Minnesota Uniform Companion Guide

005010X222A1 Health Care Claim: Professional (837), v. 4.0 with Changes Adopted May MINNESOTA DEPARTMENT OF HEALTH DIVISION OF HEALTH POLICY CENTER FOR HEALTH CARE PURCHASING IMPROVEMENT Minnesota Uniform Companion Guide For the Implementation of the ASC X12/005010X222A1 HEALTH CARE CLAIM: PROFESSIONAL (837) Prepared In Consultation With Minnesota Administrative Uniformity Committee MAY VERSION 4.0

005010X222A1 Health Care Claim: Professional (837), v. 4.0 with Changes Adopted May Disclaimer The following Minnesota Uniform Companion Guide is intended to serve as a companion document to the corresponding ASC X12/005010X222A1 Health Care Claim: Professional (837). The document further specifies the requirements to be used when preparing, submitting, receiving and processing electronic health care administrative data. The document supplements, but does not contradict, disagree, oppose, or otherwise modify the 005010X222A1 in a manner that will make its implementation by users to be out of compliance. Using this Companion Guide does not mean that a claim will be paid. It does not imply payment policies of payers or the benefits that have been purchased by the employer or subscriber. Statutory Authority Development, adoption and use of this companion guide is mandated for all group purchasers and health care providers under Minnesota Statutes, 62J.536. The required use of this Minnesota Uniform Companion Guide was promulgated as a rule under Minnesota Statutes, 62J.61. Document Changes The content of this companion guide is subject to change. The version, release and effective date of the document is included in the document, as well as a description of the process for handling future updates or changes. About the Minnesota Department of Health The Minnesota Department of Health is responsible for protecting, maintaining and improving the health of Minnesotans. The department operates programs in the areas of disease prevention and control, health promotion, community public health, environmental health, health care policy, and registration of health care providers. http://www.health.state.mn.us/asa/index.html About the Minnesota Administrative Uniformity Committee The Administrative Uniformity Committee (AUC) is a broad-based group representing Minnesota health care public and private payers, hospitals, health care providers and state agencies. The mission of the AUC is to develop agreement among Minnesota payers and providers on standardized administrative processes when implementation of the processes will reduce administrative costs. The AUC acts as a consulting body to various public and private entities, but does not formally report to any organization and is not a statutory committee. http://www.health.state.mn.us/auc/index.html Contact for Further Information on this Companion Guide Minnesota Department of Health Division of Health Policy Center for Health Care Purchasing Improvement P.O. Box 64882 St. Paul, Minnesota 55164-0882 Phone: (651) 201-3570 Fax: (651) 201-5179 Internet: Health.ASAGuides@state.mn.us Copyright 2010 By The Minnesota Department of Health, State of Minnesota

TABLE OF CONTENTS Page 1.0 COMPANION GUIDE REVISION HISTORY 4 2.0 STATEMENT FROM THE MINNESOTA DEPARTMENT OF HEALTH 5 3.0 STATEMENT FROM THE MINNESOTA ADMINISTRATIVE UNIFORMITY COMMITTEE (MN-AUC) 7 4.0 INTRODUCTION AND OVERVIEW 8 4.1 PURPOSE AND OVERVIEW 8 4.2 INFORMATION ABOUT THE HEALTH CARE CLAIM: PROFESSIONAL (837) TRANSACTION 13 4.3 PROCESS FOR UPDATING COMPANION GUIDE DOCUMENT 18 4.4 MINNESOTA BEST PRACTICES FOR THE IMPLEMENTATION OF ELECTRONIC HEALTH CARE TRANSACTIONS 18 5.0 HEALTH CARE CLAIM: PROFESSIONAL (837): MINNESOTA UNIFORM COMPANION GUIDE TABLE 19 5.1 INTRODUCTION TO TABLE 19 5.2 COMPANION GUIDE TABLE 21 6.0 APPENDICES 32 APPENDIX A: MEDICAL CODE SET SUPPLEMENTAL INFORMATION FOR MINNESOTA UNIFORM COMPANION GUIDES 33 APPENDIX B: K3 SEGMENT USAGE 60 APPENDIX C: REPORTING MNCare TAX 61 3

1.0 Companion Guide Revision History Version Revision Date Summary Changes 1.0 February 8, 2010 Version Released for Public Comment 2.0 May 24, 2010 Final Published Version for Implementation 3.0 February, Incorporates Proposed Technical Changes and Updates to v 2.0 4.0 May Incorporates All Changes Adopted to v. 2.0 4

Protecting, maintaining and improving the health of all Minnesotans 2.0 Statement from the Minnesota Department of Health Summary Notice of Adoption of Rules Regarding the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837); Pursuant to Minnesota Statutes, Section 62J.536. Adoption: Notice is hereby given that the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837), as proposed at State of Minnesota State Register, Volume 34, Number 32, page 1079, February 8, 2010, (34 SR 1079) is adopted with modifications. Companion Guide Available: The Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837), as defined by the Commissioner of Health, is available on the World Wide Web at http://www.health.state.mn.us/asa/rules.html and at Minnesota s Bookstore at (651) 297-3000 or (800) 657-3757. The Minnesota s Bookstore TTY relay service phone number is (800) 627-3529. If you have any questions, please email health.asaguides@state.mn.us. The adopted rule differs from the rule proposed on February 8, 2010. A complete copy of the rule showing all of the changes in a strike/underline format is available at: http://www.health.state.mn.us/asa/rules.html. Interested parties may also obtain a printed copy of the rule showing all of the changes in a strike/underline format by contacting Mayumi Reuvers via e- mail at mayumi.reuvers@state.mn.us or by phone at 651-201-5508 or fax at: (651) 201-5179. Description and Statutory Reference: Minnesota Statutes, section 62J.536, requires the Minnesota Commissioner of Health, in consultation with the Minnesota Administrative Uniformity Committee (AUC), to promulgate rules pursuant to section 62J.61 establishing and requiring group purchasers and health care providers to use electronic claims and eligibility transactions with a single, uniform companion guide to the implementation guides described under Code of Federal Regulations, title 45, part 162. At present, all Minnesota health care providers and group purchasers subject to Minnesota Statutes, section 62J.536 must use Version ASC X12/004010A1 ( Version 4010A1 ) of the Minnesota Uniform Companion Guides. As further discussed below, in order to comply with recent federal regulations, new versions of the Minnesota Uniform Companion Guides, (Version ASC X12/005010, also referred to as Version 5010 ), are being adopted for use no later than January 1, 2012. 5

On January 16, 2009, the U.S. Department of Health and Human Services (HHS) published rules (CMS 0009 F) announcing the adoption of new versions of the federal transaction standards, known as ASC X12/005010 ( Version 5010 ). As a result, MDH, in consultation with the AUC, has adopted the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837) in order to be consistent with the federal regulations as cited above. The health care claims or equivalent encounter information transaction is the transmission of either of the following: a. A request to obtain payment, and the necessary accompanying information from a health care provider to a group purchaser, for health care. b. If there is no direct claim, because the reimbursement contract is based on mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care. Health care providers and group purchasers subject to Minnesota Statutes, section 62J.536 must exchange transactions covered by the statute as follows. From the date of each Version 5010 Uniform Companion Guides final adoption until January 1, 2012, providers and group purchasers may use only: the Minnesota Uniform Companion Guides, Version ASC X12N/004010A1 (Version 4010), including any subsequent technical changes or updates; or, by mutual agreement between trading partners, the Minnesota Uniform Companion Guides, Version ASC X12/005010 (Version 5010). Beginning January 1, 2012, providers and group purchasers may only use the Minnesota Uniform Companion Guides, Version ASC X12/005010 (Version 5010), including this Guide, the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837). Development: The Commissioner of Health developed this rule in consultation with the AUC and its Claims Data Definition Technical Advisory Group (TAG). This rule was submitted for public comment in the State Register, Volume 34, Number 32, page 1079, February 8, 2010. The comment period was from February 8, 2010 through March 10, 2010. MDH consulted with the AUC Claims Data Definition TAG in reviewing comments and in making modifications to the rule proposed on February 8, 2010. Required Date of Compliance: As described above, the required date of compliance is no later than January 1, 2012. Dated: May 24, 2010 Sanne Magnan, M.D., Ph.D. Commissioner P.O. Box 64975 St. Paul, MN 55164-0975 6

3.0 Statement from the Minnesota Administrative Uniformity Committee (MN-AUC) Administrative Uniformity Committee C/O Minnesota Department of Health P.O. Box 64882 St. Paul, MN 55162-0882 health.auc@state.mn.us December, 2009 The 2007 Minnesota Legislature amended the Minnesota Health Care Administrative Simplification Act (Minnesota Statutes, 62J.50-62J.61) by adding 62J.536, entitled Uniform Electronic Transactions and Implementation Guide Standards. This section requires all group purchasers and health care providers to electronically transmit and accept eligibility verification, claims and remittance advice transactions using a single uniform companion guide. The Commissioner of Health is required to base the companion guides billing, coding rules, and standards on the Medicare program and to consult with the Minnesota Administrative Uniformity Committee (AUC) in the development of the uniform companion guides. The AUC is a broad-based group representing Minnesota health care public and private group purchasers, hospitals, physicians, other providers and State agencies. The goal of the AUC is to reduce administrative costs for both payers and providers by standardizing their administrative processes and requirements. The AUC is made up of a Strategic Steering Committee, an Operations Committee, and various Technical Advisory Groups (TAGs), and Work Groups. Minnesota Statutes, 62J.536 builds upon Minnesota s already significant leadership in health care administrative simplification. The AUC is confident that the Minnesota approach will provide more efficient communication of administrative health care information between payers and providers throughout the state. This Health Care Claim Transaction Companion Guide was developed by the AUC Claims Data Definition TAG. The TAG reviewed and considered the ASC X12/005010X222A1 Health Care Claim: Professional (837) and recommended clarifications to it where Minnesota providers and payers deemed it appropriate. As part of its responsibility of consultation, the AUC Operations Committee presented recommendations for content of this Minnesota Companion Guide to the Commissioner of Health on January 12, 2010. The AUC also recommended that this companion guide be reviewed and updated approximately every 12 months or more often if deemed necessary by the Commissioner of Health in consultation with the AUC. The AUC will continue to work in partnership with the Commissioner of Health to improve the clarity and usefulness of the manual. 7

4.0 Introduction and Overview 4.1 Purpose and Overview 4.1.1 Purpose The purpose of this Companion Guide is to clarify, supplement and further define specific data content requirements to be used in conjunction with the ASC X12/005010X222A1 Health Care Claim: Professional (837) created for the electronic transaction standard mandated by the HIPAA regulations. The terms companion guide, guide, state companion guide and state guide are used interchangeably throughout this document to refer to each single, uniform companion guide being created pursuant to Minnesota Statutes, 62J.536. 4.1.2 Applicability Effective July 15, 2009, all group purchasers licensed or doing business in Minnesota and health care providers providing services for a fee in Minnesota must exchange health care claims electronically using the transactions, companion guides, 005010X222A1, and timelines required under Minnesota Statutes, section 62J.536. The only exceptions to the statutory requirements are as follow: The requirements do NOT apply to the exchange of health care claim transactions with Medicare and other payers for Medicare products; and See section 4.1.2.1 Exceptions to Applicability below. Minnesota Statutes, Section 62J.03, Subd. 6 defines group purchaser as follows: "Group purchaser" means a person or organization that purchases health care services on behalf of an identified group of persons, regardless of whether the cost of coverage or services is paid for by the purchaser or by the persons receiving coverage or services, as further defined in rules adopted by the commissioner. "Group purchaser" includes, but is not limited to, community integrated service networks; health insurance companies, health maintenance organizations, nonprofit health service plan corporations, and other health plan companies; employee health plans offered by self-insured employers; trusts established in a collective bargaining agreement under the federal Labor-Management Relations Act of 1947, United States Code, title 29, section 141, et seq.; the Minnesota Comprehensive Health Association; group health coverage offered by fraternal organizations, professional associations, or other organizations; state and federal health care programs; state and local public employee health plans; workers' compensation plans; and the medical component of automobile insurance coverage. Minnesota Statutes, Section 62J.03, Subd. 8 defines provider or health care provider as follows: 8

