slide 1 march 31, 2005 texas health care information collection thcic 837 claim technical discussion

March 31, 2005

Texas Health Care Information CollectionTexas Health Care Information Collection

THCIC 837 ClaimTHCIC 837 Claim

Technical Discussion Technical Discussion

Texas Health Care Information Collection 2

Agenda

• Terminology

• UB92 verses 837

• 837 Control Structure

• THCIC 837 Example

Terminology

• Batches of claims

• Multiple physical records per claim.

• Transaction sets

• 1 or more physical records per transaction set

Terminology

UB92• Each record

contains logically related data elements.

837• Segments

one or more related data elements

• Loops

one or more segments (groups of semantically related segments)

Terminology

• Fixed length fields and records

Every data element that can be reported has a place.

Know exactly where to look for each data element.

837• Variable length

fields and records Data elements do

not have specific locations in a record.

Identifiers used to locate data element.

UB92 versus 837

Patient Data

Name, address, city, state, zip, birth date

UB92 Record: 20

837 Loop: 2010CA Segments: NM1, N3, N4, DMG

UB92 versus 837

20⌂⌂WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂ 33 characters

NM1*QC*1*WEISS*RON* 19 characters

Patient Last Name

Patient First Name

UB92 versus 837

20WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂

NM1*QC*1*WEISS*RON*

First Name

Patient

Last Name

Name Segment

Person

Record TypeSeq

Last Name First Name

File Control Structure

ISA (Interchange Header) ------ only one per file

GS (Functional Group start) ------ multiple per submission used for a group of similar transaction

ST (Transaction Start) ------ used to identify the type of transaction multiple per GS

…Transaction Segments ------ claim data

SE (Transaction End) ------ one for each ST used for balancing transaction set GE (Functional Group End) ------ one for each GS

used for balancing functional group

IEA (Interchange End) ------ one per submissionused for balancing submission

Use example to • Describe segments• Their usage• Key data elements• Issues found during test review

Spaces in this example are represented by “^” for clarity.

Building A Submission

One submission from EL GRANDE SUBMITTER, Submitter ID = SUB000

Submitting for one hospital, TEXAS STATE HOSPITAL, THCIC ID = 000116

Submission includes two claimsadmission through discharge claims

one where the subscriber is the patient, and one where the patient is the son of the

subscriber.

One submission from EL GRANDE SUBMITTER, Submitter ID = SUB000

Submitting for one hospital, TEXAS STATE HOSPITAL, THCIC ID = 000116

Submission includes two claimsadmission through discharge claims

one where the subscriber is the patient, and one where the patient is the son of the

subscriber.

ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*1455*U*00401*111111111*0*T*:~

GS functional group ST transaction set SE GE

IEA*1*111111111~

• ISA and IEA segments wrap the submission.

• ISA segment is only segment that is fixed length.

• All positions within each data element must be filled.

Interchange ControlHeader - Trailer

ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ* 2 3 4

SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*

5 6 7 8 9

1455*U*00401*111111111*0*T*:~

1 The character in position 4 (first element separator) defines the element separator to be used throughout the entire interchange.

2 Submitter ID assigned by CCS.

3 Receiver ID – ensures that claims are intended for THCIC.

4 Date for this submission.

5 Time for this submission.

ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ* 2 3 4

SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917* 5 6 7 8 9

1455*U*00401*111111111*0*T*:~

6 Interchange control number – unique to this submission. Must match element IEA02 in the IEA segment.

7 Identifies submission as Test or Production

8 Component element separator – “:” will be used to separate components within elements.

9 Defines the segment terminator to be used throughout the entire interchange.

GS functional group ST transaction set SE GE

1 2IEA*1*111111111~

1 Number of functional groups in submission.

2 Interchange control number – unique to this submission. Must match element ISA13 in the ISA segment.

GS*HC*SUB000*YTH837*20041005*1455*22*X*004010X096A1~

ST transaction setSE

GE*1*22~

IEA*1*111222333~

• GS and GE segments wrap one or more transaction sets of like transactions.

• Identifies the version of the EDI standard used.

