 Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, healthrelated care services above the level of custodial care to other than mentally retarded individuals. 33 Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component. 34 Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided Unassigned 41 Ambulance - Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. 42 Ambulance Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured Unassigned 49 Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. (effective 10/1/03) 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility- Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 57 Non-residential Substance Abuse Treatment Facility Unassigned A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician. A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility. A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services. A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF. A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board. A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment. A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. 202

203 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility Unassigned 65 End-Stage Renal Disease Treatment Facility A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis Unassigned 71 Public Health Clinic A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician. 72 Rural Health Clinic A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician Unassigned 81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office Unassigned 99 Other Place of Service Other place of service not identified above. Direct Entry Place of Service field is validated against table values above. 203

204 5010 Change Summary The following information is a change summary of changes implemented for LNI EDI 837 transaction processing supporting the 5010 transaction format from 4010 format. 837 Professional & Institutional Change Summary Loop Segment/Element Description of Change ISA ISA11 Element Header name/usage changed in P 837I Element name: Repetition Separator. ^ (Caret) Element name: Interchange Control Standards Identifier. U x x ISA Header GS Header ST Header ST Header ISA12 Interchange Control Version Number GS08 Version Release Industry ID Code ST03 Implementation convention Reference REF*87 Transmission Type Identification Value change x x Value change. New required element. Segment deleted. Values: X222A X223A2 Values: X222A X223A2 Values: X098A X096A1 x x Not applicable x x Not applicable Required x x 2000A Loop BILLING PROVIDER HIERARCHICAL LEVEL Segment/Element Description P 837I of Change HL Segment 2000A Billing 2000A Billing/Pay- x x Name change Provider HL To Provider HL PRV Segment Name change x x PRV-PRV02 Reference Identification Qualifier Value change Added PXC Deleted - ZZ 2000A Billing Provider Specialty Information 2000A Billing/Pay- To Provider Specialty Information PXC ZZ x x 204

205 5010 Change Summary 2010AA Loop BILLING PROVIDER NM1*85 Segment/Element Description of Change NM1-NM108 Usage change Identification Code Value change Qualifier Deleted 24, NM1-NM109 Billing Provider Primary Identifier N4-N402 Billing Provider State N4-N403 Billing Provider Zip Code REF - Billing Provider Tax Identification REF-REF01 Reference Identification Qualifier REF-REF02 Billing Provider Tax Identification Number 34 Usage change P 837I Situational XX Situational Billing provider NPI Required 24, 34 or XX Required Billing provider EIN, SSN or NPI Usage change Situational Required x x Usage change Situational Required x x New Required Segment added Billing Provider tax identification number (TIN) Employer s Identification Number (EIN) or Social Security Number (SSN). Required Not applicable x x EI, SY EI EIN SY - SSN Exactly nine numbers. No formatting. x x x x x x x x REF - Billing Provider Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Billing Provider Secondary ID Segment Deleted. Moved to 2010BB Payer Name Not applicable Situational x x Not applicable X5 x x Not applicable Billing Provider s LNI Provider account number REF - Billing Provider Secondary Identification Segment deleted from 2010AA in 5010 and moved to 2010BB Payer Name. x x 205

206 5010 Change Summary 2010AB Loop PAY-TO ADDRESS NAME SEGMENT NM1*87 Segment/Element Description of Change P 837I NM1 2010AB Pay-To Address Name 2010AB Pay-To Provider Name x x REF Pay-To Provider Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Billing Provider Secondary ID Segment Deleted NA Situational x x NA X5 x x NA Pay-To Provider s LNI Provider account number 2010AB Pay-To Address Name replaces 2010AB Pay-To Provider Name segment. Segment usage changed to contain only address information removing all applicable provider identifiers available in version LNI MIPS processing does not utilize information sent in this loop. x x 2010BA Loop SUBSCRIBER NAME NM1*IL Segment/Element Description of Change NM1-NM108 Usage change Identification Code Qualifier NM1-NM109 Usage change Subscriber Primary Identifier N4-N402 Subscriber State N4-N403 Subscriber Zip Code P 837I Required MI Required Injured worker s LNI Claim Number Situational MI Situational Injured worker s LNI Claim Number Usage change Situational Required x x Usage change Situational Required x x x x x x 206