"Provider" or "health care provider" means a person or organization other than a nursing home that provides health care or medical care services within Minnesota for a fee and is eligible for reimbursement under the medical assistance program under chapter 256B. For purposes of this subdivision, "for a fee" includes traditional feefor-service arrangements, capitation arrangements, and any other arrangement in which a provider receives compensation for providing health care services or has the authority to directly bill a group purchaser, health carrier, or individual for providing health care services. For purposes of this subdivision, "eligible for reimbursement under the medical assistance program" means that the provider's services would be reimbursed by the medical assistance program if the services were provided to medical assistance enrollees and the provider sought reimbursement, or that the services would be eligible for reimbursement under medical assistance except that those services are characterized as experimental, cosmetic, or voluntary. Minnesota Statutes, Section 62J.536, Subd. 3 defines "health care provider" to also include licensed nursing homes, licensed boarding care homes, and licensed home care providers. As described in the beginning of this section, this Minnesota Uniform Companion Guide applies to all professional health care claims submitted electronically after July 15, 2009 that use the transaction standard and corresponding 005010X222A1 described under Code of Federal Regulations, title 45, part 162, subpart K - the ASC X12/005010X222A1 Health Care Claim: Professional (837), herein referred to as 005010X222A1. The Companion Guide applies ONLY to the purposes identified and described in the 005010X222A1 for which the health care claims transaction is used. Entities conducting (e.g., submitting or receiving) professional health care claim transactions electronically via direct data entry system (e.g., internet-based interactive applications) must also comply with the data content requirements established in this Companion Guide. This Companion Guide contains the maximum data set of values allowed to be submitted or received by health care providers and group purchasers when conducting a professional health care claim transaction. No other Data Element values will be allowed to be used in connection with this transaction. If information is submitted on the 005010X222A1 that is needed to adjudicate, then it must be utilized. A group purchaser may not make additional requirements of the provider to submit the information in another format or in a different element or position than that defined in the 005010X222A1 and the Minnesota Companion Guide. Consistent with Minnesota Statutes, 62J.536, no additions or modifications may be made to this Companion Guide by group purchasers or health care providers through their own companion guides or by establishing other requirements. 4.1.2.1 Exceptions to Applicability Chapter 305, section 7, of 2008 Minnesota Laws (to be codified as Minnesota Statutes, section 62J.536, subd. 4) authorizes the Commissioner of Health to exempt group purchasers not covered by HIPAA (group purchasers not covered 9

under United States Code, title 42, sections 1320d to 1320d-8) from one or more of the requirements to exchange information electronically as required by Minnesota Statutes, 62J.536 if the Commissioner determines that: i. a transaction is incapable of exchanging data that are currently being exchanged on paper and is necessary to accomplish the purpose of the transaction; or ii. another national electronic transaction standard would be more appropriate and effective to accomplish the purpose of the transaction. If group purchasers are exempt from one or more of the requirements, providers shall also be exempt from exchanging those transactions with the group purchaser. The Commissioner has determined that the criteria above are not met and that all health care providers and group purchasers are required to comply with these rules for the standard, electronic exchange of health care claims. No exception to these rules has been granted. 4.1.3 Scope This Companion Guide covers all the required and situational Loops, Segments and Data Elements contained in the Reference 005010X222A1. This Companion Guide does NOT include any of the Loops, Segments or Data Elements defined as NOT USED in the Reference 005010X222A1. Consistent with the HIPAA requirements and 005010X222A1 instructions, the NOT USED Loops, Segments and Data Elements are not permitted to be submitted or received when conducting this transaction. This Companion Guide excludes any of the EDI transmission instructions, generally defined in trading partner agreement documents. The Interchange Control Header (ISA) and Trailer (IEA), and the Functional Group Header (GS) and Trailer (GE) are not covered by this Companion Guide. The specifications of these Loops, Segments and Data Elements are generally defined in trading partner agreement documents. 4.1.4 ASC X12/005010X222A1 Health Care Claim: Professional (837) The reference for this Companion Guide is the ASC X12/005010X222A1 Health Care Claim: Professional (837) (Copyright 2008, Data Interchange Standards Association on behalf of ASC X12. Format 2008, Washington Publishing Company. All Rights Reserved). A copy of the full 005010X222A1 can be obtained from the Washington Publishing Company at http://www.wpc-edi.com. 4.1.5 Key Terminology Used in This Companion Guide 10

This Companion Guide treats the required and situational Loops, Segments and Data Elements included in the 005010X222A1 as described in the following sections. 4.1.5.1 Required Loops, Segments and Data Elements In some instances, the values and conditions defined in the 005010X222A1 for required Loops, Segments and Data Elements are further clarified by the Companion Guide. Such further clarifications are appropriately noted in the Companion Guide table included in Section 5. Under no circumstance does the Companion Guide add new or different values to those defined in the Reference 005010X222A1. 4.1.5.2 Situational Loops, Segments and Data Elements The Companion Guide further defines or refines the conditions and values of Situational Loops, Segments and Data Elements to one of the following three possibilities: o o Required, with further definition of condition and/or values: This means that in Minnesota, group purchasers do consider and need this data for proper adjudication of the transaction and that the Loop, Segment and Data Element will be REQUIRED for ALL values further defined in the Minnesota Companion Guide. Situational, with or without further definition of condition: This means that the Loop, Segment or Data Element will retain in the Minnesota Companion Guide the original Situational classification given in the 005010X222A1, and that the Minnesota Companion Guide will follow either: The exact same conditions and values defined in the 005010X222A1 (because the conditions and values are closeended, unambiguous, and straight-forward); or A set of further refined conditions and values applicable to that Situational Loop, Segment or Data Element. o Not Considered for Processing: see next section. 4.1.5.3 Segments and Data Elements Classified as Not Considered for Processing (NCFP) Required and Situational Segments and Data Elements may also be classified in the Minnesota Companion Guide as Not Considered for Processing. This means that receivers of this transaction in Minnesota do not consider these Segments or Data Elements necessary for adjudication of the transaction for services covered under this companion guide. 11

With respect to these NCFP Segments and Data Elements, the interpretation of this classification will be as follows: o o If the Segment or Data Element is REQUIRED by the 005010X222A1 and the Minnesota Usage in the table included in Section 5 of this Companion Guide is NCFP, then the Segment or Data Element must be sent by the sender and received by the receiver (to meet HIPAA requirements) but the receiver may ignore it for adjudication. If the Segment or Data Element is SITUATIONAL in the 005010X222A1 and the Minnesota Usage in the table included in Section 5 of this Companion Guide is NCFP, then the Segment or Data Element: Will not be required by a receiver May be submitted by a sender Will be accepted by a receiver May be ignored by the receiver for adjudication The receiver will not reject transaction if sender submits this element It is important to note that the parameters of Situational elements in the 005010X222A1 are generally written in a manner that creates a requirement for the element to be used (if such conditions are met). Please refer to the disclaimer in the front matter of this guide. 4.1.6 Addressing Code Set Issues in the Companion Guide Code sets utilized in HIPAA electronic transactions are classified as: Internal Transaction Codes (included and defined inside the 005010X222A1). The Companion Guide may define a set of values that are identical to or a subset of the values permitted in the 005010X222A1. Within the Companion Guide there are situations where only a subset of values is permitted. As business needs change, additional codes may be defined and made available for use as a best practice. Please refer to Section 4.4 for information on AUC Best Practices. External Code Sets (referenced by 005010X222A1, defined and maintained by external bodies) including: 1) Non-Medical External Code Sets (such as Taxonomy Codes, Claims Adjustment Reason Codes, Remark Codes, etc). These values are effective based upon transaction date; 2) Medical External Code Sets (such as ICD-9, ICD-10, HCPCS). These values are effective based upon service date 12

This Companion Guide does not redefine existing external code sets used in the transactions. Rather, the Companion Guide may identify a subset of external codes to be used in specific Loops, Segments and Data Elements of the transaction. For information regarding clarification of medical code set usage see Appendix A. 4.1.7 Trading Partner Agreements This Companion Guide is not intended to replace trading partner agreements that define other transaction parameters (such as EDI transmission parameters or transaction header information). Trading partner agreements may NOT add or modify the requirements established by this Companion Guide. Trading Partners will exchange the appropriate and necessary identification numbers to be reported in Loops 1000A and 1000B (Submitter and Receiver). 4.2 Information About the Health Care Claim: Professional (837) Transaction 4.2.1 Business Terminology 1 For purposes of this Companion Guide, the following terms have the meaning given to them in this section. Definitions used apply at both the claim and line level. For other definitions related to the professional health care claim, please refer to section 1.5 of the 005010X222A1. Provider Definitions Billing Provider The Billing Provider must be a health care or service provider. Information concerning a billing agent or a healthcare clearinghouse may never be reported in the billing provider loop. Please refer to the 005010X222A1 for more billing provider and other types of provider requirements. Billing Provider Name: Titles must not be used as part of the name as there is a separate field to report titles. If enrolled with the payer, the Billing Provider Name must match the enrollment with the payer. Billing Provider Address: 1 Sources: 005010X222A1; National Uniform Billing Committee UB04 Manual. Cited with permission. 13

U.S. Postal Addressing Standards the address must meet the U.S. Postal addressing standards. Ordering Provider This is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician s or non-physician practitioner s service. Loop 2310A should be used to report the ordering provider when applicable. Pay-To Address Other Definitions The Pay-To Address loop allows the billing provider to indicate a payment address that is different than the billing. For providers who participate with the group purchaser health plan and are required to complete enrollment forms as part of the contracting process, the payment address submitted on the claim transaction may not be the address where payment is ultimately sent for the claim. The payer in this case may use the payment address from the enrollment form or within the contract rather than the address that is submitted in the 2010AB loop of an electronic claim. The contracted provider must request address changes to the payer records according to the instructions within the provider contract. When a Pay-To Address loop is sent in addition to billing provider loop, it is the pay-to loop address where the payment should be sent, unless the payer utilizes an enrollment form or a contract. Factoring Agent Business models exist in the healthcare industry where services are performed by a provider, which are billed to an entity acting as a receivables Factoring Agent. The entity pays the provider directly. The Factoring Agent then bills the insurance company. In this case both the name/address of Pay-To are different than Billing Provider. In order to use the 005010X222A1 for this business situation, X12 recommends that the Factoring Agent entity name, address, and identification be submitted as the Pay-To Plan in loop 2010AC. The notes and guidelines should be followed as if the Pay-To Plan entity was performing post payment recovery as described. Other Payer The term other payer indicates any payer who is not the destination payer. The other payer may be the primary, secondary, tertiary, or even quaternary payer. Patient The term patient as used in this Companion Guide is intended to convey the case where the Patient loop (Loop ID-2000C) is used. In that case, the patient is 14

not the same person as the subscriber and can not be uniquely identified separately from the subscriber. However, it also happens that the patient is sometimes the same person as the subscriber. In that case, all information about the patient/subscriber is carried in the Subscriber loop (Loop ID-2000B). See Section 1.5 of the 005010X222A1 for further details. Pay-To Plan In addition to the definition in the 005010X222A1, business models exist in the healthcare industry where services are performed by a provider, which are billed to an entity acting as a receivables Factoring Agent. The entity pays the provider directly. The Factoring Agent then bills the insurance company. In this case both the name and address of Pay-To are different than the Billing Provider. The Factoring Agent name will be placed in the Pay-To Plan loop. Subscriber The subscriber is the person or entity whose name is listed on the insurance policy. Other synonymous terms include member and/or insured. In some cases the subscriber is the same person as the patient. See the definition of patient, and see Section 1.5 of the 005010X222A1 for further details. 4.2.2 Provider Identifiers and NPI Assignments Provider Identifiers If the provider is a health care provider as defined under federal standards, then the only identifier that is valid is the NPI with the exception of the billing loop. For the billing provider, a secondary identifier of the TIN is also required. If the provider is not a health care provider as defined under federal standards they are known as atypical providers. Atypical providers do meet the Minnesota statutory definition of health care provider and therefore are required to utilize the electronic administrative transactions for eligibility, claims and remittance advices. For atypical providers, the primary identifier is the TIN and a secondary identifier is allowable. The qualifier for the secondary identifier is G2. The identifier for this qualifier would be the specific payer assigned/required identifier. 4.2.3 Minnesota Requirements for Compliance This section contains general Minnesota requirements for compliance applicable to this transaction. 4.2.3.1 Handling Adjustments and Appeals Determination of Action: 15

