4010A1 to 5010 Training 1 2 Loop ID Reference Name Codes Notes / Comments SD 2 Loop ID Reference Name Codes 3 4010A1 4 8 9 10 1000A PER03 1000A PER05 1000A PER07 Communication Number ED, EM, FX. Qualifier TE Communication Number ED, EM, EX, Qualifier FX, TE Communication Number ED, EM, EX, Qualifier FX, TE 2010AA NM108 Identification Code Qualifier 2010AA NM109 Billing Provider Identifier 2010AB NM108 Identification Code Qualifier 2010AB NM109 Pay-to Provider Identifier 11 12 13 5010 START 837 P 5 6 7 24, 34, XX 837P - 1000A - PER - SUBMITTER EDI CONTACT INFORMATION Communication Number EM, FX. TE 1000A PER03 R Qualifier Communication Number EM, EX, FX, 1000A PER05 S Qualifier TE Communication Number EM, EX, FX, 1000A PER07 S Qualifier TE 837P - 2010AA - NM1 - BILLING PROVIDER NAME R 2010AA NM108 Identification Code Qualifier Billing Provider Identifier 837P - 2010AB - NM1 - PAY-TO ADDRESS NAME 24, 34, XX XX Value Deleted Value Deleted Value Deleted Value Deleted Usage change to Situational Usage change to Situational 4010 - 70/ 5010 - 77 4010 -71/ 5010 - 77 4010 - 71/ 5010 - 78 4010 - 83/ 5010 - 89 4010 - 83/ 5010 - 90 R 2010AA NM109 R 2010AB NM108 Identification Code Qualifier Value Deleted 4010 - 97/ Usage changed 5010 to N/U 102 R 2010AB NM109 Identification Code Name Change 4010 - 97/ Usage changed 5010 to N/U 102 14 15 16 4010 Notes / Page # / FOR REVIEW 5010 Comments Page # 837P - 2300 - HI - HEALTH CARE DIAGNOSIS CODE 2300 HI HEALTH CARE DIAGNOSIS CODE S 17 18 NM101 Entity Identifier Code 77, FA, LI, TL 19 20 2320 SBR01 21 2320 24 25 SBR02 Payer Responsibility Sequence Number Code Individual Relationship Code P, S, T R 2310C HEALTH CARE DIAGNOSIS CODE NM101 Entity Identifier Code 837P - 2320 - SBR - OTHER SUBSCRIBER INFORMATION Payer Responsibility 2320 SBR01 Sequence Number R Code 77 A, B, C, D, E, F, G, H, P, S, T, U 01, 04, 05, 07, 10, 15, 17, 18, 19, Individual Relationship 20, 21, 22, 2320 SBR02 R Code 23, 24, 29, 01, 18, 19, 32, 33, 36, 20, 21, 39, 39, 40, 41, 43, 53, G8 40, 53, G8 837P - 2320 - AMT - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT COORDINATION OF BENEFITS (COB) 2320 AMT TOTAL NONCOVERED AMOUNT 837P - 2320 - AMT - REMAINING PATIENT LIABILITY 2320 26 27 HI Usage changed to Required 4010 252 / 5010 - 226 Loop ID Change Value Deleted 4010 2310D 289 5010 2310C 270 Value Added 4010 302/ 5010-296 Value Deleted 4010 302/ 5010-296 837P - 2310C - NM1 - SERVICE FACILITY LOCATION NAME 2310D 22 23 2300 AMT REMAINING PATIENT LIABILITY 837P 2320 - AMT - COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT New Segment 5010-306 New Segment 5010 -307 2320 AMT 28 29 COORDINATION OF BENEFITS (COB) PATIENT RESPONSIBILITY AMOUNT S DMG 30 31 OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION S Segment Deleted 4010 326 Value Deleted 4010 329 / 5010 - 308 New Segment 5010 322 Usage changed to Situational ERRATA Jun 10 5010 323 837P - 2320 - OI - OTHER INSURANCE COVERAGE 2320 OI06 Release of Information Code A, I, M, N, O, Y 32 33 R 2320 OI06 Release of Information Code I, Y 837P - 2330B - N3 - OTHER PAYER ADDRESS OTHER PAYER S 2330B N3 ADDRESS 837P - 2330B - N4 - OTHER PAYER CITY, STATE, ZIP CODE 2330B 2330B S 36 37 2330B N4 OTHER PAYER CITY, STATE, ZIP CODE 837P - 2420A - PRV - RENDERING PROVIDER SPECIALTY INFORMATION 2420A PRV02 Reference Identification Qualifier ZZ 38 39 R 2420A PRV02 Reference Identification Qualifier PXC 4010 Value Changed 490 / 5010 - 433 837P 2420C - NM1 - SERVICE FACILITY LOCATION NAME 2420C 40 4010 318 837P - 2320 - DMG - OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION 2320 34 35 Segment Deleted NM101 Entity Identifier Code 77, FA, LI, TL R 2420C NM101 Entity Identifier Code 77 Value Deleted 4010 499 / 5010 - 442 2420C NM103 Laboratory or Facility