Functional Group

1 2 3 4 5

GS*HC*SUB000*YTH837*20041005*1455*22*X* 6 004010X096A1~

1 Submitter ID assigned by CCS.

2 Receiver ID – ensures that claims are intended for THCIC.

3 Date for this functional group.

4 Time for this functional group.

5 Group control number – unique to this functional group. Must match element GE02 in the GE segment.

Functional GroupHeader - Trailer

GS*HC*SUB000*YTH837*20041005*1455*22*X*004010X096A1~

1 2GE*1*22~

1 Number of transaction sets in group.

2 Group control number – unique to this submission. Must match element GS06 in the GS segment.

Functional GroupHeader - Trailer

GS*HC*SUB000*YTH837*20041005*1455*22*X*004010X096A1~

ST*837*3333~

SE*10*3333~

GE*1*22~IEA*1*111222333~

• ST and SE segments wrap the data segments that comprise the claims for the transaction.

Transaction Set

1 2 ST*837*3333~

SE*10*3333~

1 837 claims are being reported in this transaction set.

2 Transaction set control number – unique to this transaction set. Must match element SE02 in the SE segment.

3 Number of segments in this set, including ST and SE segments.

4 Transaction Set control number – unique to this transaction set. Must match element ST02 in the ST segment.

Transaction SetHeader - Trailer

Transmission

ST*837*3333~ 1 2 3 4

BHT*0019*00*5*20040917*1455*CH~

5 REF*87*004010X96DA1~

1 Describes hierarchical application structure.

2 Transaction set reference ID.

3 Date transaction was created.

4 Time transaction was created.

5 Identifies transaction as production or test and which version of the EDI standard is used.

TransmissionSubmitter and Receiver

ST*837*3333~BHT*0019*00*5*20040917*1455*CH~REF*87*004010X96DA1~

NM1*41*2*El Grande Submitter*****46*SUB000~

NM1*40*2*THCIC*****46*YTH837~

Data segments identifying submitter and receiver.

Submitter & Receiver

ST*837*3333~BHT*0019*00*5*20040917*1455*CH~REF*87*004010X96DA1~

1 2 3 NM1*41*2*El Grande Submitter*****46*SUB000~

4 5 6NM1*40*2*THCIC*****46*YTH837~

1 Identifies segment as for submitter 2 Submitter Name 3 THCIC Submitter ID.

4 Identifies segment as for receiver 5 THCIC – receiver name 6 Receiver identifier

Billing / Pay-To Provider

ST*837*3333~BHT*0019*00*5*20040917*1455*CH~REF*87*004010X96DA1~NM1*41*2*El Grande Submitter*****46*SUB000~N1*40*2*THCIC*****46*YTH837~

HL*1**20*1~PRV*BI*ZZ~NM1*85*2*TEXAS STATE HOSPITAL*****24*750000111~N3*4901 W. 49 ST*SUITE 660~N4*AUSTIN*TX*78751~REF*1J*000116~

Goal with these segments is to identify the service provider.

HL*1**20*1~ HL*2*1*22*1~ HL*3*2*23*0~ HL*4*1*22*0~

HL segments identify levels of detail information using a hierarchical structures.

HLs used in our example: 1 Provider

2 Subscriber 3 Patient

4 Subscriber

1 2 3 4HL*1**20*1~ provider

HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient HL*4*1*22*0~ subscriber

The first HL in transaction set is for the provider.

1 HL ID 2 No parent HL 3 Characteristic - 20 – information source 4 Subordinate HLs follow

HL*1**20*1~ provider 1 2 3 4HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient HL*4*1*22*0~ subscriber

The second HL in transaction set is for the subscriber.

1 HL ID is one more than previous HL 2 Parent HL is the provider 3 Characteristic - 22 Subscriber 4 Subordinate HLs follow

HL*1**20*1~ provider HL*2*1*22*1~ subscriber 1 2 3 4HL*3*2*23*0~ patient HL*4*1*22*0~ subscriber

3rd HL in transaction set is for the patient. 1 ID of HL is one more than previous HL2 Parent HL is that of subscriber 3 Characteristic - 23 – patient 4 No subordinate HLs follow

HL*1**20*1~ provider HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient 1 2 3 4HL*4*1*22*0~ subscriber