When determining whether to resubmit a claim as an original, request an adjustment or request an appeal, first determine whether the payer has accepted and adjudicated the original claim submission. If the original submission was not accepted into the payer adjudication system, resubmit the claim as an original. This is not considered to be an adjustment. If the original submission was accepted into the payer adjudication system, see definitions below to determine whether an adjustment or appeal should be requested. Definitions: Adjustment Provider has additional data that should have been submitted on the original claim or has a need to correct data that was sent incorrectly on the original claim. Appeal Provider is requesting a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted. Therefore the submission of the appeal is not covered by this guide. Examples of Appeals include: o o o o o o Timely filing denial Payer allowance Incorrect benefit applied Eligibility issues Benefit Accumulation Errors Medical Policy / Medical Necessity Process for submission: Adjustment Provider should submit an adjustment electronically using the appropriate value in CLM05-3 to indicate that this is a replacement claim. If the payer has assigned a payer number to the claim, it must be submitted in loop 2300, REF02, using qualifier F8 in REF01 (Note: the original payer-assigned claim number is not the property and casualty number). If additional information is required to support the adjustment based on payer business rules, the SV101-7, NTE segment, PWK segment, or Condition Codes should be used. See section 4.2.3.3 below regarding these segments for appropriate instructions. Appeal Follow payer standard processes for requesting an appeal to a previously adjudicated claim. If paper appeal process is utilized, then a standard, Best Practice Minnesota appeal form is available at the AUC website at http://www.health.state.mn.us/auc/index.html. Additional documentation should be sent as required by the payer to support the appeal consideration; this documentation does not include resubmission of the claim. 4.2.3.2 Claim Frequency Type Code (CFTC) Values 16

Claim/Bill submissions are often original, first time submissions with no follow-up submissions. In some cases, subsequent submissions directly related to a prior submission will be necessary. When subsequent submissions occur, for legitimate business purposes, the normal processing flow may change. Since a relationship between an original submission and subsequent submissions are necessary, the data requirements both for original and subsequent submissions must be specified. For example, when a Replacement bill is submitted (CFTC 7), in order to meet the processing requirement to void the original and replace it with the re-submitted bill, common consistent data elements would be required. To qualify as a Replacement, some data would need to be different than the original. If the bill is re-submitted with no changes from the original, and the claim was accepted by the payer, this would be considered a Duplicate instead of a Replacement. If the bill is resubmitted with no changes from the original and the original was not accepted by the payer, this will be considered an original claim. These distinctions are important to allow for proper handling of the submission. Refer to the current National Uniform Billing Committee (NUBC) code list for allowed values and usage descriptions. Both the sender and receiver must understand how each code value should be interpreted and what processing requirements need to be applied. In conjunction with the CFTC code values, Condition Codes may be submitted that will impact processing and handling requirements. For example, a Replacement bill (CFTC 7) may also contain a Condition Code D0 indicating service dates have been changed. 4.2.3.3 Claim Attachments and Notes Use the NTE segment at the claim or line level to provide free-form text of additional information. The NTE segment must not be used to report data elements that are codified within this transaction. If reporting a simple description of the service is required, such as when a non-specific code is being reported, the SV101-7 in the 2400 loop must be used. Do not exceed the usage available in the 005010X222A1. Be succinct and abbreviate when possible. Do not repeat code descriptions or unnecessary information. If the NTE segment must be exceeded, or a hard copy document sent, use the PWK segment at the claim level. If the number of characters for the NTE or SV101-7 will exceed available characters, use only the PWK segment at the claim level. When populating the PWK segment, the following guidelines must be followed: o PWK01 - Attachment Report Type Code is a required element: The qualifier value of OZ should only be used if none of the other values apply. The most specific qualifier value must be utilized. 17

o PWK06 - Attachment Control Number is a situational element that is required if the transmission type is anything other than available upon request. This value is used to identify the attachment. Billing providers must use a unique number for this field for each individual attachment on the claim, as well as, a unique number across all claims requiring attachments. This unique number identifies a specific attachment within the billing providers system. This unique number is the key that associates the attachment to the claim. The number must be sent in PWK06 of the claim and with the attachment. The provider must not use the same number on any other claim in their system to identify different attachments. 4.3 Process for Updating Companion Guide Document The process for updating Minnesota Uniform Companion Guide documents, including submitting and collecting change requests, reviewing and evaluating requests and making recommendations, adopting and publishing a new version of the guide is available from the Minnesota Department of Health s website at http://www.health.state.mn.us/asa/index.html. 4.4 Minnesota Best Practices for the Implementation of Electronic Health Care Transactions The Minnesota Administrative Uniformity Committee (MN AUC) is continuously working on the identification of Best Practices for the implementation of administrative transactions and processes. Although they are not required as part of this Companion Guide, they are helpful in aiding payers and providers in implementing these transactions. Please visit the MN-AUC website at http://www.health.state.mn.us/auc/index.html for more information about Best Practices for implementing electronic health care transactions in Minnesota. 18

5.0 ASC X12/005010X222A1 Health Care Claim: Professional (837) - Minnesota Uniform Companion Guide Table - 5.1 Introduction to Table All the information related to the way this Companion Guide classifies and defines required and situational Data Elements is presented in a table format in the next sections. The table is organized by Loops and Segments, to make it easier to review and locate. The table includes the following: o o ALL of the Loops, Segments and Data Elements that are classified as REQUIRED by the 005010X222A1 (except as noted in Section Compressing Data Element Rows into Segment Rows below) ALL of the Loops, Segments and Data Elements that are classified as SITUATIONAL by the 005010X222A1 (except as noted in Section Compressing Data Element Rows into Segment Rows below) The table DOES NOT include any of the Loops, Segments or Data Elements classified as NOT USED by the 005010X222A1. The table is organized into the following columns: o o Segment and Data Element Information: The ID, NAME, USAGE and 005010X222A1 VALUES given to Segments and Data Elements on the 005010X222A1 Minnesota Information: Minnesota Usage - The only permitted values are: R for Required S for Situational NCFP for Not Considered for Processing Values, Definition and Notes: The specific values and other notes applicable to the Segment/Data Element required to be followed in Minnesota. If Minnesota values have been limited to a subset of values, additional HIPAA compliant values will be considered NCFP. MN Usage Same as 005010X222A1: If checked, it means that the Minnesota Companion Guide conditions, values and notes for the Segment or Data Element are identical to the conditions, values and notes from the 005010X222A1 A single row (with no column separators) across the entire table designates a transaction Loop. Segment rows are noted with a light gray background. 5.1.1 Compressing Data Element Rows into Segment Rows 19

In preparing the companion guides, some compression or collapsing of Data Element rows into Segment rows has been done to simplify the size and content of the document. This compression or collapsing was done as follows: If the Minnesota Usage classification of a Segment and its Data Elements are ALL IDENTICAL with the 005010X222A1, then the Data Element rows for that Segment are NOT included in these tables and only the Segment-level row is presented. 5.1.2 Relationship Between Condition Given to Segments and Data Elements in the 005010X222A1 and the Minnesota Usage Classification Given in this Companion Guide A summary of the seven (7) scenarios that could occur in the companion guide when relating the following three elements are presented in the table below: 1. The condition that a Loop, Segment or Data Element has in the original 005010X222A1 (Required or Situational) 2. The Minnesota Usage as defined by the companion guide development teams (Required; Situational; Not Considered for Processing) 3. Whether the Minnesota Usage and Notes are identical to the 005010X222A1 Table 1 Seven Specific Minnesota Companion Guide Scenarios for Minnesota-defined Usage of Loops, Segments and Data Elements Condition of Loop/ Segment/Data Element from 005010X222A1 Minnesota Usage Classification Companion Guide Minnesota Notes about Usage 1. Required Required Same as 005010X222A1 2. Required Required Further clarifies the 005010X222A1 3. Required NCFP (Not Considered for Processing) Same as 005010X222A1 4. Situational Required Further defines the requirements from the 005010X222A1 5. Situational Situational Same as 005010X222A1 6. Situational Situational Further refines the requirements from the 005010X222A1 7. Situational NCFP (Not Considered for Processing) Same as 005010X222A1 20

5.2 Companion Guide Table Please note: Table 5.2 below references the ASC X12/005010X221A1 Health Care Claim Payment/Advice (835) transaction as 835. Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 ST - TRANSACTION SET HEADER (Loop Repeat: 1) ST Transaction Set Header R R X BHT - BEGINNING OF HIERARCHICAL TRANSACTION (Loop Repeat: 1) BHT Beginning of Hierarchical Transaction R R X LOOP ID - 1000A SUBMITTER NAME (Loop Repeat: 1) NM1 Submitter Name R R X PER Submitter EDI Contact Information R R X LOOP ID - 1000B RECEIVER NAME (Loop Repeat: 1) NM1 Receiver Name R R X LOOP ID - 2000A BILLING PROVIDER HIERARCHICAL LEVEL (Loop Repeat: >1) HL Billing Provider Hierarchical Level R R X PRV Billing Provider Specialty Information S S X CUR Foreign Currency Information S NCFP X LOOP ID - 2010AA BILLING PROVIDER NAME (Loop Repeat: 1) NM1 Billing Provider Name R R See front matter Section 4.2.1 for definition and usage of billing information. N3 Billing Provider Address R R X N4 Billing Provider City, State, ZIP Code R R X REF Billing Provider Tax Identification R R X REF Billing Provider UPIN/License Information R NCFP X PER Billing Provider Contact Information S S X LOOP ID - 2010AB PAY-TO ADDRESS NAME (Loop Repeat: 1) NM1 Pay-to Address Name S S See front matter Section 4.2.1 for definition and usage of pay-to information. N3 Pay-to Address-Address R R X N4 Pay-To Address City, State, ZIP Code R R X LOOP ID - 2010AC PAY-TO PLAN NAME (Loop Repeat: 1) NM1 Pay-To Plan Name S S See front matter Section 4.2.1 for definition and usage of pay-to plan information. N3 Pay-to Plan Address R R X N4 Pay-To Plan City, State, ZIP Code R R X REF Pay-to Plan Secondary Identification S S X REF Pay-To Plan Tax Identification Number R R X LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL (Loop Repeat: >1) HL Subscriber Hierarchical Level R R X SBR Subscriber Information R R X 21

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 SBR01 Payer Responsibility Sequence Number Code R A, B, C, D, E, F, G, H, P, S, T, U R Do not send claims to secondary, tertiary, or any subsequent payer until previous payer(s) has processed. SBR02 Individual Relationship Code S 18 S X SBR03 Subscriber Group or Policy Number S S X SBR04 Subscriber Group Name S S X SBR05 Insurance Type Code S 12, 13, 14, 15, 16, 41, 42, 43, 47 S X SBR09 Claim Filing Indicator Code S 11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, S X MB, MC, OF, TV, VA, WC, ZZ PAT Patient Information S S X PAT05 Date Time Period Format Qualifier S D8 S X PAT06 Patient Death Date S S X PAT07 Unit or Basis for Measurement Code S 01 S X PAT08 Patient Weight S S X PAT09 Pregnancy Indicator S Y NCFP X LOOP ID - 2010BA SUBSCRIBER NAME (Loop Repeat: 1) NM1 Subscriber Name R R X NM101 Entity Identifier Code R IL R X NM102 Entity Type Qualifier R 1, 2 R X NM103 Name Last or Organization Name R R For Workers' Compensation this is the employer name. For Property & Casualty this may be a non-person. NM104 Name First S S X NM105 Name Middle S S X NM107 Name Suffix S S X NM108 Identification Code Qualifier S II, MI S X NM109 Identification Code S S X N3 Subscriber Address S S X N4 Subscriber City, State, ZIP Code S S X DMG Subscriber Demographic Information S S X DMG01 Date Time Period Format Qualifier R D8 R X DMG02 Subscriber Birth Date R R Services to unborn children should be billed under the mother as the patient. DMG03 Subscriber Gender Code R F, M, U R X REF Subscriber Secondary Identification S NCFP X REF Property and Casualty Claim Number S S X PER Property and Casualty Subscriber Contact Information S S X LOOP ID - 2010BB PAYER NAME (Loop Repeat: 1) NM1 Payer Name R R X N3 Payer Address S NCFP X 22

