Health Care Claim 837 Companion Guide - Blue Cross Blue Shield ...

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEBlue Cross Blue Shield of MassachusettsHealth Care Claim837 Companion GuideRefers to the following Technical Report Type 3 Guides:ASC X12N 837 Institutional (Version 005010X223A2)ASC X12N 837 Professional (Version 005010X222A1)ASC X12N 837 Dental (Version 005010X224A2)Companion Guide Version Number: 1.2.2©Blue Cross Blue Shield of Massachusetts, January 2013 1

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEPREFACEThis Companion Guide to the ASC X12N Implementation Guides adopted under HIPAA clarifies andspecifies the data content when exchanging electronically with Blue Cross Blue Shield of Massachusetts.Transmissions based on this companion guide, used in tandem with the X12N Technical Report Type 3Guides, are compliant with both X12 syntax and those guides. This Companion Guide is intended toconvey information that is within the framework of the ASC X12N Implementation Guides adopted foruse under HIPAA. The Companion Guide is not intended to convey information that in any way exceedsthe requirements or usages of data expressed in the Implementation Technical Report Type 3 Guides.©Blue Cross Blue Shield of Massachusetts, January 2013 2

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDETABLE OF CONTENTS1. INTRODUCTION ...........................................................................................................................51.1. Overview ....................................................................................................................................... 51.2. References .................................................................................................................................... 51.3. NPI Information............................................................................................................................. 51.4. Establishing a Trading Partner with BCBSMA ............................................................................... 62. TESTING.......................................................................................................................................62.1. Ramp Management ...................................................................................................................... 72.2. File Submission.............................................................................................................................. 72.3. Test Results ................................................................................................................................... 72.4. Approval........................................................................................................................................ 73. CONNECTING AND COMMUNICATING ..........................................................................................73.1. Setting Up Your Connection.......................................................................................................... 73.2. SFTP Account Request Forms........................................................................................................ 83.3. NEHEN and VPN Users .................................................................................................................. 83.4. Password Protocol ........................................................................................................................ 83.4.1. Server Accounts .................................................................................................................... 93.4.2. Individual User IDs ................................................................................................................ 93.5. Security ......................................................................................................................................... 93.6. Maintenance ...............................................................................................................................104. BCBSMA PROVIDER SUPPORT ....................................................................................................105. BCBSMA CLAIM SUBMISSION GUIDELINES..................................................................................105.1. Usage of BCBSMA Secure FTP Server Mailbox............................................................................105.2. File Name Extension....................................................................................................................115.3. Usage Indicator (ISA15)...............................................................................................................115.4. Delimiters....................................................................................................................................115.5. Special Characters.......................................................................................................................115.6. File Size Specifications ................................................................................................................116. BCBSMA Identification Number Requirements ...........................................................................127. BCBSMA SPECIFIC CONDITIONAL DATA REQUIREMENTS .............................................................127.1. 837P Professional Claims Data Specifications ............................................................................12Header Data ........................................................................................................................................12Loop Specific Data...............................................................................................................................137.2. 837I Institutional Claims Data Specifications..............................................................................17Header Data ........................................................................................................................................17Loop Specific Data...............................................................................................................................177.3. 837D Dental Claims Data Specifications .....................................................................................20Header Data ........................................................................................................................................20Loop Specific Data...............................................................................................................................208. REPORTS AND ACKNOWLEDGMENTS..........................................................................................229. BCBSMA AS A SECONDARY PAYER ..............................................................................................239.1. BCBSMA COB Requirements Quick Reference ...........................................................................2310. SPECIAL BILLING INSTRUCTIONS .................................................................................................2410.1. Medicare as Primary Payer .....................................................................................................2410.2. 837 - Subscriber Claims vs. Dependent Claims .......................................................................2410.3. 837 - Atypical Providers ..........................................................................................................2410.4. 837 Institutional - Type of Bill Convention..............................................................................25©Blue Cross Blue Shield of Massachusetts, January 2013 3

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE10.5. 837 Institutional/Professional - Provider Taxonomy Codes ...................................................2510.6. 837 Institutional - Revenue Codes ..........................................................................................2510.6.1. Vent Bends & Complex Rehabilitation Stays ......................................................................2510.6.2. ASC & Observation Services................................................................................................2510.7. 837 Professional - Early Intervention Providers......................................................................2610.8. 837 Professional - Procedure Code Modifiers for CMHC........................................................2610.9. 837 Professional - Professional/Technical Components for Radiology Services ....................2611. FACILITY CODE REQUIREMENTS FOR 837P ..................................................................................2812. APPENDICES ..............................................................................................................................28Appendix A - Interchange Acknowledgment (TA1).............................................................................28Appendix B - Health Care Claim Acknowledgment (277CA) ...............................................................28Appendix C - Implementation Acknowledgment for Health Care Insurance (999) ............................30Appendix D - Revision History.............................................................................................................31©Blue Cross Blue Shield of Massachusetts, January 2013 4