4th HL in transaction set is for the next subscriber. 1 ID of HL is one more than the previous HL2 Parent HL is the provider 3 Characteristic - 22 subscriber4 No subordinate HLs follow

1 2 3 4HL*1**20*1~PRV*BI*ZZ~NM1*85*2*TEXAS STATE HOSPITAL*****24*7500001111~N3*4901 W. 49 ST*SUITE 660~N4*AUSTIN*TX*78751~REF*1J*000116~

Starts the Billing Provider Hierarchical Level

1 The first HL ID number is 1

2 There is no parent HL as this is the first.

3 Code defining characteristics of the HL level20 – information source

4 Child code indicator – 1 indicates that there are HLs that are subordinate to this HL.

HL*1**20*1~

1 PRV*BI~NM1*85*2*TEXAS STATE HOSPITAL*****24*7500001111~N3*4901 W. 49 ST*SUITE 660~N4*AUSTIN*TX*78751~REF*1J*000116~

Identifies which of the reported providers is the service provider.

1 Options are BI (billing) and PT (pay-to).

If the service provider is not the billing provider or the pay-to provider, then there is no PRV segment and the service provider is reported in the 2310E segments within the claim.

HL*1**20*1~PRV*BI~

1 2 3 NM1*85*2*TEXAS STATE HOSPITAL*****24*7500001111~ N3*4901 W. 49 ST*SUITE 660~N4*AUSTIN*TX*78751~REF*1J*000116~

Segment names billing provider.

1 Identifies the segment as being for the billing provider.

2 This is the only place that the provider name is reported.

3 EIN of the billing provider. Must match EIN in THCIC Provider Database.

Contact Dee Shaw at dee.shaw@dshs.state.tx.us to verify information.

HL*1**20*1~PRV*BI~NM1*85*2*TEXAS STATE HOSPITAL*****24*7500001111~

1 2 N3*4901 W. 49 ST*SUITE 660~ 3 4 5N4*AUSTIN*TX*78751~ REF*1J*000116~

1 Line one of the street address of the provider.

2 Line two of the street address of the provider.

3 City of the provider. 4 State of the provider.

5 Zip code of the provider. 1st 15 characters of address line 1 are used to validate provider.

HL*1**20*1~PRV*BI~NM1*85*2*TEXAS STATE HOSPITAL*****24*7500001111~N3*4901 W. 49 ST*SUITE 660~N4*AUSTIN*TX*78751~

1 REF*1J*000116~

THCIC hospital identifier. 1 The THCIC 6-digit hospital ID.

• Replaces the 3-digit alphanumeric THCIC facility ID used in the UB92. • Same as record 10, field 10 of the UB92T

Subscriber – Primary Payer

HL*2*1*22*1~SBR*P********CI~NM1*PR*2*ALWAYS PAYS CLAIM*****PI*HH4504~

HL and subordinate segments describing the subscriber of a claim where the subscriber is not the patient.

1 2 3 4HL*2*1*22*1~

SBR*P********CI~NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~ HL segment for subscriber with a subordinate HL for patient

1 HL ID number

2 ID of parent HL

3 HL level code – 22 for subscriber

4 Child code – 1 subordinate HL follows

HL*2*1*22*1~

1 2 3 SBR*P********CI~

NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~

Identifies payer source of claim.

1 Primary payer code.

2 Indicates that subscriber is not the patient.

3 Commercial insurance.

HL*2*1*22*1~SBR*P********CI~

1 2 3NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~

1 Payer name

2 Payer ID qualifier

3 Payer ID

In the situation where there is not insurance, then if self pay: payer name = SELF PAY, payer ID = SELF

indigent: payer name = INDIGENT, payer ID = INDIGENTcharity: payer name = CHARITY, payer ID = CHARITY, andunknown: payer name = UNKNOWN, payer ID = UNKNOWN.

Patient Info

HL*3*2*23*0~PAT*19~NM1*QC*1*WEISS*NATE~N3*P O BOX 001~N4*AUSTIN*TX*78701~DMG*D8*19800330*M**4~REF*SY*444556666~

Patient name, identifiers, demographics.