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 N4 Payer City, State, ZIP Code S NCFP X REF Payer Secondary Identification S NCFP X REF Billing Provider Secondary Identification S S REF01 Reference Identification Qualifier R G2, LU R Use G2 for atypical providers. REF02 Reference Identification R R X LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL (Loop Repeat: >1) HL Patient Hierarchical Level S S X PAT Patient Information R R X LOOP ID - 2010CA PATIENT NAME (Loop Repeat: 1) NM1 Patient Name R R X N3 Patient Address R R X N4 Patient City, State, ZIP Code R R X DMG Patient Demographic Information R R X DMG01 Date Time Period Format Qualifier R D8 R X DMG02 Patient Birth Date R R Services to unborn children should be billed under the mother as the patient. DMG03 Patient Gender Code R F, M, U R X REF Property and Casualty Claim Number S S X REF Property and Casualty Patient Identifier S S X PER Property and Casualty Patient Contact Information S S X LOOP ID - 2300 CLAIM INFORMATION (Loop Repeat: 100) CLM Claim Information R R X CLM01 Claim Submitter's Identifier R R X CLM02 Monetary Amount R R X CLM05 HEALTH CARE SERVICE LOCATION INFORMATION R R X CLM05-1 Facility Code Value R See Code Source 237 R X CLM05-2 Facility Code Qualifier R B R X CLM05-3 Claim Frequency Type Code R See Code Source 235 R See front matter section 4.2.3.2 for definitions. CLM06 Yes/No Condition or Response Code R N, Y R X CLM07 Provider Accept Assignment Code R A, B, C R X CLM08 Yes/No Condition or Response Code R N, W, Y R X CLM09 Release of Information Code R I, Y R X CLM10 Patient Signature Source Code S P S X CLM11 RELATED CAUSES INFORMATION S S X CLM11-1 Related Causes Code R AA, EM, OA R X CLM11-2 Related Causes Code S AA, EM, OA S X CLM11-4 State or Province Code S S X CLM11-5 Country Code S S X CLM12 Special Program Code S 02, 03, 05, 09 S X CLM20 Delay Reason Code S If code 11 (Other) is used, additional 1, 2, 3, 4, 5, 6, 7, 8, 9, S documentation is 10, 11, 15 required using NTE or PWK,.. Refer to 23

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 section 4.2.3.3 for usage. If CLM20 value of 11 is used, PWK02 must not be a value of AA. DTP Date - Onset of Current Illness or Symptom S S X DTP Date - Initial Treatment Date S S X DTP Date - Last Seen Date S NCFP X DTP Date - Acute Manifestation S S X DTP Date - Accident S S X DTP Date - Last Menstrual Period S S X DTP Date - Last X-ray Date S S X DTP Date - Hearing and Vision Prescription Date S S X DTP Date - Disability Dates S S X DTP Date - Last Worked S S X DTP Date - Authorized Return to Work S S X DTP Date - Admission S S X DTP Date - Discharge S S X DTP Date - Assumed and Relinquished Care Dates S S X DTP Date - Property and Casualty Date of First Contact S S X DTP Date - Repricer Received Date S NCFP X PWK Claim Supplemental Information S S See front matter Section 4.2.3.3 for definition. PWK01 Report Type Code R 03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, R X MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP PWK02 Report Transmission Code R Use of AA value may result in a delay in claim payment. If an AA, BM, EL, EM, FT, R attachment is known FX to be needed by the payer it should be sent. PWK05 Identification Code Qualifier S AC S X PWK06 Identification Code S S X CN1 Contract Information S S X AMT Patient Amount Paid S S X AMT01 Amount Qualifier Code R F5 R X AMT02 Monetary Amount R R Must not exceed total 24

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 claim charge amount in CLM02. REF Service Authorization Exception Code S NCFP X REF Mandatory Medicare (Section 4081) Crossover Indicator S NCFP X REF Mammography Certification Number S S X REF Referral Number S S X REF Prior Authorization S S X REF Payer Claim Control Number S S If the original payer assigned claim number is obtained from the 835, it corresponds to CLP07. REF Clinical Laboratory Improvement Amendment (CLIA) Number S S X REF Repriced Claim Number S NCFP X REF Adjusted Repriced Claim Number S NCFP X REF Investigational Device Exemption Number S S X REF Claim Identifier For Transmission Intermediaries S S X REF Medical Record Number S S X REF Demonstration Project Identifier S S X REF Care Plan Oversight S S X K3 File Information S S See Appendix B for usage instructions. NTE Claim Note S S See front matter Section 4.2.3.3 for definition. CR1 Ambulance Transport Information S S X CR2 Spinal Manipulation Service Information S NCFP X CRC Ambulance Certification S S X CRC Patient Condition Information: Vision S NCFP X CRC Homebound Indicator S NCFP X CRC EPSDT Referral S S Required for Medicaid Programs when service is rendered under the Minnesota Child and Teen Checkup Programs. HI Health Care Diagnosis Code R R X HI Anesthesia Related Procedure S S X HI Condition Information S S X HCP Claim Pricing/Repricing Information S NCFP X LOOP ID - 2310A REFERRING PROVIDER NAME (Loop Repeat: 2) NM1 Referring Provider Name S S X REF Referring Provider Secondary Identification REF01 Reference Identification Qualifier R 0B, 1G, G2 R S S See front matter Section 4.2.2 for usage. Use G2 for atypical providers. 25

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 REF02 Reference Identification R R X LOOP ID - 2310B RENDERING PROVIDER NAME (Loop Repeat: 1) NM1 Rendering Provider Name S S X PRV Rendering Provider Specialty Information S S X REF Rendering Provider Secondary Identification REF01 Reference Identification Qualifier R 0B, 1G, G2, LU R S S See front matter Section 4.2.2 for usage Use G2 for atypical providers. REF02 Reference Identification R R X LOOP ID - 2310C SERVICE FACILITY LOCATION NAME (Loop Repeat: 1) NM1 Service Facility Location Name S S X N3 Service Facility Location Address R R X N4 Service Facility Location City, State, ZIP Code R R X REF Service Facility Location Secondary Identification REF01 Reference Identification Qualifier R 0B, G2,LU R S S See front matter Section 4.2.2 for usage. Use G2 for atypical providers. REF02 Reference Identification R R X PER Service Facility Contact Information S S X LOOP ID - 2310D SUPERVISING PROVIDER NAME (Loop Repeat: 1) NM1 Supervising Provider Name S S X REF Supervising Provider Secondary Identification S NCFP X LOOP ID - 2310E AMBULANCE PICK-UP LOCATION (Loop Repeat: 1) NM1 Ambulance Pick-up Location S S X N3 Ambulance Pick-up Location Address R R X N4 Ambulance Pick-up Location City, State, ZIP Code R R X LOOP ID - 2310F AMBULANCE DROP-OFF LOCATION (Loop Repeat: 1) NM1 Ambulance Drop-off Location S S X N3 Ambulance Drop-off Location Address R R X N4 Ambulance Drop-off Location City, State, ZIP Code R R X LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION (Loop Repeat: 10) SBR Other Subscriber Information S S Do not send claim to secondary or any subsequent payer until previous payer has processed. SBR01 Payor Responsibility Sequence Number A, B, C, D, E, F, G, H, R Code P, S, T, U R X SBR02 Individual Relationship Code R 01, 18, 19, 20, 21, 39, 40, 53, G8 R X SBR03 Reference Identification S NCFP X SBR04 Name S NCFP X SBR05 Insurance Type Code S 12, 13, 14, 15, 16, 41, 42, 43, 47 S X SBR09 Claim Filing Indicator Code S 11, 12, 13, 14, 15, 16, S X 26

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ CAS Claim Level Adjustments S S X AMT Coordination of Benefits (COB) Payer Paid Amount S S X AMT Coordination of Benefits (COB) Total Non-Covered Amount S S X AMT Remaining Patient Liability S S X OI Other Insurance Coverage Information R R X MOA Outpatient Adjudication Information S S X LOOP ID - 2330A OTHER SUBSCRIBER NAME (Loop Repeat: 1) NM1 Other Subscriber Name R R X N3 Other Subscriber Address S NCFP X N4 Other Subscriber City, State, ZIP Code S NCFP X REF Other Subscriber Secondary Identification S NCFP X LOOP ID - 2330B OTHER PAYER NAME (Loop Repeat: 1) NM1 Other Payer Name R R X NM101 Entity Identifier Code R PR R X NM102 Entity Type Qualifier R 2 R X NM103 Name Last or Organization Name R R X NM108 Identification Code Qualifier R PI, XV R X NM109 Identification Code R R If multiple other insureds, the payer ID values contained in the 2330B loop must be unique within the claim. N3 Other Payer Address S NCFP X N4 Other Payer City, State, ZIP Code S NCFP X DTP Claim Check or Remittance Date S S X REF Other Payer Secondary Identifier S NCFP X REF Other Payer Prior Authorization Number S NCFP X REF Other Payer Referral Number S NCFP X REF Other Payer Claim Adjustment Indicator S NCFP X REF Other Payer Claim Control Number S S X LOOP ID - 2330C OTHER PAYER REFERRING PROVIDER (Loop Repeat: 2) NM1 Other Payer Referring Provider S NCFP X REF Other Payer Referring Provider Secondary Identification R NCFP X LOOP ID - 2330D OTHER PAYER RENDERING PROVIDER (Loop Repeat: 1) NM1 Other Payer Rendering Provider S NCFP X REF Other Payer Rendering Provider Secondary Identification R NCFP X LOOP ID - 2330E OTHER PAYER SERVICE FACILITY LOCATION (Loop Repeat: 1) NM1 Other Payer Service Facility Location S NCFP X REF Other Payer Service Facility Location Secondary Identification R NCFP X 27

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 LOOP ID - 2330F OTHER PAYER SUPERVISING PROVIDER (Loop Repeat: 1) NM1 Other Payer Supervising Provider S NCFP X REF Other Payer Supervising Provider Secondary Identification R NCFP X LOOP ID - 2330G OTHER PAYER BILLING PROVIDER (Loop Repeat: 1) NM1 Other Payer Billing Provider S NCFP X REF Other Payer Billing Provider Secondary Identification R NCFP X LOOP ID - 2400 SERVICE LINE NUMBER (Loop Repeat: 50) LX Service Line Number R R X SV1 Professional Service R R X SV101 COMPOSITE MEDICAL PROCEDURE IDENTIFIER R R X SV101-1 Product/Service ID Qualifier R ER, HC, IV, WK R X SV101-2 Product/Service ID R R X SV101-3 Procedure Modifier S Code Source 130 S X SV101-4 Procedure Modifier S Code Source 130 S X SV101-5 Procedure Modifier S Code Source 130 S X SV101-6 Procedure Modifier S Code Source 130 S X SV101-7 Description S S See front matter section 4.2.3.3 for additional instructions. SV102 Monetary Amount R R X SV103 Unit or Basis for Measurement Code R UN, MJ R See Appendix A for coding units. SV104 Quantity R R Zero 0 is not a valid value. SV105 Facility Code Value S See code source 237 S X SV107 COMPOSITE DIAGNOSIS CODE POINTER R R X SV107-1 Diagnosis Code Pointer R R Primary diagnosis code can not point to an External Cause of Injury code. SV107-2 Diagnosis Code Pointer S S X SV107-3 Diagnosis Code Pointer S S X SV107-4 Diagnosis Code Pointer S S X SV109 Yes/No Condition or Response Code S Y S X SV111 Yes/No Condition or Response Code S Y S X SV112 Yes/No Condition or Response Code S Y NCFP X SV115 Copay Status Code S 0 NCFP X SV5 Durable Medical Equipment Service S S X PWK Line Supplemental Information S NCFP X PWK Durable Medical Equipment Certificate of Medical Necessity Indicator S NCFP X CR1 Ambulance Transport Information S S X CR3 Durable Medical Equipment Certification S NCFP X CRC Ambulance Certification S S X CRC Hospice Employee Indicator S NCFP X CRC Condition Indicator/Durable Medical Equipment S NCFP X 28