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE1. INTRODUCTION1.1. OverviewThe Health Insurance Portability and Accountability Act–Administration Simplification (HIPAA-AS) requires Blue Cross Blue Shield of Massachusetts (BCBSMA) and all other covered entitiesto comply with the electronic data interchange standards for health care as established by theSecretary of Health and Human Services.This document has been prepared as the Blue Cross Blue Shield of Massachusetts (BCBSMA)specific Companion Guide to the ASC X12N Implementation Guide(s). The goals of the BCBSMACompanion Guide are:To describe the process to become an EDI Trading Partner with Blue Cross Blue Shieldof MassachusettsTo describe the processes to set up, test, and make operational a Trading Partnerrelationship with Blue Cross Blue Shield of MassachusettsTo clarify when conditional data elements and segments must be used with Blue CrossBlue Shield of Massachusetts transactionsTo identify those codes and data elements that are not applicable to Blue Cross BlueShield of Massachusetts transactionsThis BCBSMA Companion Guide document supplements, but does not contradict anyrequirements in the ASC X12N version 5010 Implementation Guide(s) or the Addenda.1.2. ReferencesThe ASC X12N Technical Report Type 3 guides have been established as the standardfor Health Care Claims transactions, Claim Acknowledgments, and Claim Payment &Advice transactions. They are available at http://www.wpc-edi.com/HIPAA.BCBSMA Provider Portal containing documentation on transactions for providers islocated at http://www.bluecrossma.com/provider.1.3. NPI InformationAdditional information and National Provider Identifier (NPI) billing instructions are availableon the BlueLinks for Providers website at www.bluecrossma.com/provider. After logging on tothe site, click on the Resource Center tab and navigate to the Admin Guidelines & Info page.Select Blue Books and then select the subject of interest.©Blue Cross Blue Shield of Massachusetts, January 2013 5

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE1.4. Establishing a Trading Partner with BCBSMAIn order to take advantage of the transactions and communication services offered by BlueCross Blue Shield of Massachusetts, you must execute a Trading Partner agreement. ExistingBCBSMA Trading Partners for 837 Health Care Claim transactions do not need to obtain a newTrading Partner Agreement for version 5010 of the HIPAA Standard. This process is intendedfor new submitters to BCBSMA.You will receive a Trading Partner Starter Kit, which will include:Trading Partner Agreement – This legal document should be distributed to an Officerof the Corporation empowered to enter a contract on behalf of the Corporation. Werequire that two signed hard copies be delivered to BCBSMA at:Blue Cross and Blue Shield of Massachusetts, Inc.Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.Attn: Kimberly Karbott – Director, EDI Support401 Park DriveBoston, MA 02215-3326Trading Partner Enrollment Form – A collaboration of effort from your Billing Officeand Information Technology areas is suggested in order to provide accurateinformation.Secure File Transfer (SFTP) Account Request Form – This form is used for connectivitypurposes. The data provided by your Information Technology group and agents of yourBilling Office is used to grant them file transmission privileges.Both the Trading Partner Enrollment Form and Secure File Transfer Account Request Form canbe emailed to EDISupport@bcbsma.com. Please use “Enrollment and Security Forms” in theSubject of the e-mail.2. TESTINGAll sites submitting HIPAA claim submissions to BCBSMA for the first time are required to test withus prior to actual submission to the production environment. To help you achieve a successful test,appropriate format specifications have been listed in the BCBSMA Specific Data Elements section ofthis companion guide, as well as submission directions. In order to receive approval to move fromtest to production you must receive a minimum ninety-five percent “correct rate” for the test filesubmitted.Testing is an iterative process. BCBSMA will only accept one submission per iteration of testing. Thefollowing overview of the BCBSMA process for claims testing briefly describes each milestone in thetesting process.©Blue Cross Blue Shield of Massachusetts, January 2013 6

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE2.1. Ramp ManagementBCBSMA employs Edifecs Ramp Management for Trading Partner self-testing. BCBSMA canprovide you with a user name and password in order to access Edifecs Ramp Management andupload test files for automatic verification.2.2. File SubmissionYour test Health Care Claim file submission should be coordinated with a BCBSMA EDI Supportrepresentative (see Section 4 of this companion guide). For testing, we are not able to processa normal day of your production. However, the claims in your test file should simulate claimsfrom normal business. Submit your test file to BCBSMA’s Secure File Transfer Test server. ABCBSMA EDI Support representative will review the file for HIPAA compliance and BCBSMAsegment requirements.2.3. Test ResultsOnce your test file has been submitted and reviewed, a BCBSMA EDI Support representativewill contact you with the results of your most recent test. Additionally, you must retrieve youracknowledgments and reports from the test BCBSMA Secure FTP Server. If a minimum ninetyfivepercent “correct rate” was not achieved, you must coordinate with a BCBSMA EDI Supportrepresentative to submit another file.2.4. ApprovalWhen the most current test iteration has a “correct rate” of at least ninety-five percent, aProduction Move Approval message will be sent to the Primary Contract email addressprovided on your Trading Partner Enrollment Form. You may then submit and retrieve yourfiles from the Production BCBSMA Secure FTP Server.BCBSMA provides testing support Monday through Friday, 8:30AM to 4:00PM EST.3. CONNECTING AND COMMUNICATINGThe purpose of this section is to identify the process for establishing connectivity to transmitand receive electronic transactions with Blue Cross Blue Shield of Massachusetts (BCBSMA).3.1. Setting Up Your ConnectionProviders deliver and pick up files using BCBSMA’s Secure File Transfer server. Beforesubmitting transactions, all appropriate authorization forms must be completed and returnedto BCBSMA. Please refer to Section 1.4 for a list of required forms.BCBSMA provides access to its Secure File Transfer server using the HTTPS (Hypertext TransferProtocol Secure) scheme in order to create a secure channel via your web browser. It isimportant to note the differentiation between using http and https when accessing the servers.Listed below are the BCBSMA servers for Test and Production activities.©Blue Cross Blue Shield of Massachusetts, January 2013 7