Patient Info

1 2 3 4 HL*3*2*23*0~

5 PAT*19~NM1*QC*1*WEISS*NATE~N3*P O BOX 001~N4*AUSTIN*TX*78701~DMG*D8*19800330*M**4~REF*SY*444556666~

HL segment for patient that is subordinate to the previous subscriber

1 HL ID number 2 ID of parent HL 3 HL level code – dependent 4 Child code – no subordinate HLs follow5 Identifies patient’s relationship to insured.

Patient Info

HL*3*2*23*0~PAT*19~

1 2 NM1*QC*1*WEISS*NATE~ 3 N3*P O BOX 001~ 4 5 6 N4*AUSTIN*TX*78701~

DMG*D8*19800330*M**4~REF*SY*444556666~

1 Patient last name 2 Patient first name

3 Line one of the street address of the patient

4 City 5 State 6 Zip Code

Patient Info

HL*3*2*23*0~PAT*19~ NM1*QC*1*WEISS*NATE~N3*P O BOX 001~N4*AUSTIN*TX*78701~

1 2 3DMG*D8*19800330*M**4~ 4 REF*SY*444556666~

1 Patient birth date 2 Gender 3 Race

4 Patient social security number.– Use SY qualifier.– Use 999999999 for patients without social security numbers, who

refuse to provide the number, or are covered by 42 USC 290dd-2 and 42 CFR Part 2.1.

Claim Info

CLM*100381*1000.40***11:A:1~DTP*096*TM*1045~DTP*434*RD8*20031230-20040103~DTP*435*DT*200312301119~CL1*3*2*01~REF*EA*187~NTE*UPI*2~

Claim details: including admission, diagnosis and treatment data.

Claim Info

1 2 3 4 CLM*100381*1000.40***11:A:1~DTP*096*TM*1045~DTP*434*RD8*20031230-20040103~DTP*435*DT*200312301119~CL1*3*2*01~REF*EA*187~NTE*UPI*2~

1 Patient account number (patient control number).

2 Total claim charges

3 Facility code

4 Claim frequency code

Claim Dates

CLM*100381*1000.40***11:A:1~

1 DTP*096*TM*1045~ 2 DTP*434*RD8*20031230-20040103~ 3DTP*435*DT*200312301119~ CL1*3*2*01~REF*EA*187~NTE*UPI*2~

1 Discharge time – hhmm format.2 Statement dates in a range.

3 Admission date and time - ccyymmddhhmm.

Claim Codes

CLM*100381*1000.40***11:A:1~ DTP*096*TM*1045~DTP*434*RD8*20031230-20040103~DTP*435*DT*200312301119~

1 2 3CL1*3*2*01~

4REF*EA*187~

5NTE*UPI*2~

1 Admission type 2 Admission source 3 Patient status

4 Medical record number 5 Patient ethnicity

Diagnoses, E-Codes, Treatment Codes

NTE*UPI*2~

HI*BK:486*BJ:486*BN:E2021*BN:E2022~HI*BF:49121*BF:4019~HI*BR:10012:D8:20040102~HI*BQ:4001:D8:20040102*BO:8853:20040102~HI*BI:71:RD8:20041128-20051129~HI*BH:06:D8:20041128~HI*BE:01:::307.65~HI*BG*17~

All reported using HI segment.

Identifiers are key to defining field values.

Can mix and match but best kept in order.

Principal, Admitting Diagnoses, E-Codes

1 2 3 4 5 6 7 8HI*BK:486*BJ:486*BN:E2021*BN:E2022~HI*BF:49121*BF:4019~HI*BR:10012:D8:20040102~HI*BQ:4001:D8:20040102*BO:8853:20040102~HI*BI:71:RD8:20041128-20051129~HI*BH:06:D8:20041128~HI*BE:01:::307.65~HI*BG*17~

1 Identifier for principal diagnosis 2 Principal diagnosis

3 Identifier for admitting diagnosis 4 Admitting diagnosis

5 Identifier for external cause of injury 6 E-code

7 Identifier for external cause of injury 8 E-Code

Other Diagnoses

HI*BK:486*BJ:486*BN:E2021*BN:E2022~

1 2 3 4 HI*BF:49121*BF:4019~HI*BR:10012:D8:20040102~HI*BQ:4001:D8:20040102*BO:8853:20040102~HI*BI:71:RD8:20041128-20051129~HI*BH:06:D8:20041128~HI*BE:01:::307.65~HI*BG*17~