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 DTP Date - Service Date R R X DTP01 Date/Time Qualifier R 472 R X DTP02 Date Time Period Format Qualifier R D8, RD8 R X DTP03 Date Time Period R R Must be greater than or equal to patient's date of birth. If DTP02 is RD8, then the 'to' date must be equal to or greater than the 'from' date. DTP Date - Prescription Date S S X DTP DATE - Certification Revision/Recertification Date S NCFP X DTP Date - Begin Therapy Date S NCFP X DTP Date - Last Certification Date S NCFP X DTP Date - Last Seen Date S NCFP X DTP Date - Test Date S S X DTP Date - Shipped Date S S X DTP Date - Last X-ray Date S S X DTP Date - Initial Treatment Date S S X QTY Ambulance Patient Count S S X QTY Obstetric Anesthesia Additional Units S NCFP X MEA Test Result S S X CN1 Contract Information S NCFP X REF Repriced Line Item Reference Number S NCFP X REF Adjusted Repriced Line Item Reference S NCFP X Number REF Prior Authorization S S X REF Line Item Control Number S S X REF Mammography Certification Number S S X REF Clinical Laboratory Improvement Amendment (CLIA) Number S S X REF Referring Clinical Laboratory Improvement Amendment (CLIA) S NCFP X Facility Identification REF Immunization Batch Number S NCFP X REF Referral Number S NCFP X AMT Sales Tax Amount S S See Appendix C for details on reporting MNCare AMT Postage Claimed Amount S S X K3 File Information S S See Appendix B for usage instructions. NTE Line Note S S See front matter Section 4.2.3.3 for definition and usage. NTE Third Party Organization Notes S NCFP X PS1 Purchased Service Information S NCFP X HCP Line Pricing/Repricing Information S NCFP X LOOP ID - 2410 DRUG IDENTIFICATION (Loop Repeat: 1) LIN Drug Identification S S X CTP Drug Quantity R R X 29

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 REF Prescription or Compound Drug Association Number S S X LOOP ID - 2420A RENDERING PROVIDER NAME (Loop Repeat: 1) NM1 Rendering Provider Name S S X PRV Rendering Provider Specialty Information S S X REF See front matter Rendering Provider Secondary S S Section 4.2.2 for Identification usage. REF01 Reference Identification Qualifier R 0B, 1G, G2, LU R Use G2 for atypical providers. REF02 Reference Identification R R X REF04 Reference Identifier S S X REF04-1 Reference Identification Qualifier R 2U R X REF04-2 Reference Identification R R X LOOP ID - 2420B PURCHASED SERVICE PROVIDER NAME (Loop Repeat: 1) NM1 Purchased Service Provider Name S S X REF Purchased Service Provider Secondary Identification S S X REF01 Reference Identification Qualifier R 0B, 1G, G2 R Use G2 for atypical providers. REF02 Reference Identification R R X REF04 Reference Identifier S S X REF04-1 Reference Identification Qualifier R 2U R X REF04-2 Reference Identification R R X LOOP ID - 2420C SERVICE FACILITY LOCATION NAME (Loop Repeat: 1) NM1 Service Facility Location Name S S X N3 Service Facility Location Address R R X N4 Service Facility Location City, State, ZIP Code R R X REF Service Facility Location Secondary Identification REF01 Reference Identification Qualifier R G2, LU R S S See front matter Section 4.2.2 for usage. Use G2 for atypical providers. REF02 Reference Identification R R X REF04 Reference Identifier S S X REF04-1 Reference Identification Qualifier R 2U R X REF04-2 Reference Identification R R X LOOP ID - 2420D SUPERVISING PROVIDER NAME (Loop Repeat: 1) NM1 Supervising Provider Name S S X REF Supervising Provider Secondary Identification S NCFP X LOOP ID - 2420E ORDERING PROVIDER NAME (Loop Repeat: 1) NM1 Ordering Provider Name S S See front matter Section 4.2.1 for definition. N3 Ordering Provider Address S S This segment is recommended for use when the following N4 segment is used. N4 Ordering Provider City, State, ZIP Code S S X 30

Minnesota Uniform Companion Guide for the Implementation of the ASC/X12 005010X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e 005010X222A1 Values Usage Values, Definition and Notes MN Usage Same as 005010 X222A1 REF Ordering Provider Secondary Identification REF01 Reference Identification Qualifier R 0B, 1G, G2 R S S See front matter Section 4.2.2 for usage. Use G2 for atypical providers. REF02 Reference Identification R R X REF04 Reference Identifier S S X REF04-1 Reference Identification Qualifier R 2U R X REF04-2 Reference Identification R R X PER Ordering Provider Contact Information S NCFP X LOOP ID - 2420F REFERRING PROVIDER NAME (Loop Repeat: 2) NM1 Referring Provider Name S S X REF Referring Provider Secondary Identification REF01 Reference Identification Qualifier R 0B, 1G, G2 R S S See front matter Section 4.2.2 for usage. Use G2 for atypical providers. REF02 Reference Identification R R X REF04 Reference Identifier S S X REF04-1 Reference Identification Qualifier R 2U R X REF04-2 Reference Identification R R X LOOP ID - 2420G AMBULANCE PICK-UP LOCATION (Loop Repeat: 1) NM1 Ambulance Pick-up Location S S X N3 Ambulance Pick-up Location Address R R X N4 Ambulance Pick-up Location City, State, ZIP Code R R X LOOP ID - 2420H AMBULANCE DROP-OFF LOCATION (Loop Repeat: 1) NM1 Ambulance Drop-off Location S S X N3 Ambulance Drop-off Location Address R R X N4 Ambulance Drop-off Location City, State, ZIP Code R R X LOOP ID - 2430 LINE ADJUDICATION INFORMATION (Loop Repeat: 15) SVD Line Adjudication Information S S X CAS Line Adjustment S S X DTP Line Check or Remittance Date R R X AMT Remaining Patient Liability S S X LOOP ID - 2440 FORM IDENTIFICATION CODE (Loop Repeat: >1) LQ Form Identification Code S NCFP X FRM Supporting Documentation R NCFP X SE - TRANSACTION SET TRAILER (Loop Repeat: 1) SE Transaction Set Trailer R R X 31

6.0 Appendices List of Appendices: Appendix A: MEDICAL CODE SET SUPPLEMENTAL INFORMATION FOR MINNESOTA UNIFORM COMPANION GUIDES Appendix B: K3 SEGMENT USAGE INSTRUCTIONS Appendix C: REPORTING MNCare TAX Appendix D: EXAMPLES: DATA PREVIOUSLY SUBMITTED IN THE NTE SEGMENT NOW SUBMITTED IN THE SV, LIN, OR HI SEGMENTS 32

Appendix A Medical Code Set -- Supplemental Information for Minnesota Uniform Companion Guides A.1 Introduction and Overview Minnesota Statutes, Section 62J.536 requires all health care providers and group purchasers (payers) to exchange health care claims electronically using a single, uniform companion guide to HIPAA implementation guides, including uniform billing and coding standards, effective July 15, 2009. The statute further requires the Commissioner of Health to base the transaction standards and billing and coding rules on federal HIPAA requirements and on the Medicare program, with modifications that the commissioner deems appropriate after consulting with the Minnesota Administrative Uniformity Committee (AUC). This Appendix, including accompanying tables, describes rules for submitters and receivers of professional/institutional electronic health care claims to follow in the selection and use of medical codes from the HIPAA code sets that are associated with these transactions. The Appendix was developed in consultation with the AUC and its Medical Code Technical Advisory Group (TAG). NOTE-- As further described in the sections below: 1. All codes must be compliant with federal HIPAA requirements. 2. This Appendix does not address or govern: the services or benefits that are eligible for payment under a contract, insurance policy, or law; payment for health care services under a contract, insurance policy, or law. 3. This Appendix includes three tables which must also be consulted when selecting and using medical codes: a. Table A.5.1: Minnesota Coding Specifications: When to Use Codes Different From Medicare; b. Table A.5.2: Behavioral Health Procedure Code/Modifier Combinations: For Specific Benefit Packages Unique to State Government Programs; c. Table A.5.3: Substance Abuse Services. 4. This Appendix and its accompanying tables establish requirements for the selection and use of medical codes. The coding requirements vary as indicated by the type of 33

service/procedure/product being provided. Depending on the service/procedure/product provided, the requirement in this Appendix will be to select codes in the following order: A. The subset of HIPAA codes based on specific Minnesota coding requirements in Tables A.5.1, A.5.2, or A.5.3. B. If the tables above do not apply, or if the table states follow Medicare guidelines, use HIPAA codes for the federal Medicare program ( Follow Medicare coding guidelines ); C. If #1 or #2 above does not apply, use the HIPAA-compliant codes that most appropriately describe the service/procedure/product provided. Codes with identical descriptions may be used interchangeably. If codes do not have an identical description then follow section A.3.2, Instructions for Use, regarding use of the most appropriate code. 5. This appendix does not replace or substitute for standard, national coding resources for HIPAA-adopted code sets (including manuals, online resources, etc.). Consult the corresponding coding resources for descriptions, definitions, and directions for code usage. 6. Medicare and national codes often change. National organizations are responsible for maintenance of medical codes and periodically add, delete, or make other changes to these codes. This Guide and Appendix incorporate by reference any changes adopted by national organizations with responsibilities for these codes. Submitters of health care claims are responsible for selecting and using the correct, appropriate codes. (See A.4.) A.2 HIPAA Code Sets Code sets have been adopted under federal HIPAA rules (45 CFR 162 Subpart J). Consistent with the HIPAA electronic Transactions and Code Sets regulations, all covered entities are required to submit or receive codes that are: valid on the date of service for medical code sets; valid at the time the transaction was created and submitted for non-medical code sets. This Appendix includes requirements and information related to the HIPAA code sets, as well as: modifiers found in the CPT and HCPCS Level II including those established for definition by State Medicaid; Revenue codes a data element of the institutional claim; Units of service (basis for measurement). A.3 Code Selection and Use A.3.1 General Rules 34