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEEnvironmentTestProductionDNShttps://staging.sftp.bluecrossma.com/https://sftp.bluecrossma.com/3.2. SFTP Account Request FormsWhen submitting your Secure FTP Account Request forms, please (where applicable):Submit a Secure FTP Account Request form for your server. Include your Primary andSecondary contacts.Submit a Secure FTP Account Request form for your Primary System AdministratorSubmit a Secure FTP Account Request form for your Secondary System AdministratorSubmit a Secure FTP Account Request form for each individual Business User requiringaccess to deliver and retrieve your files.Once BCBSMA has completed processing the Secure FTP form(s) along with your ProviderTrading Partner agreement and Trading Partner Enrollment Form, you will receive:Your BCBSMA Server mailbox and supporting directory.Your User ID and password to connect your server to your BCBSMA Server mailbox.*Two individual User IDs and passwords for your Primary and Secondary SystemAdministrators.Additional individual User IDs and passwords for Business Area users, if requestedusing the Secure FTP Account Request forms.*Note: The Server account is created for those submitters utilizing a server to deliver/retrievefiles rather than the HTTPS method via their web browser.3.3. NEHEN and VPN UsersIn addition to the information above, providers using NEHEN should refer to the NEHENBCBSMA Direct Claims Implementation Guide to update their eClaims configuration files and, ifutilizing, the appropriate NEHEN Service Configurator.Providers using VPN to connect to BCBSMA should anticipate their Change Control schedule fornecessary updates to their Remote Host’s file(s) and other network configuration files.3.4. Password ProtocolThe password for your BCBSMA Secure Server account will be system generated. The passwordwill need to be changed every 90 days.©Blue Cross Blue Shield of Massachusetts, January 2013 8

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE3.4.1. Server AccountsEach registered user (using the name and email address from the Secure FTP AccountRequest form) will receive three notifications via email that the password for the Serveraccount is about to expire:Ten days prior to password expirationFive days prior to password expirationThe day of password expirationOnce one of the registered users has changed the password using the instructionsincluded in the reminder email, BCBSMA will email each registered user of your BCBSMAServer account the new password. Please remember that your server will need to beupdated with the new password for successful connection to the BCBSMA SecureServer.3.4.2. Individual User IDs3.5. SecurityAfter ninety days, BCBSMA’s Secure Server application will display an error messageindicating your password has expired. The message will advise you to reset yourpassword. A “Manage Your Password” link is provided at the bottom of the web pagewhich will allow you to change your password. Instructions as well as password criteriaare also provided via the link. The new password is good for the next ninety days.If you have forgotten your password, you can request a new one via BCBSMA’s SecureServer application. A “Manage Your Password” link is provided at the bottom of theweb page which will allow you to initiate this request. Click the “Forgot Password”button and then provide your User ID and the email address that was submitted on yourSecure FTP Account Request form. The system will generate a new password and emailthe new password directly to the individual user. The new password is good for ninetydays.BCBSMA is dedicated to maintaining the confidentiality of personal health information.BCBSMA has adopted a mindset to safeguard member information as if it were our own.Associates are required to safeguard member privacy by using reasonable measures during allphases of the information-handling process: from collection and storage, to disclosure anddisposal. This policy applies to the personally identifiable health information of all applicantsand past or present members. Information may be in the form of data in storage or in transit,on paper or in electronic format.Due to its sensitivity, the use and disclosure of PHI is restricted, except in circumstances wherepermitted or required by law or where appropriate authorization for use or disclosure isobtained. Access to PHI is limited to those with a business need to know the information fortreatment, payment, or health care operations, or as otherwise permitted or required by law.Associates with a business need to handle PHI must be identified and granted appropriateaccess in accordance with their department-level policies and procedures.©Blue Cross Blue Shield of Massachusetts, January 2013 9