207 5010 Change Summary 2010BB Loop PAYER NAME NM1*PR Segment/Element Description P 837I of Change N4 - Payer City, Usage change Required Situational x x State, Zip Code N4-N402 Payer Usage change Situational Required x x State N4-N403 Payer Zip Code Usage change Situational Required x x REF - Billing Provider Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Billing Provider Secondary ID New Segment added to loop Value change Value X5 deleted Situational Not applicable x x G2 x x LNI Billing/payee provider account number Billing Provider Secondary Identification reference REF segment deleted from 2010AA Billing Provider and moved to 2010BB Payer Name. x x 207

208 5010 Change Summary 2300 Loop Claim Information CLM Segment/Element Description of Change CLM05-2 Facility Usage change Code Qualifier to Required from Not Used in Professional CLM05-3 Claim Frequency Code CLM06 Provider or Supplier Signature Indicator CLM18 Explanation of Benefits Indicator 837 Implemented usage of code values for electronic adjustment Usage change to Not Used from Required for Institutional 837 Usage change to Not Used from Required for Institutional P 837I B Not Used x 7 Replacement 7 Replacement 8 8 Void Void Not Used Required x Not Used Required x x x REFERRAL NUMBER REF*9F PRIOR AUTHORIZATION REF*G1 REF - Prior Segment Authorization or change Referral Number REF-REF01 Reference ID Qualifier REF-REF02 Reference Identification REF - Referral Number REF-REF01 Reference ID Qualifier REF-REF02 Reference Identification: Situational Situational x x G1 G1 x x Prior Authorization number or LNI Referral ID Prior Authorization number or LNI Referral ID New Segment Situational x n/a for LNI 9F x n/a for LNI LNI Referral ID Referral Number LNI Professional bill processing utilized REF*G1 for providers to submit Prior Authorization and/or Referral Number information in the 4010 format. The 5010 format supports both REF Prior Authorization, REF*G1 and Referral Number, REF*9F segments. LNI will utilize Referral Number REF*9F for Referral information and continue to utilize Prior Authorization REF*G1 for Prior Authorization AND Referral Number information. If both segments are submitted the Prior Authorization REF*G1 segment is used. x x x n/a For LNI 208

209 5010 Change Summary 2300 Loop Claim Information CLM continued PAYER CLAIM CONTROL NUMBER REF*F8 Segment/Element Description P 837I of Change REF - Payer Claim x x Control Number REF-REF01 F8 F8 x x Reference ID Qualifier REF-REF02 17-digit 17-digit x x Reference Identification: Internal Control Number (ICN) ICN assigned to bill & returned on provider s remittance advice ICN assigned to bill & returned on provider s remittance advice New/Added: Implemented segment for processing request for electronic adjustment Replacement and Void. CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES REF*D9 REF - Claim Situational: Identifier for Submitted at Transmission Clearinghouse Intermediaries discretion REF-REF01 Reference ID Qualifier REF-REF02 Reference Identification: Value Added Network Trace Number Not applicable in LNI processing of 4010 transactions D9 x x Clearinghouse trace number New/Added: The department now accepts and processes this segment in the 5010 transaction and returns the Clearinghouse Value Added Network Trace Number submitted in this segment back to the Submitter in the 277 Notification (5010) REF*D9 REF02. x x x x 209

210 5010 Change Summary 2300 Loop Claim Information CLM Segment/Element Description of Change HI Health Care Usage change Diagnosis Code to Required segment from HI01-1 Diagnosis Type Code Principle Diagnosis HI02-1 H12-1 Additional Diagnosis HI01-1 Diagnosis Type Code Principle Diagnosis HI01-1 Admitting Diagnosis HI01-1 Patient s Reason for Visit HI01-1 External Cause of Injury Situational Value change Added ABK Value change Added ABK Value change Added ABK Value change Added ABJ Value change Added ABJ Value change Added ABN P 837I Required Situational x Values: BK, ABK BK x Values: BF, ABF BF x Values: BK, ABK BK x Values: BJ, ABJ BJ x Values: PR, APR ZZ x Values: BN, ABN BN x A 2310F Loop 2310A 2310F REFERRING PROVIDER NAME NM1*DN Segment/Element Description of Change P 837I NM1-NM108 Identification Code Qualifier NM1-NM109 Referring Provider Primary Identifier REF - Referring Provider Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Referring Provider Secondary ID PRV Referring Provider Specialty Information 837 Professional Value change Deleted 24, 34 Value change Value change to G2 from X5 Usage change Segment deleted Situational XX Situational Referring provider NPI Situational 24, 34 or XX Situational Referring provider EIN, SSN or NPI Situational Situational x x G2 X5 deleted Referring Provider s LNI Provider account number X5 x x Referring Provider s LNI Provider account number Usage: Deleted Usage: Situational x x 837 Institutional - Name changed to 2310F Referring Provider from 2310D Referring Provider x x x x x x 210