1. Select codes that most accurately identify the procedure/service/product provided. Codes with identical descriptions may be used interchangeably. If codes do not have identical description, then follow A.3.2 regarding use of the most appropriate code. 2. The medical record must always reflect the procedure/service/product provided. 3. Use instructions in this appendix and the accompanying tables A.5.1, A.5.2, and A.5.3 to select and use required codes. A.3.2 Instructions for Using This Appendix and Its Accompanying Tables For the state government behavioral health programs identified in Table A.5.2, use the codes referenced in that table. For substance abuse services, use the codes listed in Table A.5.3. For all other procedures/services/products, use Table A.5.1 as follows: Find the appropriate row ( Medicare Claims Processing Manual Chapter ) in Table A.5.1 for the type of procedure/service/product provided. (a) If the Minnesota Rule column for the row describing the type of procedure/service/product being provided states Follow Medicare Coding Guidelines, then codes must be selected and used consistent with the claims submission coding instructions and requirements maintained by or on behalf of the Centers for Medicare and Medicaid Service (CMS) (e.g., Medicare Claims Processing Manual and communications from or on behalf of CMS). i. Exception to the Follow Medicare Coding Guidelines statement above. If either of the following applies: The procedure/service/product is listed in a Medicare coding resource but is limited by Medicare coverage; OR The procedure/service/product is not listed in a Medicare coding resource; THEN: select the code(s) that most accurately identify the procedure/service/product provided. CPT codes are preferred, but HCPCS Level II codes can be used if they describe the service more completely (e.g. H, S, T codes). Codes with identical descriptions may be used interchangeably. (b) If the Minnesota Rule column for the row describing the type of procedure/service/product being provided states 35

other than Follow Medicare Coding Guidelines, then use the specific code(s) and/or instructions listed. For procedures/services/products not found in Tables A.5.1, A.5.2, or A.5.3, select the code(s) that most accurately identify the procedure/service/product provided. CPT codes are preferred, but HCPCS Level II codes can be used if they describe the service more completely (e.g. H, S, T codes). Codes with identical descriptions may be used interchangeably. Note: Table A.5.1 lists chapter headings from the Medicare Claims Processing Manual. Each chapter entry has an associated Minnesota Rule (e.g., Follow Medicare Coding Guidelines or other, more specific instructions). For some chapters (e.g., Chapter 21 Medicare Summary Notices, Chapter 22 Remittance Notice to Providers, and others), the requirement is stated as "Not applicable to coding guidelines". These chapters are relevant to Medicare business processes but do not pertain to coding requirements of this Appendix and may be disregarded. A.3.3 When Instructions Differ From Follow Medicare Coding Guidelines In some instances shown in the accompanying tables, requirements are to code differently than Medicare with the code(s) and/or instructions stated. Coding that is different from Medicare resulted because: 1. Minnesota group purchasers accept and adjudicate codes for services above and beyond Medicare s coding guidelines based on their coverage policies and member benefits. 2. More specific or appropriate codes are needed in order to reduce manual processing and administrative costs. 3. Duplicate codes exist and clarification of which code(s) to use is needed. 4. Medicare does not have a guideline for coding a service or made no specific reference to a service but the AUC Medical Code Technical Advisory Group (TAG) had knowledge of differing submission requirements. Specific coding instructions that are listed in Tables A.5.1, A.5.2, and A.5.3 as other than Follow Medicare Coding Guidelines apply only to a limited subset of particular codes or a category of codes selected on the basis of criteria above. A.3.4 Additional Coding Specifications A.3.4.1 Modifiers Modifiers are found in the CPT and HCPCS Level II including those allowed by CMS to be defined by State Medicaid agencies. 36

Minnesota Department of Human Services (DHS) has specifically defined select U modifiers to help identify and administer their legislatively required programs. These definitions can be found in the Minnesota HCPCS manual located on the AUC website. Minnesota group purchasers accept all modifiers including DHS defined modifiers. This appendix includes a list of required modifiers for Minnesota Department of Human Services (DHS) behavioral health programs. A.3.4.2 Units (basis for measurement) The number of units is the number of services performed and reported per service line item as defined in the code description unless instructed differently in this appendix. The following are clarifications/exceptions: Report one unit for all services without a measure in the description. Report the number of units as the number of services performed for services with a measure in the description. For example, one unit equals: o o o o o per vertebral body each 30 minutes each specimen 15 or more lesions initial. Follow all related AMA guidelines in CPT 2 (e.g. unit of service is the specimen for pathology codes). Definition of specimen : "A specimen is defined as tissue(s) that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis." 3 In the case of time as part of the code definition, more than half the time must be spent performing the service in order to report that code. Follow general rounding rules for reporting more than the code s time value. If the time spent results in more than one and one half times the defined value of the code and no additional time increment code exists, round up to the next whole number. Do not follow Medicare s rounding rules for speech, occupational, and physical therapy services. Each modality and unit(s) is reported separately by code definition. Do not combine codes to determine total time units. Anesthesia codes 00100-01999: 1 unit = 1 minute 2 Current Procedural Terminology (CPT ), copyright 2010 American Medical Association 3 Current Procedural Terminology (CPT ), copyright 2010 American Medical Association 37

Decimals are accepted with codes that have a defined quantity in their description, such as supplies or drugs and biologicals. Units of service that are based on time are never reported with decimals. Drugs are billed in multiples of the dosage specified in the HCPCS Code. A.4 Submitters and Receivers Are Responsible for Selecting And Using The Correct, Appropriate Medical Codes Codes used in this appendix were valid at the time of approval for publication of this companion guide. Code set changes may result in this appendix reflecting a deleted code or not reflecting a new code. This Guide and Appendix incorporate by reference any changes adopted by national organizations with responsibilities for these codes. Per the HIPAA Transactions and Code Set Rule, those that [send or] receive standard electronic administrative transactions must be able to [send], receive and process all standard codes irrespective of local policies regarding reimbursement for certain conditions or procedures, coverage policies, or need for certain types of information that are part of a standard transaction. Code set updates 4 can be found at websites of the following organizations: Centers for Medicare and Medicaid Services (CMS) American Medical Association (AMA) National Center for Health Statistics (NCHS) National Uniform Billing Committee (NUBC) A.5 Tables of Coding Requirements Please note: Table A.5.1 below references several standard health care claims transactions as follows: ASC X12/005010X222A1 Health Care Claim: Professional (837), referred to in Table A.5.1 as professional claim type or 837P or Professional claim ASC X12/005010X224A2 Health Care Claim: Dental (837), referred to in Table A.5.1 as 837D Pharmacy Claims Submission and Response and the Pharmacy Reversal Submission and Response Transactions per the NCPDP Telecommunication Standard Implementation Guide, Version D.Ø, referred to in Table A.5.1 as NCPDP. 4 CPT is a registered trademark of the American Medical Association (AMA); ICD-9-CM is maintained and distributed by the National Center for Health Statistics, U.S. Department of Health and Human Services (HHS); HCPCS are developed by the Centers for Medicare and Medicaid Services (CMS); Revenue codes are developed by the National Uniform Billing Committee (NUBC). 38

A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title General Billing 1 Requirements Admission and 2 Registration Requirements 3 4 5 Inpatient Hospital Billing Part B Hospital (Including Inpatient Hospital Part B and OPPS) Part B Outpatient Rehabilitation and CORF/OPT Services 6 Inpatient Part A Billing and SNF Consolidated Billing SNF Part B (Including Inpatient Part B and 7 Outpatient Fee Schedule) Outpatient ESRD Hospital, Independent 8 Facility and Physician/Supplier Claims 9 Rural Health Clinics/Federal Qualified Health Centers Minnesota Rule Follow Medicare coding guidelines Not applicable to coding guidelines Follow Medicare coding guidelines Outpatient professional services provided by Critical Access Hospitals electing Method II billing should be reported on the professional claim type (i.e. 837P). Follow Medicare coding guidelines Not applicable to Professional claim Not applicable to Professional claim Follow Medicare coding guidelines Report on the claim type with procedure codes appropriate to the services provided, e.g., physician/clinic services on the 837P, dental services on the 837D, pharmacy on NCPDP. 10 Home Health Agency Billing PCA & Homemaking Services PCA: T1019 39

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title Minnesota Rule PCA Shared 1:2: T1019-TT PCA Shared 1:3 or more: T1019-HQ PCA Temporary Service Increase: T1019-U6 PCA Notice of Reduction: T1019-U5 RN PCA Supervision: T1019-UA Homemaking: S5130, S5131 11 12 Processing Hospice Claims Physicians/Nonphysician Practitioners Home Infusion is not addressed in this chapter. See instructions following the Medicare Claims Processing Manual chapters. PCA services may not be billed with a span of dates, each date of service must be billed separately. Not applicable to Professional claim Medicare does not allow all allergy and clinical immunology codes, but group purchasers accept all applicable codes. Follow the code selection guidelines in the front of Appendix A. Modifier 50 should only be used on surgical services that can be performed bilaterally and are not already defined as a bilateral service. When appropriate, report the service appended with the 50 modifier on one line with one unit. Bilateral radiology services are reported as either: o one line with a 50 modifier and one unit, or o two separate lines, one with RT modifier and one with LT modifier. For E-visits, use 99444 for MD/DO/DC; use 98969 for nonphysician healthcare professionals (e.g.. Nurse Practitioner, Physician Assistant, Clinical Nurse Specialist). For telephone services, use 99441-99443 for MD/DO/DC; use 98966-98968 for nonphysician 40

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title Minnesota Rule healthcare professionals (e.g.. Nurse Practitioner, Physician Assistant, Clinical Nurse Specialist). To report interpreter services: Note: Rounding rules apply to all services below. A minimum of eight minutes must be spent in order to report one unit T1013 -- Face-to-face oral language interpreter services per 15 minutes T1013-U3 -- Face-to-face sign language interpreter services per 15 minutes T1013-GT -- Telemedicine interpreter services per 15 minutes T1013-U4 -- Telephone interpreter services per 15 minutes T1013-UN, UP, UQ, UR, US Interpreter services provided to multiple patients in a group setting T1013-52 -- Interpreter drive time, wait time, no show/cancellation per 15 minutes Report one unit per 15 minutes per client If more than one service is provided, report each on a separate line appended with the -59 modifier o T1013-52 x 2 units (30 minutes of drive time) o T1013-5259 (12 minutes of wait time) Add narrative(s) in the NTE segment to report the service(s) rendered. An NTE segment is required for each line. Reporting drive time versus mileage is based on individual contract. T1013-52 may not be used for drive time if mileage (see 99199) is reported A canceled service may only be reported if the interpreter has already arrived for the appointment prior to the cancellation 99199 -- Mileage for interpreter service o Reporting mileage versus drive time is based on individual contract. 99199 may not be used if drive time (T1013-52) is 41

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title o Minnesota Rule reported Report one unit per mile Coding for a discussion initiated by the primary care provider (MD, DO, NPP) to a psychiatrist for an opinion or advice regarding a patient should be reported using 99499 as follows: Brief - 99499. Intermediate 99499, TF Complex 99499, TG There are circumstances when it is inappropriate to have the patient in the exam room with the physician or nurse practitioner due to extenuating circumstances regarding the patient s condition. When a discussion between clinician and caregiver is vital for the health of the patient and necessary for the patient to be properly cared for, the appropriate CPT code for evaluation and management services may be billed based on time to the patient s group purchaser. Report the appropriate ICD-9-CM code(s) for the diagnosis of the patient as the primary diagnosis or diagnoses. Also ICD-9-CM code V65.19 Other person consulting on behalf of another person must be reported. See also the row below for Chapter No. 16 for Laboratory Services from Independent Labs, Physicians, and Providers Health Care Homes The following instructions are for reporting health care home with patient complexity level and supplemental factor modifiers. Use U modifiers in conjunction with medical home codes S0280 or S0281 as shown below: 42

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title Patient Complexity Level Minnesota Rule Complexity Modifiers Non English Speaking Modifier Active Mental Health Condition Modifier Low (no No modifier U3 U4 major conditions) Basic U1 U3 U4 Intermediate TF U3 U4 Extended U2 U3 U4 Complex (most major conditions) TG U3 U4 13 Radiology Services and Other Diagnostic Procedures Definitions of U modifiers with S0280 or S0281: U1 Care coordination, basic complexity level U2 Care coordination, extended complexity level U3 Care coordination, supplemental factor; Non- English language U4 Care coordination, supplemental factor; Major Active Mental Health Condition If both technical and professional component are being billed by the same billing provider, same place of service, a global code should be used rather than TC/26 modifiers and separate components Bilateral radiology services are reported as either: o one line with a 50 modifier and one unit, or o two separate lines, one with RT modifier and one with LT modifier. See also the row below for Chapter No. 16 for Laboratory Services from Independent Labs, Physicians, and Providers 43