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEBCBSMA maintains policies and procedures for the HIPAA compliant transfer of protectedhealth information to external health care partners. These provisions include secure filetransfer, encryption, password protection, secure fax, and other measures, as indicated basedon the nature of the data being transferred.NEHEN trading partners transmit transactions using private network frame relay connections,Virtual Private Networks (VPN) or X.509 digital certificates for Web Services connections.3.6. MaintenanceBCBSMA allows transmission of 837 Claim files 24/7. In the event of unscheduled maintenance(system abnormalities, outages), users will be notified via the contact information supplied onthe Secure FTP Account Request Form(s). To avoid possible claim errors, please do not submitany files during BCBSMA these periods.4. BCBSMA PROVIDER SUPPORTIf you cannot find the answers to your questions within this Companion Guide, please use thecontact information below to reach the appropriate BCBSMA Support area.BCBSMA EDI SupportFor technical questions or help related to any of the transactions, acknowledgments, or reportsrelated to your Health Care Claims submissions, please contact BCBSMA EDI Support.Phone: 800-771-4097 (option 4)Email: EDISupport@bcbsma.comBCBSMA Provider PortalBCBSMA Provider Portal provides information regarding our Products, Policies and Procedures,FAQs, as well as Companion Guides for various electronic transactions. Please refer to onlinedocumentation for the most up-to-date materials.Website: http://www.bluecrossma.com/provider5. BCBSMA CLAIM SUBMISSION GUIDELINES5.1. Usage of BCBSMA Secure FTP Server MailboxEvery Submitter ID mailbox contains an inbound and outbound folder. Your User ID grants youaccess to these folders. Use the inbound folder to submit your ANSI 837 claim file. Theoutbound folder should be used to retrieve the ANSI acknowledgment files, reports, and ANSI835 (if applicable).©Blue Cross Blue Shield of Massachusetts, January 2013 10

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE5.2. File Name ExtensionYour ANSI 837 claim file must be submitted with an extension of .837 (e.g. My.ClaimFile.837).You may continue to use your naming convention for the file name. Multiple nodes (periodmarkers) may also be present in the file name. BCBSMA uses the extension of .837 as a triggerto process the file. If the extension is missing or not 837, your file may not be processed.5.3. Usage Indicator (ISA15)The Usage Indicator (ISA15) in the Interchange Control Header must be appropriate for theclaims submission environment. ISA15 must equal “T” for test files. ISA15 must equal “P” forproduction files. An incorrect Usage Indicator is reported in an ANSI TA1. No other reports oracknowledgments are generated.5.4. DelimitersDelimiters are characters used to separate Data and Component elements. They are also usedto terminate a segment. The following delimiters should be used when submitting an 837 claimfile:5.5. Special CharactersCharacter Name Delimiter* Asterisk Data Element Separator^ Carat Repetition Separator: Colon Component Element Separator~ Tilde Segment TerminatorThe use of the following special characters should not be used within the claim data (e.g.Names, Addresses, and Identifiers):5.6. File Size SpecificationsComma Period Colon Semicolon, . ; :Test Claim files should contain a minimum of twenty-five (25) claims. There should not bemore than fifty (50) claims in any one Transaction Set (Batch). For testing, BCBSMA is not ableto process a normal day’s worth of production claims. However, the claims contained in yourtest file should simulate claims from normal business.Production Claim files must not exceed 4,999 claims in a single transmission. You may sendmultiple transmissions per day as long as each transmission does not exceed the notedthreshold.Note: BCBSMA will only accept claims that adhere to the requirements outlined in the most currenterrata version for an 837 Health Care Claim file.©Blue Cross Blue Shield of Massachusetts, January 2013 11

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE6. BCBSMA Identification Number RequirementsBCBSMA member IDs begin with a three character alpha prefix followed by nine (without suffix) oreleven (with suffix) numeric characters.Out-of-State BCBS member IDs begin with a three character alpha prefix followed by four tofourteen alpha-numeric characters.Federal Employee Plan (FEP) member IDs begin with the letter “R” followed by eight numericcharacters.Note: Member IDs should not contain hyphens, spaces, or any special characters.7. BCBSMA SPECIFIC CONDITIONAL DATA REQUIREMENTSThe purpose of this section is to clarify when conditional data elements and segments must be usedfor BCBSMA claims transactions. The following information is designed to help you complete an 837(P, I, D) transaction appropriately. If you follow these guidelines, we'll be better able to process yourclaims accurately and efficiently. As this is a Companion Guide, Required Segments/Elements fromthe Technical Report Guides that do not require further instructions specific to BCBSMA are notincluded in the tables below. Please refer to the appropriate Technical Report Guide.7.1. 837P Professional Claims Data SpecificationsHeader DataSegment ID Element ID Data Element Name BCBSMA Business RuleISAInterchange Control Header01 Authorization Information“00”Qualifier02 Authorization Information Use 10 spaces03 Security Information Qualifier “00”04 Security Information Use 10 spaces05 Interchange ID Qualifier “ZZ”06 Interchange Sender ID Use your BCBSMA assigned SubmitterID07 Interchange ID Qualifier “ZZ”08 Interchange Receiver ID “00200”15 Interchange Usage Indicator P – Production TransmissionT – Test TransmissionGSFunctional Group Header02 Application Sender’s Code Use your BCBSMA assigned SubmitterID03 Application Receiver’s Code “00200”08 Version/Release/IndustryIdentifier Code“005010X222A1”©Blue Cross Blue Shield of Massachusetts, January 2013 12