1 Identifier for other diagnosis 2 Diagnosis code

3 Identifier for other diagnosis 4 Diagnosis code

Principal Procedure

HI*BK:486*BJ:486*BN:E2021*BN:E2022~HI*BF:49121*BF:4019~

1 2 3 4 HI*BR:10012:D8:20040102~

HI*BQ:4001:D8:20040102*BO:8853:20040102~HI*BI:71:RD8:20041128-20051129~HI*BH:06:D8:20041128~HI*BE:01:::307.65~HI*BG*17~

1 Identifier for principal procedure

2 Principal procedure code

3 Qualifier for date type 4 Principal procedure date

Other Procedure

HI*BK:486*BJ:486*BN:E2021*BN:E2022~HI*BF:49121*BF:4019~HI*BR:10012:D8:20040102~

1 2 3 4 5 6 7 8 HI*BQ:4001:D8:20040102*BO:8853:D8:20040102~HI*BI:71:RD8:20041128-20051129~HI*BH:06:D8:20041128~HI*BE:01:::307.65~HI*BG*17~

1 Identifier for ICD code 2 Other procedure code 3 Qualifier for date type 4 Other procedure date 5 Identifier for HCPCS code 6 Other procedure code 7 Qualifier for date type 8 Other procedure date

Occurrence Span

HI*BK:486*BJ:486*BN:E2021*BN:E2022~HI*BF:49121*BF:4019~HI*BR:10012:D8:20040102~HI*BQ:4001:D8:20040102*BO:8853:D8:20040102~

1 2 3 4 HI*BI:71:RD8:20041128-20051129~

HI*BH:06:D8:20041128~HI*BE:01:::307.65~HI*BG*17~

1 Identifier for occurrence span

2 Occurrence span code

3 Qualifier for date type

4 Date range associated with occurrence span code

Occurrence

HI*BK:486*BJ:486*BN:E2021*BN:E2022~HI*BF:49121*BF:4019~HI*BR:10012:D8:20040102~HI*BQ:4001:D8:20040102*BO:8853:D8:20040102~HI*BI:71:RD8:20041128-20051129~

1 2 3 4 HI*BH:06:D8:20041128~

HI*BE:01:::307.65~HI*BG*17~

1 Identifier for occurrence code

2 Occurrence code

3 Qualifier for date type

4 Date associated with occurrence code

Occurrence

HI*BK:486*BJ:486*BN:E2021*BN:E2022~HI*BF:49121*BF:4019~HI*BR:10012:D8:20040102~HI*BQ:4001:D8:20040102*BO:8853:D8:20040102~HI*BI:71:RD8:20041128-20051129~HI*BH:06:D8:20041128~

1 2 3 HI*BE:01:::307.65~ 4 5 HI*BG*17~

1 Identifier for value code 2 Value code 3 Amount

4 Identifier for condition code 5 Condition code

Practitioners

NM1*71*1*RICKSHAW*ROBERT~REF*1G*C12321~NM1*72*1*SHAW*RICK~REF*0B*C3926~

Attending and operating practitioners

Validate against license number/ UPINfirst three characters of last name first character of first name.

Practitioners

1 2 3 NM1*71*1*RICKSHAW*ROBERT~ 4 5REF*1G*C12321~

NM1*72*1*SHAW*RICK~REF*0B*C3926~

1 Identifier for attending practitioner

2 Last name 3 First name

4 Qualifier for UPIN 5 UPIN

Practitioners

NM1*71*1*RICKSHAW*ROBERT~REF*1G*C12321~

1 2 3 NM1*72*1*SHAW*RICK~ 4 5REF*0B*C3926~

1 Identifier for operating practitioner

4 Qualifier for state license 5 State license

Other Subscriber - Payer

1 2 SBR*S********ZZ~

3 4 5 NM1*PR*2*CHARITY*****PI*CHARITY~

1 Secondary subscriber2 Payer source 3 Payer name4 Payer ID qualifier5 Payer ID In the situation where there is not insurance, then if

self pay: payer name = SELF PAY, payer ID = SELF indigent: payer name = INDIGENT, payer ID = INDIGENT

charity: payer name = CHARITY, payer ID = CHARITY, andunknown: payer name = UNKNOWN, payer ID = UNKNOWN.