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title Minnesota Rule 14 Ambulatory Surgical Centers Modifier 50 should be used on surgical services that can be performed bilaterally and are not already defined as a bilateral service. When appropriate, report the service appended with the 50 modifier on one line with one unit. Professional bilateral radiology services are reported as two lines with LT and RT modifiers Per trading partner agreement, either transaction is allowed pending further guidance from CMS. Check with payer to determine the preferred billing method. 15 Ambulance 16 Laboratory Services Follow Medicare coding guidelines For non-emergent, scheduled transportation by non-ambulance providers: o A0080 o A0090 o A0100 o A0110 o A0120 o T2002 o T2003 o T2004 Modifiers 76 or 91 are to be used for repeat services subsequent to the original service only. The number of units reported is the number of services performed as defined in the code description or relevant AMA guidelines in CPT 5. Genetic coding modifiers are required when reporting a genetic lab procedure Lab panels should be reported as 1 line item with 1 unit per panel. CPT defines panel components. 5 Current Procedural Terminology (CPT ), copyright 2010 American Medical Association 44

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title 17 Drugs and Biologicals Minnesota Rule If reporting any portion of a single use vial or package as discarded, the JW modifier is required and the charges and units must be prorated between the administered drug and discarded drug lines. This does not apply to multiple use vials. 18 Preventive and Screening Services Preventive services and coding as defined by Medicare (i.e. Welcome to Medicare ) are only applicable to Medicare and Medicare replacement products In instances when a new patient receives preventive care and an illness-related E/M service at the same visit, an established patient E/M service should be used to report a separatelyidentifiable problem-oriented E/M code in addition to a new patient preventive medicine service HCPCS code on the same date. Append 25 modifier to problem oriented E/M code. In lieu of Medicare s limitations, diagnosis coding for screening services must follow the ICD-9 code set instructions. All applicable diagnoses should be submitted. Roster billing is not applicable to Minnesota Group Purchasers Either G codes or CPT codes may be reported as needed for vaccine administration. If using G codes for covered Medicare vaccines, use CPT for subsequent administration of additional immunizations When vaccines are acquired through the Minnesota Vaccines For Children (MnVFC) program, Group purchasers require the SL modifier be appended to the vaccine code S0302 is reported in addition to all of the age appropriate components of a Child and Teen Checkups (C&TC) exam to indicate a complete C&TC exam has been performed. 45

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title Minnesota Rule Vaccine administration with counseling for patients through 18 years of age: o Vaccine administration with counseling should be reported in units with the accumulated total administrations representing initial and additional vaccine/toxoid components. o Do not report separate administration lines for each administered vaccine. For example, DTaP-IPV/Hib would be reported with 1 unit of initial vaccine/toxoid component administration with counseling and 4 units of additional vaccine/toxoid component administration with counseling. 19 Indian Health Services Report on the claim type with procedure codes appropriate to the services provided, e.g., physician/clinic services on the 837P, dental services on the 837D, pharmacy on NCPDP. 20 Durable Medical Equipment, Prosthetics, Orthotics and Supplies Oxygen codes are used as defined. When appropriate to report contents, MN providers may report E or S oxygen content codes as definition allows. Appropriate modifiers are required to indicate rental or purchase of DME, e.g., NU, RR Binaural hearing aids are reported as one line, with one unit Upgrades if a patient prefers an item with features or upgrades that are not medically necessary and has elected responsibility, the items are billed as two lines using the same code on both lines, if no upgrade code is available. Use the GA modifier for the upgraded and GK for the standard 46

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title item. Minnesota Rule 21 Medicare Summary Notices Not applicable to coding guidelines 22 Remittance Advice Not applicable to coding guidelines 23 Fee Schedule Follow the code selection guidelines in the Appendix A Administration and front matter Coding Requirements 24 General EDI and EDI Support Requirements, Electronic Claims and Coordination of Benefits Requirements, Mandatory Electronic Filing of Medicare Claims Not applicable to coding guidelines 25 26 27 28 29 30 Completing and Processing the Form CMS-1450 Data Set Completing and Processing Form CMS- 1500 Data Set Contractor Instructions for CWF Coordination with Medigap, Medicaid, and other Complementary Insurers Appeals of Claims Decisions Financial Liability Protections Not applicable to coding guidelines Not applicable to coding guidelines Not applicable to coding guidelines Not applicable to coding guidelines Not applicable to coding guidelines Not applicable to coding guidelines 31 ANSI X12N Formats Not applicable to coding guidelines 32 Billing Requirements for Special Services Follow the code selection guidelines in the front matter of Appendix A 47

TABLE A.5.1 Minnesota Coding Specifications: When to Use Codes Different From Medicare (For Instructions on the use of this table see Section A.3.2) Medicare Claims Processing Manual Chapter Chapter Number Description/Title 33 34 Miscellaneous Hold Harmless Provisions Reopening and Revision of Claim Determinations and Decisions Minnesota Rule Not applicable to coding guidelines Not applicable to coding guidelines NOTE Home Infusion Therapy Medicare has limited coverage for home infusion services. Home Infusion services must be reported on the 837P transaction using applicable home infusion HCPCS codes (per diem S codes, CPT home infusion nurse visit codes, and drug codes). Providers must perform/provide all services as defined in order to report the S code(s). Related NDC codes for compounded products are itemized using the LIN and CTP segments. 48

A.5.2 Behavioral Health Procedure Code/Modifier Combinations for Specific Benefit Packages Unique to State Government Programs The table below represents a list of behavioral health procedure code and modifier combinations for identifying specific benefit packages unique to state government programs. Mental Health Related Modifiers HA HE HK HM HN HQ HR HW UA UD U4 U5 U7 Child/adolescent program Mental health program Specialized mental health programs for high-risk populations Less than bachelor s degree Bachelor s degree Group setting Family/couple with client present Funded by state mental health agency (service provided by state staff person) Children s Therapeutic Services and Supports (CTSS) Transition to community living (Adult Rehabilitation Mental Health Services (ARMHS)) Via other than face to face contact; e.g. telephone Advanced level Physician extender (includes mental health practitioner as defined by MN Statute 245.4711, Subd. 17) Please note: Table A.5.2 below references standard health care claims transactions as follows: ASC X12/005010X223A2 Health Care Claim: Institutional (837), referred to in Table A.5.2 as 837I. TABLE A.5.2 Behavioral Health Procedure Code/Modifier Combinations: For Specific Benefit Packages Unique To State Government Programs Assertive Community Treatment (ACT) An intensive, comprehensive, non-residential rehabilitative mental health services (ARMHS) team model. Consistent with ARMHS - multidisciplinary total team approach. Patients with serious mental illness who require intensive services; time unlimited basis, available 24/7/365. Face-to-face, all-inclusive daily rate. One provider per day. 49

TABLE A.5.2 Behavioral Health Procedure Code/Modifier Combinations: For Specific Benefit Packages Unique To State Government Programs Codes: H0040 - Assertive community treatment program, per diem Adult Crisis Response Services -- County or county-contracted mental health professional, practitioner, or rehab worker; or crisis intervention team. Crisis assessment, intervention, stabilization, community intervention. Immediate, face-to-face evaluation, determine need for emergency services or referrals to other resources. Codes: S9484 adult individual crisis assessment, intervention and stabilization, individual, by mental health professional or practitioner S9484 HM adult crisis assessment, intervention and stabilization, individual, by mental health rehabilitation worker S9484 HN adult crisis assessment, intervention and stabilization, individual, by mental health practitioner S9484 HQ adult crisis stabilization, group H0018 adult crisis stabilization, residential 90882 HK environmental intervention for medical management, community intervention 90882 HK HM environmental intervention for medical management, community intervention, mental health rehabilitation worker Children's Mental Health Crisis Response Services Intensive face-to-face, short-term services initiated during a crisis; provided on-site by a mobile crisis response team. County or county contracted agency. Codes: S9484 UA - crisis intervention mental health services, per hour, Children s Crisis Response Services, mental health professional S9484 UA HN - crisis intervention mental health services, per hour, Children s Crisis Response Services, bachelors degree level mental health practitioner Mental Health Targeted Case Management (MH-TCM) Community support plan and functional assessment to help SPMI adults and SED children gain access to needed medical, social educational, vocational, financial services relative to mental health needs. Codes: T2023 HE HA targeted case management; per month, mental health program, child/adolescent program, face-to-face contact between case manager and recipient under 18 years T2023 HE targeted case management; per month, mental health program, face-toface contact between case manager and recipient 18 years or older T2023 HE TF - targeted case management intermediate level of care; per month, 50

TABLE A.5.2 Behavioral Health Procedure Code/Modifier Combinations: For Specific Benefit Packages Unique To State Government Programs mental health program, face-to face contact between case manager and recipient 18 years or older T2023 HE TG - targeted case management complex/high level of care; per month, mental health program, face-to face contact between case manager and recipient 18 years or older T2023 HE U4 targeted case management, per month, mental health program, telephone contact between case manager and recipient 18 years or older T1017 HE targeted case management, per encounter (day), mental health program, adult, face-to-face contact between case manager and recipient age 18 or older, IHS/638 facilities and FQHCs T1017 HE HA targeted case management, per encounter (day), mental health program, child/adolescent program, face-to-face contact between case manager and recipient under 18 years, IHS/638 facilities and FQHCs Children's Mental Health Residential Treatment Services 24-hour-a-day program under clinical supervision of a mental health professional, provided in a community setting. When reporting room and board and/or treatment services, report on the 837I type of bill 86X, with the room and board and treatment services as separate line items. Submit the room and board charges under revenue code 1001 and the treatment services under revenue codes 090X or 091X. Intensive Residential Treatment Services (IRTS) Time-limited mental health services provided in a residential setting to recipients in need of more restrictive settings and at risk of significant functional deterioration. Develop and enhance psychiatric stability, personal and emotional adjustment, self-sufficiency and skills to live in a more independent setting. When reporting room and board and treatment services, report on the 837I type of bill 86X, with the room and board and treatment services as separate line items. Submit the room and board charges under revenue code 1001 and the treatment services under revenue codes 090X or 091X. When room and board and treatment are billed to separate entities, treatment is reported on the 837P, with HCPCS Code H0019. Adult Day Treatment A structured program of group psychotherapy and other intensive therapeutic services provided by a multidisciplinary team to stabilize a recipient's mental health status, develop and improve independent living and socialization skills Codes: H2012 - behavioral health day treatment, per hour Children's Day Treatment 51

TABLE A.5.2 Behavioral Health Procedure Code/Modifier Combinations: For Specific Benefit Packages Unique To State Government Programs A structured MH treatment program consisting of group psychotherapy and other intensive therapeutic services provided by multidisciplinary team. Codes: 90804 UA HK - individual psychotherapy, 20-30 minutes, CTSS, specialized mental health treatment program for high risk population, children s day treatment 90805 UA HK - individual psychotherapy with E/M, 20-30 minutes, CTSS, specialized mental health treatment program for high risk population, children s day treatment 90806 UA HK - individual psychotherapy, 45-50 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90807 UA HK - individual psychotherapy with E/M, 45-50 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90808 UA HK - individual psychotherapy, 75-80 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90809 UA HK - individual psychotherapy, with E/M, 75-80 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90810 UA HK individual psychotherapy, interactive, CTSS, specialized mental heath treatment program for high risk population, children s day treatment 90853 UA HK group psychotherapy, CTSS, specialized mental health treatment program for high risk population, children s day treatment 90857 UA HK interactive group psychotherapy, CTSS, specialized mental health treatment program for high risk population, children s day treatment 90875 UA HK - biofeedback training, CTSS, specialized treatment program for high risk population, children s day treatment 90811 UA HK - interactive individual psychotherapy with E/M 20-30 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90812 UA HK - interactive individual psychotherapy 45-50 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90813 UA HK - interactive individual psychotherapy with E/M 45-50 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90814 UA HK - interactive individual psychotherapy 75-80 minutes, CTSS, specialized treatment program for high risk population, children s day treatment 90815 UA HK - interactive individual psychotherapy 75-80 minutes, CTSS, specialized treatment program for high risk population, children s day treatment H2014 UA HK - skills training & development, individual, per 15 minutes, CTSS, specialized treatment program for high risk population, children s day treatment H2014 UA HK HQ - skills training & development, group, per 15 minutes, CTSS, specialized treatment program for high risk population, children s day treatment Children's Therapeutic Services and Supports (CTSS) Rehabilitative services that offer a broad range of medical and remedial services and skills to help restore individuals self-sufficiency/functional abilities - a flexible package of mental health services for children. Codes: 52