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDELoop Specific DataLoop ID Segment/ Data Element NameBCBSMA Business RuleElement ID1000A NM1 Submitter Name09 Identification Code Use your BCBSMA assigned SubmitterID1000B NM1 Receiver Name09 Identification Code “00200”2000A PRV Billing Provider SpecialtyInformationIn general, Provider Taxonomy Code isnot required for BCBSMA claims.However, if you have been instructedby BCBSMA to submit your ProviderTaxonomy Code in order to crosswalkyour NPI, it is required.Refer to Section 10.5 for additionalinformation. Also, refer to this segmentin the 837P TR3 Guide for instructions.2010AA NM1 Billing Provider Name01 Entity Code Identifier “85”08 Identification Code Qualifier “XX”09 Identification Code Use Billing Provider’s 10-digit NPIAtypical Providers will not use NM108or NM109. Please see Section 10 forspecial billing instructions.2010ABPay-To AddressThe purpose of this loop is to provide analternate location to send areimbursement. BCBSMA will use theaddress on its Corporate Provider filefor all reimbursement.Please refer to this Loop in the 837PTR3 Guide for instructions.2000B SBR Subscriber Information02 Individual Relationship Code “18” – Use this code only when thesubscriber is the patient. Otherwise, donot use this element.2010BA NM1 Subscriber Name08 Identification Code Qualifier “MI” – Required when MemberIdentification Number is submitted inNM109.©Blue Cross Blue Shield of Massachusetts, January 2013 13

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE09 Identification Code Use the Subscriber’s identificationnumber that was in effect on the dateof service, exactly as it appears on theBCBS ID card*. You must include theappropriate alpha prefix.*BCBSMA does not issue IdentificationNumbers to all of its members. Ifsubmitting claims for anyone other thanthe Subscriber, use Loop 2010CA.2010BB NM1 Payer Name08 Identification Code Qualifier “PI”09 Identification Code “00200”2010BB REF Billing Provider SecondaryIdentificationThis segment should only be used byAtypical Providers.01 Reference Identification Qualifier “G2”02 Reference Identification ATYPICAL PROVIDERS - Use BCBSMALegacy Provider Number2300 DTP Date - AccidentUse if CLM11-1 or CLM11-2 = “AA”,“OA”, or “EM” (and claim is the result ofan accident).Refer to this segment in the 837P TR3Guide for instructions.2310A NM1 Referring Provider Name01 Entity Identifier Code “DN”08 Identification Code Qualifier “XX”09 Identification Code Use Referring Provider’s 10-digit NPI2310BRendering Provider NameIf you have been instructed by BCBSMAto submit Rendering Providerinformation, it is required.Refer to this loop in the 837P TR3 Guidefor instructions.2310B NM1 Rendering Provider Name01 Entity Identifier Code “82”08 Identification Code Qualifier “XX”09 Identification Code Use Rendering Provider’s 10-digit NPIAtypical Providers will not use NM108or NM109. Please see Section 10 forspecial billing instructions.2310B REF Rendering Provider SecondaryIdentificationThis segment should only be used byAtypical Providers.01 Reference Identification Qualifier “G2”08 Reference Identification ATYPICAL PROVIDERS - Use BCBSMALegacy Provider Number©Blue Cross Blue Shield of Massachusetts, January 2013 14

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE2310B PRV Rendering Provider SpecialtyInformation2310C NM1 Service Facility Location Name01020308092310C N3 Service Facility Location Address2310C N4 Service Facility Location City,State, Zip Code010203In general, Provider Taxonomy Code isnot required for BCBSMA claims.However, if you have been instructedby BCBSMA to submit your ProviderTaxonomy Code in order to crosswalkyour NPI, it is required.Refer to Section 10.5 for additionalinformation. Also, refer to this segmentin the 837P TR3 Guide for instructions.Required when the location of thehealth care service is different than thatcarried in Loop 2010AA or 2010ABRefer to this segment in the 837P TR3Guide for instructions.Required when the location of thehealth care service is different than thatcarried in Loop 2010AA or 2010ABRefer to this segment in the 837P TR3Guide for instructions.Required when the location of thehealth care service is different than thatcarried in Loop 2010AA or 2010ABRefer to this segment in the 837P TR3Guide for instructions.2400 SV1 Professional Service01-1 Product/Service ID Qualifier “HC”01-2 Product/Service ID Use applicable Procedure CodeIf a HCPCS J-Code is a generic coderequiring further explanation, alsoreport the National Drug code (NDC) inthe LIN segment of Loop 2410. ©Blue Cross Blue Shield of Massachusetts, January 2013 15