Name S 41 42 NM103 837P - 2430 - SVD - LINE ADJUDICATION INFORMATION 2430 SVD03-1 Product or Service ID Qualifier HC, IV, ZZ 43 44 R 2430 SVD03-1 Product or Service ID Qualifier ER, HC, IV, WK 837P - 2430 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2430 AMT LIABILITY 45 46 END 837 P 47 48 START 835 Value Change 4010 555 / 5010 - 481 New Segment 5010 491 Value Deleted 4010 - 53 / 5010 78 835 - __ - TRN - REASSOCIATION TRACE NUMBER ___ TRN03 Payer Identifier =BPR10 49 50 R ___ TRN03 Payer Identifier 835 - 1000A - PER - PAYER TECHNICAL CONTACT INFORMATION PAYER TECHNICAL 1000A PER CONTACT INFORMATION 835 - 2100 - DTM - CLAIM RECEIVED DATE CLAIM RECEIVED 2100 DTM DATE 51 52 53 54 55 56 New Segment 5010 - 97 New Segment 5010 177 END 835 START 837 I 837I - 1000A - PER - SUBMITTER EDI CONTACT INFORMATION 1000A PER03 Communication Number ED, EM, FX. Qualifier TE R 1000A PER03 Communication Number EM, FX. TE Qualifier Value Deleted 1000A PER05 Communication Number ED, EM, EX, Qualifier FX, TE S 1000A PER05 Communication Number EM, EX, FX, Qualifier TE Value Deleted 1000A PER07 Communication Number ED, EM, EX, Qualifier FX, TE S 1000A PER07 Communication Number EM, EX, FX, Qualifier TE Value Deleted 57 58 59 2420C Usage changed 4010 to Required 499 / 5010 Increase from - 442 35 -60 Laboratory or Facility Name 4010 - 65 / 5010 74 4010 - 65 / 5010 74 4010 - 66 / 5010 75 837I - 2010AA - NM - BILLING PROVIDER NAME 60 2010AA NM108 Identification Code Qualifier 2010AA NM109 Billing Provider Identifier 61 24, 34, XX 62 63 R 2010AA NM108 Identification Code Qualifier R 2010AA NM109 Billing Provider Identifier Value Deleted Usage change to Situational Usage change to Situational 4010 - 77 / 5010 86 4010 - 78 / 5010 86 837I - 2010AB - NM - PAY-TO ADDRESS NAME 2010AB NM108 Identification Code Qualifier 2010AB NM109 Pay-to Provider Identifier 24, 34, XX R 2010AB NM108 Identification Code Qualifier Value Deleted 4010 - 92 Usage changed / 5010 to N/U 95 R 2010AB NM109 Identification Code Name Change 4010 - 93 Usage changed / 5010 to N/U 95 64 65 66 837I - 2010BC - NM1 - PAYER NAME 2010BC NM1 PAYER NAME 67 68 R 2010BB NM1 PAYER NAME Loop Change 4010 123 / 5010 - 122 837I - 2010BB - N3 - PAYER ADDRESS 2010BC N3 PAYER ADDRESS 69 70 S 2010BB N3 PAYER ADDRESS 4010 Loop Change 126 / 5010 - 124 837I - N4 - PAYER CITY, STATE, ZIP CODE 2010BC N4 71 XX PAYER CITY/STATE/ZIP CODE S 2010BB N4 PAYER CITY, STATE, ZIP CODE Usage Changed to Required Usage changed to Situational ERRATA Jun 10 Loop Change Name Change 4010 127 / 5010 125 837I - 2300 CL1 - INSTITUTIONAL CLAIM CODE 72 2300 CL1 INSTITUTIONAL CLAIM CODE S 2300 CL1 INSTITUTIONAL CLAIM CODE 4010 Usage change 166 / 5010 to Required - 153 4010 166 / 5010 - 153 4010 167 / 5010 - 153 73 2300 CL101 Admission Type Code S 2300 CL101 Admission Type Code Code Source Change, Change to required ERRATA Jun 10 2300 CL103 Patient Status Code S 2300 CL103 Patient Status Code Usage change to Required HI PRINCIPAL ADMITTING, E-CODE AND PATIENT REASON FOR VISIT DIAGNOSIS INFORMATION 74 75 76 837I - 2300 - HI - PRINCIPAL DIAGNOSIS 2300 77 78 S HI Name Change 4010 Usage change 234 / 5010 - 184 to Required PRINCIPAL DIAGNOSIS 837I - 2310E - NM1 - SERVICE FACILITY LOCATION NAME 2310E NM101 Entity Identifier Code FA 79 80 R 2310E NM101 Entity Identifier Code 77 Value Change 4010 346 / 5010 - 342 Value Added 4010 354 / 5010 - 355 837I - 2320 - SBR - OTHER SUBSCRIBER INFORMATION 2320 81 2300 SBR01 Payer Responsibility Sequence Number Code P, S, T R 2320 SBR01 Payer Responsibility Sequence Number Code A, B, C, D, E, F, G, H, P, S, T, U 2320 SBR02 Individual Relationship Code 2320 AMT01 Amount Qualifier Code 82 83 84 85 C4 R 2320 AMT01 Amount Qualifier Code D 837I - 2320 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2320 