TABLE A.5.2 Behavioral Health Procedure Code/Modifier Combinations: For Specific Benefit Packages Unique To State Government Programs 90804 UA - individual psychotherapy, 20-30 minutes, CTSS 90805 UA - individual psychotherapy with E/M, 20-30 minutes, CTSS 90806 UA - individual psychotherapy, 45-50 minutes, CTSS 90807 UA - individual psychotherapy with E/M, 45-50 minutes, CTSS 90808 UA - individual psychotherapy, 75-80 minutes, CTSS 90809 UA - individual psychotherapy, with E/M, 75-80 minutes, CTSS 90875 UA - biofeedback training, CTSS 90846 UA - family psychotherapy without patient, CTSS 90847 UA - family psychotherapy with patient, CTSS 90849 UA - multiple family group psychotherapy, CTSS 90810 UA - interactive individual psychotherapy 20-30 minutes, CTSS 90811 UA - interactive individual psychotherapy with E/M 20-30 minutes, CTCC 90812 UA - interactive individual psychotherapy 45-50 minutes, CTSS 90813 UA - interactive individual psychotherapy with E/M 45-50 minutes, CTSS 90814 UA - interactive individual psychotherapy 75-80 minutes, CTSS 90815 UA - interactive individual psychotherapy 75-80 minutes, CTSS 90853 UA - group psychotherapy, CTSS H2014 UA - skills training & development, individual, per 15 minutes, CTSS H2014 UA HQ - skills training & development, group, per 15 minutes, CTSS H2014 UA HR - skills training & development - family, per 15 minutes, CTSS H2015 UA - comprehensive community support services - crisis assistance, 15 minutes, CTSS H2012 UA - behavioral health day treatment, per hour, therapeutic components of preschool program, 60 minutes, CTSS H2019 UA - therapeutic behavioral services, Level I Mental Health Behavioral Aide (MHBA), 15 minutes, CTSS H2019 UA HM - therapeutic behavioral services, Level II MHBA, 15 minutes, CTSS H2019 UA HE - Therapeutic behavioral services direction of MHBA, 15 minutes, CTSS Adult Rehabilitative Mental Health Services (ARMHS) Develop and enhance psychiatric stability, social competencies, personal and emotional adjustment and independent living and community skills. Codes: H2017 - basic living and social skills, individual; mental health professional or practitioner, per 15 minutes H2017 HM - basic living and social skills, individual; mental health rehabilitation worker, per 15 minutes H2017 HQ - basic living and social skills, group; mental health professional, practitioner, or rehabilitation worker, per 15 minutes H2017 UD - basic living and social skills, transitioning to community, mental health professional or practitioner H2017 UD HM - basic skills, transitioning to community, less than bachelor's degree level, mental health rehabilitation worker 90882 environmental/community intervention, mental health professional or practitioner 53

TABLE A.5.2 Behavioral Health Procedure Code/Modifier Combinations: For Specific Benefit Packages Unique To State Government Programs 90882 HM environmental/community intervention, mental health rehabilitation worker 90882 UD environmental/community intervention; transition to community living intervention 90882 UD HM environmental/community intervention; transition to community living intervention, less than bachelor's degree level, mental health rehabilitation worker H0034 - Medication education,- individual: MD, RN, PA or Pharmacist H0034 HQ - Medication education, group setting Peer Services Non-clinical support counseling services provided by certified peer specialist. H0038 certified peer specialist services, per 15 minutes H0038 U5 advanced level certified peer specialist services, per 15 minutes A.5.3 Table 3 Substance Abuse Services Please note: Table A.5.3 below references standard health care claims transactions as follows: ASC X12/005010X222A1 Health Care Claim: Professional (837), referred to in Table A.5.3 as Professional or 837P. ASC X12/005010X223A2 Health Care Claim: Institutional (837), referred to in Table A.5.3 as Institutional or 837I The table below is for reporting substance abuse services. It incorporates both institutional and professional claim types for ease of reference. Service Description A.5.3 Table 3 Substance Abuse Services Unit Revenue Code HCPCS Procedure Code Claim Type Type of Bill Hospital (Facility licensed as a hospital under Minnesota Statutes section 144.50 to 144.56) Room and board Day 0118 0128 0138 N/A 837I 011x hospital inpatient Option 1 0148 0158 Detox 0116, 0126, 0136, 0146, 54

A.5.3 Table 3 Substance Abuse Services Service Description Unit Revenue Code 0156 Treatment component 0944 or 0945 Ancillary services Based on revenue code As appropriate HCPCS Procedure Code Claim Type Type of Bill Option 2 All inclusive room and board Day 0101 and treatment Detox 0116, 0126, 0136, 0146, 0156 Ancillary services Based As appropriate on revenue code All Other Residential Room and board Day 1002 (residentially licensed chemical dependency treatment provider, e.g., Rule 31 Licensed facility, Children s Residential Facility with CD certification, Tribal CD licensed facility) None 837I 086x special facility, residential facility 1003 (facilities licensed to provide room and board services only, e.g., board and lodge, supervised living facility, 55

A.5.3 Table 3 Substance Abuse Services Service Description Unit Revenue Code foster care) HCPCS Procedure Code Claim Type Type of Bill Detox 0116, 0126, 0136, 0146, 0156 Treatment program, treatment component 0944 or 0945 or 0949 0944 or 0945 or 0949 are appropriate, but may not be reported together (must be used separately) Ancillary services Based As appropriate on revenue code Outpatient Services Applicable to all providers and settings Outpatient program; Treatment only Hour 0944 or 0945 H2035 H0005 837I 089x or 013x Medication Assisted Therapy (MAT) methadone, buprenorphine, naltrexone, antabuse Hour N/A H2035 H0005 837P 0944 H0020 837I Day (LIN segment to identify drug) N/A H0020 837P Day (LIN segment to identify drug) N/A 089x or 013x N/A 56

Service Description Alcohol and/or drug assessment Outpatient Ancillary Services A.5.3 Table 3 Substance Abuse Services Unit Session/ visit Session/ visit Based on revenue code Revenue Code HCPCS Procedure Code Claim Type Type of Bill 0900 H0001 837I As appropriate N/A H0001 837P N/A As appropriate 837I 089X or 013X 57

A.5.4 Agencies Maternal And Child Health Billing Guide For Public Health The table below is for reporting Maternal and Child Health services for public health agencies. Maternal And Child Health Billing Guide For Public Health Agencies Place of Service Home or Place of Residence (Use appropriate POS) Public Health Clinic (POS 71) PUBLIC HEALTH NURSE CLINIC SERVICES Services Include: Health Promotion & Counseling T1015 Nursing Assessment & Diagnostic Testing S9123 Medication Management Nursing Treatment Nursing Care, in the home, by RN (PHN & CPHN) Home health aide or CNA, per visit T1021 Patient Education only - if no other services (includes car seat education) S9123 Individual S9445 Group S9446 MATERNAL & CHILD HEALTH VISITS Birthing Classes S9442 Home Visit for Postnatal assessment & follow up care - Mother 99501 Home Visit for Post-natal assessment & follow up care - newborn 99502 Enhanced Services - for at-risk pregnancies as determined by the physician/nurse practitioner At-Risk Antepartum Management H1001 H1001 58

Maternal And Child Health Billing Guide For Public Health Agencies Place of Service Home or Place of Residence (Use appropriate POS) Public Health Clinic (POS 71) At-Risk Care Coordination H1002 H1002 At-Risk Prenatal Health Education H1003 H1003 At-Risk Prenatal Health Education I H1003 H1003 At-Risk Prenatal Health Education II H1003 H1003 At-Risk Enhanced Service; Follow-up Home Visit H1004 At-Risk Enhanced Service Package H1005 H1005 OTHER SERVICES Prenatal Nutrition Education, Medical Nutrition Therapy; initial assessment and intervention, individual, face-to-face with 97802 97802 patient, each 15 minutes Prenatal Nutrition Education, Medical Nutrition Therapy; initial re-assessment and intervention, individual, face-to-face 97803 97803 with patient, each 15 minutes MISCELLANEOUS Maternal Depression Screenings 99420 99420 Child Developmental Screenings 96110 96110 Child Mental Health Screenings 96110 UC 96110 UC TB Case Management T1016 T1016 TB Direct Observation Therapy H0033 H0033 59

Appendix B K3 SEGMENT USAGE INSTRUCTIONS The K3 segment in the 2300 and 2400 Loops is used to meet regulatory requirements when the X12N Committee has determined that there is no alternative solution within the current structure of the 005010X222A1. The situations noted here have been approved by the X12N Committee and will be considered as a business need in development of future versions of this transaction. If multiple K3 needs exist on a single claim at the same loop level, it is recommended that separate K3 segments be sent. State of Jurisdiction In workers compensation, insurance carriers have indicated a need to determine jurisdiction in certain situations. For this workers compensation implementation, providers may populate this field with the appropriate state code. LU is the qualifier to indicate this value and should be followed by the two-character state code. Report at 2300 Loop only. K3*LUMN~ Tooth Number/Oral Cavity Oral surgeons and other non-dentist providers that supply oral cavity related procedures may have a need to report tooth number and/or oral cavity within the 005010X222A1 for proper benefit determination. To report the tooth number and/or oral cavity, the K3 segment should be used. JP is the qualifier to indicate this value tooth number and should be followed by the actual tooth number value. Multiple tooth numbers may be reported in the same K3 segment with a space break between each number as indicated by the second example below. Report at 2400 Loop only. K3*JP12~ K3*JP12 14~ JO is the qualifier to indicate oral cavity and should be followed by the oral cavity value. Multiple oral cavities may be reported in the same K3 segment with a space break between each number. Report at 2400 Loop only. K3*JO10~ NOTE: Additional information can be found concerning the use of the K3 segment discussed here on the ASC X12N Interpretations Portal: http://www.x12n.org/portal. Search for HIR numbers: 628: State of Jurisdiction 638: Send Tooth Information in K3 60

Appendix C REPORTING MNCare TAX NOTE: Instructions for MNCare Tax billing only apply if the provider bills the group purchaser for MNCare Tax. Some providers do not bill the group purchaser for MNCare Tax. This document DOES NOT require them to do so but if they do identify the tax it must be done as follows. Some group purchasers may not reimburse MNCare Tax unless it is identified in the AMT. MNCare Tax must be reported as part of the line item charge and reported in the corresponding AMT tax segment on the lines. 61

Appendix D EXAMPLES: DATA PREVIOUSLY SUBMITTED IN THE NTE SEGMENT NOW SUBMITTED IN THE SV, LIN, OR HI SEGMENTS The 5010 version of the 837 (ASC/X12 005010X222A1 Health Care Claim: Professional (837)) requires that certain information previously submitted in the NTE segment now be submitted in the SV, LIN, or HI segments. The table below is not an all-inclusive list but provides examples of scenarios in which data reporting has changed. Table 1. Example data previously provided in NTE in version 4010 with current 5010 usage Examples Data provided in NTE in 4010 5010 Usage Dental Policy Dental policy to include the diagnosis if the treatment is accident related, for cleft lip/palate or TMJ diagnosis HI Hearing Aids Hearing Aids: Purchase requires the model number from the hearing aid contract. SV Medical Supplies/Enteral Products Medical Supplies/ Enteral Products: Description of supply for auto pricing SV Modifiers Modifiers: 5 + modifiers; use 99 in the fourth modifier position and list the additional modifiers SV NDC for certain drugs E.g., unlisted drug codes, compounded drugs, physician administered drugs LIN Unlisted codes SV 62

NOC HCPCS/CPT code, regardless of charge, needs a narrative description submitted. Miscellaneous CPT/CDT Codes require a description of service to determine if covered. 63