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE01-3 Procedure Modifier BCBSMA requires standard modifiersfor:Community Mental Health CentersTechnical ComponentsProfessional ComponentsIn addition, use standard modifierswhen other services require them.Refer to the CPT and HCPCS manuals fora complete listing of standardmodifiers.2410 LIN Drug Identification02032420A NM1 Rendering Provider Name010809Refer to Sections 10.8 & 10.9 forspecific Billing instructions.If the J-code reported in SV101-2 is ageneric code that requires furtherexplanation, this segment is required.Refer to this segment in the 837P TR3Guide for instructions.This segment is only required of theRendering Provider is different than theprovider identified in Loop 2310B.Refer to this segment in the 837P TR3Guide for instructions.Atypical Providers will not use NM108or NM109. Please see Section 10 forspecial billing instructions.2420A REF Rendering Provider SecondaryIdentificationThis segment should only be used byAtypical Providers.01 Reference Identification Qualifier “G2”08 Reference Identification ATYPICAL PROVIDERS - Use BCBSMALegacy Provider Number©Blue Cross Blue Shield of Massachusetts, January 2013 16

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE7.2. 837I Institutional Claims Data SpecificationsHeader DataSegment ID Element ID Data Element Name BCBSMA Business RuleISAInterchange Control Header01 Authorization Information“00”Qualifier02 Authorization Information Use 10 spaces03 Security Information Qualifier “00”04 Security Information Use 10 spaces05 Interchange ID Qualifier “ZZ”06 Interchange Sender ID Use your BCBSMA assigned SubmitterID07 Interchange ID Qualifier “ZZ”08 Interchange Receiver ID “00200”15 Interchange Usage Indicator P – Production TransmissionT – Test TransmissionGSFunctional Group Header02 Application Sender’s Code Use your BCBSMA assigned SubmitterID03 Application Receiver’s Code “00200”08 Version/Release/IndustryIdentifier Code“005010X223A2”Loop Specific DataLoop ID Segment/ Data Element NameBCBSMA Business RuleElement ID1000A NM1 Submitter Name09 Identification Code Use your BCBSMA assigned SubmitterID1000B NM1 Receiver Name09 Identification Code “00200”2000A PRV Billing Provider SpecialtyInformationIn general, Provider Taxonomy Code isnot required for BCBSMA claims.However, if you have been instructedby BCBSMA to submit your ProviderTaxonomy Code in order to crosswalkyour NPI, it is required.Refer to Section 10.5 for additionalinformation. Also, refer to this segmentin the 837I TR3 Guide for instructions.2010AA NM1 Billing Provider Name01 Entity Code Identifier “85”08 Identification Code Qualifier “XX”09 Identification Code Use Billing Provider’s 10-digit NPIAtypical Providers will not use NM108or NM109. Please see Section 10 forspecial billing instructions.©Blue Cross Blue Shield of Massachusetts, January 2013 17

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE2010ABPay-To AddressThe purpose of this loop is to provide analternate location to send areimbursement. BCBSMA will use theaddress on its Corporate Provider filefor all reimbursement.Please refer to this Loop in the 837I TR3Guide for instructions.2000B SBR Subscriber Information02 Individual Relationship Code “18” – Use this code only when thesubscriber is the patient. Otherwise, donot use this element.2010BA NM1 Subscriber Name08 Identification Code Qualifier “MI” – Required when MemberIdentification Number is submitted inNM109.09 Identification Code Use the Subscriber’s identificationnumber that was in effect on the dateof service, exactly as it appears on theBCBS ID card*. You must include theappropriate alpha prefix.*BCBSMA does not issue uniqueIdentification Numbers to all of itsindividual members. When submittingclaims for a dependent you must submitthe 2010CA Loop and the dependentsdemographic segments, along with thedata for the actual subscriber of thepolicy in Loop 2010BA.2010BB NM1 Payer Name08 Identification Code Qualifier “PI”09 Identification Code “00200”2010BB REF Billing Provider SecondaryIdentificationThis segment should only be used byAtypical Providers.01 Reference Identification Qualifier “G2”02 Reference Identification ATYPICAL PROVIDERS - Use BCBSMALegacy Provider Number2300 CLM Claim Information05-1 Facility Type Code For Acute Care Hospitals, BCBSMA willcrosswalk your NPI using this field as asecondary qualifier.Refer to Section 11 for additionalinformation.©Blue Cross Blue Shield of Massachusetts, January 2013 18

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE2300 HI Principal Diagnosis01-9 Present on Admission Indicator Prior to 5010, this information wassubmitted in the K3 segment. Pleasenote this change.2300 HI Patient’s Reason for VisitRefer to this HI segment in the 837I TR3Guide for instructions.The Patient’s Reason for Visit segmentis required on Outpatient Claims.If submitted, DTP segment with DTP01= “435” must also be included.Refer to this segment in the 837I TR3Guide for instructions.2310A NM1 Attending Provider Name01 Entity Identifier Code “71”08 Identification Code Qualifier “XX”09 Identification Code Use Attending Provider’s 10-digit NPI2310A PRV Attending Provider SpecialtyInformationIn general, Provider Taxonomy Code isnot required for BCBSMA claims.However, if you have been instructedby BCBSMA to submit your ProviderTaxonomy Code in order to crosswalkyour NPI, it is required.2310DRendering Provider NameRefer to Section 10.5 for additionalinformation. Also, refer to this segmentin the 837I TR3 Guide for instructions.In general, Loop 2310D is not requiredfor BCBSMA claims. However, if youhave been instructed by BCBSMA tosubmit Rendering Provider information,it is required.Refer to this loop in the 837I TR3 Guidefor instructions.2400 SV2 Institutional Service Line01 Product/Service ID BCBSMA has issued special Billinginstructions when billing for Vent bedsor complex Rehabilitation stays.BCBSMA has also issued instructionswhen billing ASC and/or Observationservices.Refer to Section 10.6 for additionalinformation.©Blue Cross Blue Shield of Massachusetts, January 2013 19