AMT LIABILITY 837I - 2320 - AMT - COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT COORDINATION OF BENEFITS (COB) 2320 AMT TOTAL NONCOVERED AMOUNT 837I - DMG - OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION 86 87 88 89 2320 DMG 90 91 OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION S Value Deleted 4010 355 / 5010 - 355 Value Change 4010 365 / 5010 - 364 New Segment 5010 365 New Segment 5010 366 Segment Deleted 4010 382 Value Deleted 4010 385 / 5010 - 368 837I - 2320 - OI - OTHER INSURANCE COVERAGE 2320 OI06 Release of Information Code 92 93 A, I, M, N, O, Y R 2320 OI06 Release of Information Code I, Y 837I - 2400 - SV2 - INSTITUTIONAL SERVICE LINE 2400 94 95 01, 04, 05, 07, 10, 15, 17, 18, 19, 01, 18, 19, Individual Relationship 20, 21, 22, 2320 SBR02 20, 21, 39, R Code 23, 24, 29, 40, 53, G8 32, 33, 36, 39, 40, 41, 43, 53, G8 837I - 2320 - AMT - COORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT SV206 Service Line Rate S 2400 SV206 Unit Rate 837I - 2400 - REF - LINE ITEM CONTROL NUMBER Name Change, 4010 Usage change 439 / 5010 - 428 to Not Used LINE ITEM CONTROL NUMBER 837I - 2400 - NTE - THIRD PARTY ORGANIZATION NOTES THIRD PARTY 2400 NTE ORGANIZATION NOTES 837I - 2430 - SVD - LINE ADJUDICATION INFORMATION 2400 96 97 98 99 2430 SVD03-1 Product or Service ID Qualifier HC, IV, ZZ 100 101 Segment Added 5010 441 Value Change 4010 480 / 5010 - 477 New Segment 5010 487 BHT05 Time ___ BHT05 Change from 4010 - 51 Not used to / Required Element Name 5010 - 38 Change Transaction Set Creation Time 276 - 2000D - DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION 2000D DMG03 Subscriber Gender Code F, M, U 108 109 114 115 ER, HC, HP, IV, WK 5010 435 276 - ___ - BHT - BEGINNING OF HIERARCHICAL TRANSACTION 106 107 112 113 Product or Service ID Qualifier New Segment END 837 I START 276 ___ 111 SVD03-1 837I - 2430 - AMT - REMAINING PATIENT LIABILITY REMAINING PATIENT 2430 AMT LIABILITY 102 103 104 105 110 R 2430 REF R 2000D DMG03 Subscriber Gender Code F, M Usage 4010 - 73 changed from R / 5010 - S, Code - 55 Removed 276 - 2200D - REF - MEDICAL RECORD IDENTIFICATION 2200D REF REF01 REF02 REF03 REF04 END 276 MEDICAL RECORD IDENTIFICATION Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER S EA R R Segment Deleted 4010 - 83 116 117 118 START 277 277 - 2200D - REF - MEDICAL RECORD IDENTIFICATION 2200D REF REF01 119 REF02 120 121 REF03 REF04 122 123 MEDICAL RECORD IDENTIFICATION Reference Identification EA Qualifier Medical Record Number Description REFERENCE IDENTIFIER S Segment Deleted 4010 174 Value Added 4010 177 / 5010 - 155 New format allowed 4010 177 / 5010 156 R R 277 - 2200D - DTP - CLAIM SERVICE DATE 2200D DTP02 Date Time Period Format Qualifier 2200D DTP03 Claim Service Period RD8 R 2200D DTP02 Date Time Period Format Qualifier CCYYMMDDCCYYMMDD R 2200D DTP03 Claim Service Period D8, RD8 124 125 126 END 277 CCYYMMDD , CCYYMMDDCCYYMMDD
2320.dmg Segment On 837p Page
CAS 2320 Claim Level Adjustments The CAS segment in the 2320 loop is used to report prior payers claim level adjustments that caused the amount paid to differ from the amount originally charged. This segment is used if the payer in this loop has reported claim level adjustment information on the primary payer’s remittance advice. SOAPware Documentation. 2010BA Segment: DMG. Element: DMG01 (Subscriber Demographic Information Birth Date Format). NEW 837P 5010 Crosswalk (Loops. 837P – Transaction Set 5010 Change Loop ID Segment ID Data Element ID Loop/Segment/Element Name Companion Guide Rule Transaction Set Header ST Transaction Set Header (General information) Harmony recommends a maximum of 5000 CLM segments per transaction (ST – SE) as per the standard x222 (837P) implementation guide.