Service Lines

LX*1~SV2*0120*HC:2034:01:02:03:04*1230.60*DA*4*307*200~LX*2~SV2*0271**6.30*UN*1~LX*3~SV2*0258**285.80*UN*8~

Each service is preceded by a line number (LX)

Sum of charges in service lines must equal the total charges in the CLM segment.

No 0001 revenue code.

Service Lines

1 LX*1~ 2 3 4 5 6 7 8 9 10 11 12 13 SV2*0120*HC:2034:01:02:03:04*1230.60*DA*4*307*200~

LX*2~SV2*0271**6.30*UN*1~LX*3~SV2*0258**285.80*UN*8~

1 line number beginning with 1 and incremented by 1

2 Revenue Code 3 Revenue Procedure Code Qualifier

4 Revenue Procedure Code

5 - 8 Revenue Procedure Code Modifiers

Service Lines

1 LX*1~ 2 3 4 5 6 7 8 9 10 11 12 13 SV2*0120*HC:2034:01:02:03:04*1230.60*DA*4*307*200~

LX*2~SV2*0271**6.30*UN*1~LX*3~SV2*0258**285.80*UN*8~

9 Charge amount

10 Unit code 11 Quantity

12 Unit rate 13 Non-covered amount

Subscriber is PatientClaim

1 2 3 4HL*4*1*22*0~ SBR*P*18*******MA~NM1*QC*1*SMITH*JOSEPH~N3*54 TRAILS END~N4*AUSTIN*TX*78755~DMG*D8*19450220*M**4~REF*SY*555667777~NM1*PR*2*MEDICARE PART A*****PI*HH300~

HL segment for subscriber where subscriber is the patient

1 HL ID number 2 ID of parent HL 3 HL level code – 22 for subscriber

4 Child code – no subordinate HL follows

Subscriber

HL*4*1*22*0~

1 2 3SBR*P*18*******MA~NM1*QC*1*SMITH*JOSEPH~N3*54 TRAILS END~N4*AUSTIN*TX*78755~DMG*D8*19450220*M**4~REF*SY*555667777~NM1*PR*2*MEDICARE PART A*****PI*HH300~

SBR identifies payer source of claim.

1 Primary payer 2 Subscriber is the patient 3 Payer source

Patient Info

HL*4*1*22*0~ SBR*P*18*******MA~

1 2 NM1*IL*1*SMITH*JOSEPH~ 3N3*54 TRAILS END~ 4 5 6 N4*AUSTIN*TX*78755~

DMG*D8*19450220*M**4~REF*SY*555667777~NM1*PR*2*MEDICARE PART A*****PI*HH300~

1 Patient last name 2 Patient first name

3 Line 1 - Street Address 4 City 5 State 6 Zip.

Patient Info

HL*4*1*22*0~ SBR*P*18*******MA~ NM1*QC*1*SMITH*JOSEPH~N3*54 TRAILS END~N4*AUSTIN*TX*78755~

1 2 3 DMG*D8*19450220*M**4~ 4 REF*SY*555667777~ NM1*PR*2*MEDICARE PART A*****PI*HH300~

1 Patient birth date 2 Gender 3 Race

4 Social security number

Primary Payer

HL*4*1*22*0~ SBR*P*18*******MA~ NM1*QC*1*SMITH*JOSEPH~N3*54 TRAILS END~N4*AUSTIN*TX*78755~DMG*D8*19450220*M**4~ REF*SY*555667777~

1 2 NM1*PR*2*MEDICARE PART A*****PI*HH300~

1 Payer name 2 Payer ID

Claim Info

CLM*PAN1043*400***11:A:1~DTP*096*TM*0900~DTP*434*RD8*20041005-20041010~DTP*435*DT*200410050700~CL1*3*2*01~REF*EA*MRN2211~NTE*UPI*2~

Claim details: including admission, diagnosis and treatment data.