211 5010 Change Summary B 2310D Loop 2310B 2310D RENDERING PROVIDER NAME NM1*82 Segment/Element Description of Change P 837I NM1-NM108 Identification Code Qualifier NM1-NM109 Rendering Provider Primary Identifier PRV Rendering Provider Specialty Information PRV-PRV02 Reference Identification Qualifier REF - Rendering Provider Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Rendering Provider Secondary ID 837 Professional Usage change to Situational from Required Value change Deleted 24, 34 Value change Value change Added PXC Deleted - ZZ Value change to G2 from X5 Situational XX Situational Rendering provider NPI Required 24, 34 or XX Required Rendering provider EIN, SSN or NPI Situational Situational x x PXC ZZ x x Situational Situational x G2 X5 deleted Rendering Provider s LNI Provider account number X5 Rendering Provider s LNI Provider account number 837 Institutional New segment in Not utilized for LNI Institutional billing x x x x x 211

212 5010 Change Summary C 2310E Loop 2310C 2310E SERVICE FACILITY LOCATION NAME NM1*77 Segment/Element Description of Change P 837I NM1-NM101 Entity Identifier Code NM1-NM108 Identification Code Qualifier NM1-NM109 Service Facility Primary Identifier N4-N402 Service Facility Location State N4-N403 Service Facility Location Zip code PRV Service Facility Specialty Information REF Service Facility Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Service Facility Secondary ID Value Change To 77 from FA in 837I Value change Deleted 24, 34 Value change Usage change to Situational from Required Usage change to Situational from Required Usage change Segment deleted Value change To G2 from X5 77 FA x Situational XX Situational Service Facility NPI Required 24, 34 or XX Required Service Facility EIN, SSN or NPI Situational Required x x Situational Required x x Usage: Deleted Usage: Situational NA x Situational Situational x G2 X5 deleted Service Facility LNI Provider account number 837 Professional Name changed to 2310C from 2310D 837 Institutional X5 Service Facility LNI Provider account number x x x x x 212

213 5010 Change Summary A Loop ATTENDING PHYSICIAN NAME NM1*71 Segment/Element Description P 837I of Change NM1-NM108 Identification Code Qualifier Usage change to Situational from Required Value change Deleted 24, Situational XX Required 24, 34 or XX x NM1-NM109 Billing Provider Primary Identifier PRV Attending Physician Specialty Information PRV-PRV02 Reference Identification Qualifier REF Attending Physician Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Attending Physician Secondary ID 34 Value change Value change Added PXC Deleted - ZZ Value change to G2 from X5 Situational Attending Physician NPI Situational Attending Physician EIN, SSN or NPI Situational Situational x PXC ZZ x Situational Situational x G2 X5 deleted Attending Physician s LNI Provider account number X5 Attending Physician s LNI Provider account number x x x 213

214 5010 Change Summary B Loop OPERATING PHYSICIAN NAME NM1*72 Segment/Element Description P 837I of Change NM1-NM108 Identification Code Qualifier Usage change to Situational from Required Value change Deleted 24, Situational XX Required 24, 34 or XX x NM1-NM109 Operating Physician Primary Identifier PRV Operating Physician Specialty Information PRV-PRV02 Reference Identification Qualifier REF Operating Physician Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Operating Physician Secondary ID 34 Value change Value change Added PXC Deleted - ZZ Value change to G2 from X5 Situational Operating Physician NPI Required Operating Physician EIN, SSN or NPI Situational Situational x PXC ZZ x Situational Situational x G2 X5 deleted Operating Physician s LNI Provider account number X5 Operating Physician s LNI Provider account number x x x 214