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE7.3. 837D Dental Claims Data SpecificationsHeader DataSegment ID Element ID Data Element Name BCBSMA Business RuleISAInterchange Control Header01 Authorization Information“00”Qualifier02 Authorization Information Use 10 spaces03 Security Information Qualifier “00”04 Security Information Use 10 spaces05 Interchange ID Qualifier “ZZ”06 Interchange Sender ID Use your BCBSMA assigned SubmitterID07 Interchange ID Qualifier “ZZ”08 Interchange Receiver ID “00200”15 Interchange Usage Indicator P – Production TransmissionT – Test TransmissionGSFunctional Group Header02 Application Sender’s Code Use your BCBSMA assigned SubmitterID03 Application Receiver’s Code “00200”08 Version/Release/Industry IdentifierCode“005010X224A2”Loop Specific DataLoop ID Segment/ Data Element NameBCBSMA Business RuleElement ID1000A NM1 Submitter Name09 Identification Code Use your BCBSMA assigned SubmitterID1000B NM1 Receiver Name09 Identification Code “00200”2000A PRV Billing Provider SpecialtyInformationIn general, Provider Taxonomy Code isnot required for BCBSMA claims.However, if you have been instructedby BCBSMA to submit your ProviderTaxonomy Code in order to crosswalkyour NPI, it is required.Refer to Section 10.5 for additionalinformation. Also, refer to this segmentin the 837D TR3 Guide for instructions.2010AA NM1 Billing Provider Name01 Entity Code Identifier “85”08 Identification Code Qualifier “XX”09 Identification Code Use Billing Provider’s 10-digit NPI ©Blue Cross Blue Shield of Massachusetts, January 2013 20

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE2010ABPay-To AddressThe purpose of this loop is to provide analternate location to send areimbursement. BCBSMA will use theaddress on its Corporate Provider filefor all reimbursement.Please refer to this Loop in the 837DTR3 Guide for instructions.2000B SBR Subscriber Information02 Individual Relationship Code “18” – Use this code only when thesubscriber is the patient. Otherwise, donot use this element.2010BA NM1 Subscriber Name08 Identification Code Qualifier “MI” – Required when MemberIdentification Number is submitted inNM109.09 Identification Code Use the Subscriber’s identificationnumber that was in effect on the dateof service, exactly as it appears on theBCBS ID card*. You must include theappropriate alpha prefix.*BCBSMA does not issue IdentificationNumbers to all of its members. Ifsubmitting claims for anyone other thanthe Subscriber, use Loop 2010CA.2010BB NM1 Payer Name08 Identification Code Qualifier “PI”09 Identification Code “00200”2300 DTP Date - AccidentUse if CLM11-1 or CLM11-2 = “AA”,“OA”, or “EM” (and claim is the result ofan accident).Refer to this segment in the 837D TR3Guide for instructions.2300 NTE Claim Note Required for reporting Periodontalcharting information01 Note Reference Code “ADD”02 Description Required when billing for the followingPeriodontal procedures:D4341, D4910Use the following values in NTE02 toreport Periodontal case types:PERI1: Case Type I - Gingival DiseasePERI2: Case Type II – Early PeriodontitisPERI3: Case Type III - ModeratePeriodontitisPERI4: Case Type IV - AdvancedPeriodontitis©Blue Cross Blue Shield of Massachusetts, January 2013 21

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE8. REPORTS AND ACKNOWLEDGMENTSBCBSMA provides a variety of acknowledgments and reports to communicate specific aspects of atransmission. Whether a file was accepted or rejected, pre-adjudication issues, and claimacknowledgments are reported back to the submitter and can be found in the “Outbound” folder ofthe Submitter ID mailbox. These reports are stored for up to fourteen days for retrieval.The following table lists the reports generated by BCBSMA.Name Filename Convention DescriptionTA1 BCBSMA..InterchangeAck..TA1The TA1 or Interchange Acknowledgment is a means ofreplying to an interchange or transmission that has beensent. The TA1 verifies the envelopes only. This reportallows us to notify you of problems that were encounteredin the interchange control structure. It acknowledges thatwe have received or rejected an entire transmission.999 BCBSMA..FunctionalAck..999The 999 (Implementation Acknowledgment) is a means ofreplying to the functional groups that are in any oneinterchange or transmission. This report notifies you of ourability or inability to process the entire transaction basedon ASC X12 syntax and structure rules.277CAPDFBCBSMA..ClaimAck..277BCBSMA..SubmitterReport..PDFBCBSMA implements a pre-adjudication process containingBusiness and HIPAA rules to validate your claims beforebeing sent to our adjudication system. We send a 277Health Care Claim Acknowledgment to notify you oftransactions that are accepted for adjudication, as well asthose that are not accepted. Claims passing preadjudicationprocess are forwarded to the claimsadjudication system, while those that fail are not.In addition to the ANSI transactions available to you,BCBSMA prepares a user-friendly Submitter Batch Report.This is prepared in the Adobe PDF format. There are twosections – a Summary and a Detail. Totals are presented inthe Summary for each transmission. Information abouteach claim is available in the Detail section.835 BCBSMA..ClaimPayment..835If you have elected to receive your remittance adviceselectronically, then subsequent to claim adjudication, thistransaction will be available in your mailbox.©Blue Cross Blue Shield of Massachusetts, January 2013 22