Claim Info

1 2 3 CLM*PAN1043*400***11:A:1~

DTP*096*TM*0900~DTP*434*RD8*20041005-20041010~DTP*435*DT*200410050700~CL1*3*2*01~REF*EA*MRN2211~NTE*UPI*2~

1 Patient account number (patient control number).

2 Total claim charges

3 Bill Type

Discharge Time

CLM*PAN1043*400***11:A:1~

1 2 3 DTP*096*TM*0900~ DTP*434*RD8*20041005-20041010~

DTP*435*DT*200410050700~CL1*3*2*01~REF*EA*MRN2211~NTE*UPI*2~

1 Identifies DTP as for discharge data.

2 Qualifies next element as time in format of hhmm.

3 Discharge time.

Statement Dates

CLM*PAN1043*400***11:A:1~

DTP*096*TM*0900~

1 2 3 DTP*434*RD8*20041005-20041010~ DTP*435*DT*200410050700~

CL1*3*2*01~REF*EA*MRN2211~NTE*UPI*2~

1 Identifies DTP as for statement dates.

2 Qualifies next element as being a date range.

3 Statement dates.

Admission Date and Time

CLM*PAN1043*400***11:A:1~

DTP*096*TM*0900~DTP*434*RD8*20041005-20041010~

1 2 3 DTP*435*DT*200410050700~

CL1*3*2*01~REF*EA*MRN2211~NTE*UPI*2~

1 Identifies DTP as for admission date and time.

2 Qualifies next element as being a date/time combination.

3 Admission date and admission time (hhmm).

Claim Codes

CLM*PAN1043*400***11:A:1~DTP*096*TM*0900~DTP*434*RD8*20041005-20041010~DTP*435*DT*200410050700~ 1 2 3CL1*3*2*01~ 4REF*EA*MRN2211~ 5NTE*UPI*2~

1 Admission type

2 Admission source

3 Patient status (discharge status)

4 Medical record number

5 Ethnicity of patient.

HI Segments Diagnoses, E-Codes, Treatment Codes

NTE*UPI*2~

HI*BK:100*BJ:100~

All reported using HI segment.

Qualifier is key to defining field values.

Principal, Admitting Diagnoses, E-Codes

1 2 3 4 HI*BK:100*BJ:100~

1 Identifier for principal diagnosis

2 Principal diagnosis

3 Identifier for admitting diagnosis

4 Admitting diagnosis

Practitioners

NM1*71*1*RICHARDS*SAM~REF*1G*C96522~REF*0B*C9312~

Attending practitioners

Validate against license number/ UPINfirst three characters of last name first character of first name.

Practitioners

1 2 3 NM1*71*1*RICHARDS*SAM~ 4 5REF*1G*C96522~ 6 7 REF*0B*C9312~

1 Identifier for attending practitioner

4 Identifier for UPIN 5 UPIN

6 Identifier for state license 7 State license

SBR*S********BL~ NM1*PR*2*BLUE CROSS OF TEXAS*****PI*BL0325~ SBR*T********CI~ NM1*PR*2*WELLNESS HEALTH*****PI*WELLHLT~

Secondary and tertiary subscriber - payers.

Only secondary subscriber - payer will be used.

1 2 SBR*S********BL~

3 4NM1*PR*2*BLUE CROSS OF TEXAS*****PI*BL0325~

SBR*T********CI~NM1*PR*2*WELLNESS HEALTH*****PI*WELLHLT~

1 Identifier for secondary subscriber 2 Payer source code 3 Payer name4 Payer ID

Service Lines

LX*1~SV2*0120**1000*DA*2*500.00~

Each service is preceded by a line number (LX)

Sum of charges in service lines must equal the total charges in the CLM segment.

No 0001 revenue code.

Questions ?Questions ?

Ron WeissRon Weiss

ron.weiss@dshs.state.tx.us

Bruce BurnsBruce Burns

bruce.burns@dshs.state.tx.us

6453www.dshs.state.tx.us/thcic

slide 1 march 31, 2005 texas health care information collection thcic 837 claim technical discussion

balancing submission

dmg slide

case slide

transaction set slide

patient data

texas state hospital

isa segment

gs transaction segments

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