slide 1 march 31, 2005 texas health care information collection thcic 837 claim technical discussion
TRANSCRIPT
March 31, 2005
Slide 1 Texas Health Care Information CollectionTexas Health Care Information Collection
THCIC 837 ClaimTHCIC 837 Claim
Technical Discussion Technical Discussion
Texas Health Care Information Collection 2
Slide 2 Agenda
• Terminology
• UB92 verses 837
• 837 Control Structure
• THCIC 837 Example
Texas Health Care Information Collection 3
Slide 3 Terminology
UB92
• Batches of claims
• Multiple physical records per claim.
837
• Transaction sets
• 1 or more physical records per transaction set
Texas Health Care Information Collection 4
Slide 4 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)
Texas Health Care Information Collection 5
Slide 5 Terminology
UB92
• 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.
Texas Health Care Information Collection 6
Slide 6 UB92 versus 837
Patient Data
Name, address, city, state, zip, birth date
UB92 Record: 20
837 Loop: 2010CA Segments: NM1, N3, N4, DMG
Texas Health Care Information Collection 7
Slide 7 UB92 versus 837
UB92
20⌂⌂WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂ 33 characters
837
NM1*QC*1*WEISS*RON* 19 characters
Patient Last Name
Patient First Name
Texas Health Care Information Collection 8
Slide 8 UB92 versus 837
20WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂
NM1*QC*1*WEISS*RON*
First Name
Patient
Last Name
Name Segment
Person
Record TypeSeq
No
Last Name First Name
Texas Health Care Information Collection 9
Slide 9 File Control Structure
ISA (Interchange Header) ------ only one per file
GS (Functional Group start) ------ multiple per submission used for a group of similar transaction
sets
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
Texas Health Care Information Collection 10
Slide 10
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
Texas Health Care Information Collection 11
Slide 11
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.
Case
Texas Health Care Information Collection 12
Slide 12
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
Texas Health Care Information Collection 13
Slide 13
1
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.
Interchange ControlHeader - Trailer
Texas Health Care Information Collection 14
Slide 14
1
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.
Interchange ControlHeader - Trailer
Texas Health Care Information Collection 15
Slide 15
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*1455*U*00401*111111111*0*T*:~
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.
Interchange ControlHeader - Trailer
Texas Health Care Information Collection 16
Slide 16
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*1455*U*00401*111111111*0*T*:~
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
Texas Health Care Information Collection 17
Slide 17
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
Texas Health Care Information Collection 18
Slide 18
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
Texas Health Care Information Collection 19
Slide 19
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*1455*U*00401*111111111*0*T*:~
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
Texas Health Care Information Collection 20
Slide 20
1 2 ST*837*3333~
3 4
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
Texas Health Care Information Collection 21
Slide 21 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.
Texas Health Care Information Collection 22
Slide 22
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.
Texas Health Care Information Collection 23
Slide 23 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
Texas Health Care Information Collection 24
Slide 24 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.
Texas Health Care Information Collection 25
Slide 25 HLs
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
Texas Health Care Information Collection 26
Slide 26 HLs
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
Texas Health Care Information Collection 27
Slide 27 HLs
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
Texas Health Care Information Collection 28
Slide 28 HLs
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
Texas Health Care Information Collection 29
Slide 29 HLs
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
Texas Health Care Information Collection 30
Slide 30 Billing / Pay-To Provider
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.
Texas Health Care Information Collection 31
Slide 31 Billing / Pay-To Provider
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.
Texas Health Care Information Collection 32
Slide 32 Billing / Pay-To Provider
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 [email protected] to verify information.
Texas Health Care Information Collection 33
Slide 33 Billing / Pay-To Provider
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.
Texas Health Care Information Collection 34
Slide 34 Billing / Pay-To 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
Texas Health Care Information Collection 35
Slide 35 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.
Texas Health Care Information Collection 36
Slide 36 Subscriber – Primary Payer
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
Texas Health Care Information Collection 37
Slide 37 Subscriber – Primary Payer
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.
Texas Health Care Information Collection 38
Slide 38 Subscriber – Primary Payer
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.
Texas Health Care Information Collection 39
Slide 39 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.
Texas Health Care Information Collection 40
Slide 40 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.
Texas Health Care Information Collection 41
Slide 41 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
Texas Health Care Information Collection 42
Slide 42 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.
Texas Health Care Information Collection 43
Slide 43 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.
Texas Health Care Information Collection 44
Slide 44 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
Texas Health Care Information Collection 45
Slide 45 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.
Texas Health Care Information Collection 46
Slide 46 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
Texas Health Care Information Collection 47
Slide 47 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.
Texas Health Care Information Collection 48
Slide 48 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
Texas Health Care Information Collection 49
Slide 49 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
Texas Health Care Information Collection 50
Slide 50 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
Texas Health Care Information Collection 51
Slide 51 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
Texas Health Care Information Collection 52
Slide 52 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
Texas Health Care Information Collection 53
Slide 53 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
Texas Health Care Information Collection 54
Slide 54 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
Texas Health Care Information Collection 55
Slide 55 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.
Texas Health Care Information Collection 56
Slide 56 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
Texas Health Care Information Collection 57
Slide 57 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
2 Last name 3 First name
4 Qualifier for state license 5 State license
Texas Health Care Information Collection 58
Slide 58 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.
Texas Health Care Information Collection 59
Slide 59 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.
Texas Health Care Information Collection 60
Slide 60 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
Texas Health Care Information Collection 61
Slide 61 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
Texas Health Care Information Collection 62
Slide 62
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
Texas Health Care Information Collection 63
Slide 63 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
Texas Health Care Information Collection 64
Slide 64 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.
Texas Health Care Information Collection 65
Slide 65 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
Texas Health Care Information Collection 66
Slide 66 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
Texas Health Care Information Collection 67
Slide 67 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.
Texas Health Care Information Collection 68
Slide 68 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
Texas Health Care Information Collection 69
Slide 69 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.
Texas Health Care Information Collection 70
Slide 70 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.
Texas Health Care Information Collection 71
Slide 71 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).
Texas Health Care Information Collection 72
Slide 72 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.
Texas Health Care Information Collection 73
Slide 73
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.
Texas Health Care Information Collection 74
Slide 74 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
Texas Health Care Information Collection 75
Slide 75 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.
Texas Health Care Information Collection 76
Slide 76 Practitioners
1 2 3 NM1*71*1*RICHARDS*SAM~ 4 5REF*1G*C96522~ 6 7 REF*0B*C9312~
1 Identifier for attending practitioner
2 Last name 3 First name
4 Identifier for UPIN 5 UPIN
6 Identifier for state license 7 State license
Texas Health Care Information Collection 77
Slide 77 Other Subscriber - Payer
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.
Texas Health Care Information Collection 78
Slide 78 Other Subscriber - Payer
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
Texas Health Care Information Collection 79
Slide 79 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.
Texas Health Care Information Collection 80
Slide 80 Questions ?Questions ?
Ron WeissRon Weiss
Bruce BurnsBruce Burns
6453www.dshs.state.tx.us/thcic