215 5010 Change Summary C Loop OTHER OPERATING PHYSICIAN NAME NM1*ZZ Segment/Element Description P 837I of Change NM1-NM101 Entity Identifier Code Value Change To ZZ from 73 ZZ 73 x NM1-NM108 Identification Code Qualifier NM1-NM109 Other Operating Physician Primary Identifier PRV Other Operating Physician Specialty Information REF Other Operating Physician Secondary Identification REF-REF01 Reference Identification Qualifier REF-REF02 Other Operating Physician Secondary ID Usage change to Situational from Required Value change Deleted 24, 34 Value change Usage change Segment deleted Value change to G2 from X5 Situational XX Situational Other Operating Physician NPI Required 24, 34 or XX Required Other Operating Physician EIN, SSN or NPI Usage: Not Used Usage: Situational x Situational Situational x G2 X5 deleted Other Operating Physician s LNI Provider account number X5 Other Operating Physician s LNI Provider account number 837 Institutional Name changed to Other Operating Physician Name from Other Provider Name x x x x 215

216 5010 Change Summary 2400 Loop SERVICE LINE NUMBER Segment/Element Description of Change SV101-1 Value Change Product/Service ID to ER from ZZ. Qualifier Used to specify billing of LNI Local SV202-1 Product/Service ID Qualifier SV107 Composite Diagnosis Code Pointer SV504 DME Rental Price SV505 DME Purchase Price SV506 Rental Unit Price Indicator Codes Value Change to ER from ZZ. Used to specify billing of LNI Local Codes Usage Change to Required from Situational Usage Change to Required from Situational Usage Change to Required from Situational Usage Change to Required from Situational P 837I ER ZZ deleted ER ZZ deleted ZZ ZZ Required Situational x Required Situational x Required Situational x Required Situational x x x 216

217 The following information is a change summary of changes implemented for LNI EDI 835 and 277 transaction processing supporting the 5010 transaction format from 4010 format. 835 Payment Advice Change Summary Loop Segment/Element Description of Change ISA ISA11 Element name/usage Header changed in ISA Header GS Header ISA12 Interchange Control Version Number GS08 Version Release Industry ID Code Element name: Repetition Separator. ^ (Caret) Element name: Interchange Control Standards Identifier. U Value change Value change. Values: X221A1 Values: X091A1 1000A Loop PAYER IDENTIFICATION N1*PR Segment/Element Description of Change PER Payer Technical Contact Information Required segment added PER*BL NA PER Payer Web Site Information Situational segment added PER*IC NA 2100 Loop CLAIM PAYMENT INFORMATION Segment/Element Description of Change REF Original Added segment REF*F8 REF*F8 Reference Number Segment is returned when ICN (Payer Claim Control Number) identified in CLP07 is request for electronic adjustment Replacement or Void. AMT Claim Supplemental Information Segment AMT01 Amount Value change. Value ZZ Qualifier Code deleted?? ZZ mutually defined 2110 Loop SERVICE PAYMENT INFORMATION Segment/Element Description of Change SVC01-11 Service Utilize value ER ER ER ID Qualifier Return value ER for identification of LNI Local Billing Codes submitted via 837 SV101-1 ER 5010, and ZZ Past files do not include the use of ER qualifier. 217

218 277 Notification Change Summary Loop Segment/Element Description of Change ISA ISA11 Element name/usage Header changed in ISA Header GS Header ISA12 Interchange Control Version Number GS08 Version Release Industry ID Code Element name: Repetition Separator. ^ (Caret) Element name: Interchange Control Standards Identifier. U Value change Value change. Values: X214 Values: X D Loop CLAIM STATUS TRACKING CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES REF*D9 Segment/Element Description of Change REF - Claim Identifier for Transmission Intermediaries Segment usage added Situational: Submitted at Clearinghouse discretion Situational: Not utilized in LNI 3070 format REF-REF01 Reference ID Qualifier REF-REF02 Reference Identification: Value Added Network Trace D9 Clearinghouse trace number D9 Clearinghouse trace number Number New/Added: The department now accepts and processes this segment in the 5010 transaction and returns the Clearinghouse Value Added Network Trace Number submitted in this segment back to the Submitter in the 277 Notification (5010) REF*D9 REF

219 Version Chart The version chart below will assist you in selecting the correct LNI Companion Guide for the ASC X12N 837 format you intend to use for your transactions. Each companion guide contains the entire business and format information you will need to submit your medical billings electronically and retrieve electronic remittance advices. ASC X12N 837 Version Labor and Industries Companion Guide Date Issued X222A1 - Professional Version 1.0 October X223A2 - Institutional Version 1.0 October X224A2 - Dental Not Supported ASC X12N 837 Version Labor and Industries Companion Guide Date Issued X098A1 - Professional Version 3.0 March X096A1 - Institutional Version 3.0 March X097A1 - Dental Not Supported March