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE9. BCBSMA AS A SECONDARY PAYERIf the 837 claim transaction reports that Blue Cross Blue Cross Blue Shield Massachusetts (BCBSMA)is the secondary payer to Medicare or another payer (Coordination of Benefits information), pleasereview the following to ensure the data is populated correctly. Refer to the appropriate 837Technical Type 3 Report Guide for further clarification.BCBSMA realizes that the depth of COB information returned to you in the Primary Payer’sremittance may be less than ideal, but we ask you to work with these payers so that we mayproperly adjudicate your claim. The following information is required by BCBSMA:SBR01 = “S” in Loop 2000B if BCBSMA is the Secondary Payer.SBR01 = “P” in Loop 2320 for Primary Carrier Payment information.CAS segment(s) in Loop 2320 required on Inpatient Institutional Claims.AMT segments within Loop 2320 required on all Secondary Claims. Remaining PatientLiability is only required if Line Level adjudication information has not been included.SVD02 element in Loop 2430 required for all 837 Professional, Dental, and OutpatientInstitutional Claims.CAS segment(s) in Loop 2430 required for all 837 Professional, Dental, and OutpatientInstitutional Claims.In addition to the data outlined above, providers should also verify that Loop 2330A (OtherSubscriber Name) and Loop 2330B (Other Payer Name) are populated with all the requiredinformation for the various segments included within these loops.9.1. BCBSMA COB Requirements Quick ReferenceItem 837D 837I 837PClaim LevelTotal ChargesLoop 2300 | CLM02Total Paid AmountLoop 2320 | AMT02 (where AMT01 = “D”)Remaining LiabilityAmountLoop 2320 | AMT02 (where AMT01 = “EAF”)**Only required if Line Level adjudication information is not includedTotal DeductibleLoop 2320 | CAS03Amount*N/A(where CAS01 = “PR” andCAS02 = “1”)N/ATotal Co-insuranceAmount*N/ALoop 2320 | CAS03(where CAS01 = “PR” andCAS02 = “2”)Line LevelLine Charges Loop 2400 | SV302 Loop 2400 | SV203 Loop 2400 | SV102Line Payment2430 SVD02Line DeductibleLoop 2430 | CAS03 (where CAS01 = “PR” and CAS02 = “1”)Amount*Line Co-insuranceLoop 2430 | CAS03 (where CAS01 = “PR” and CAS02 = “2”)Amount*Note: If Deductible amount and Co-insurance amount are both available, do not present them in twoCAS segments. Instead, use a single “Patient Responsibility” CAS segment.N/A©Blue Cross Blue Shield of Massachusetts, January 2013 23

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE10. SPECIAL BILLING INSTRUCTIONS10.1. Medicare as Primary PayerWhen submitting claims where Medicare is the Primary Payer, BCBSMA requires that SBR09equals “MA” (Medicare Part A) or “MB” (Medicare Part B) within Loop 2320 (Other SubscriberInformation).10.2. 837 - Subscriber Claims vs. Dependent ClaimsBecause BCBSMA does not issue unique identification numbers to all BCBSMA members,BCBSMA requires that the 2010BA Loop (Subscriber Name) be used when submittingSubscriber only claims along with the demographic segments for the subscriber of the policy.When submitting claims for a dependent of the subscriber you must also submit the 2010CALoop along with the dependent demographic segments (do not submit the demographicsegments in the subscriber loop if the claim is for a dependent). You must submit a 2010BAloop with the actual subscriber of the BCBS policy in loop 2010BA for all claims submitted toBCBSMA regardless of if the services are for the subscriber or the subscriber’s dependent(spouse, child, etc.).10.3. 837 - Atypical ProvidersBecause most atypical providers do not have an NPI, the NM108 and NM109 elements withinspecific loops that refer to NPI enumeration will not be used. Instead, atypical providers shouldsubmit their BCBSMA Legacy Provider Number in element REF02 within the applicable loops.Please note that within those loops, element REF01 should equal “G2”. Instructions are alsolocated in Section 6.1 and Section 6.2 within the 837P and 837I Loop Specific Data tablesrespectively.Loop/Segment used by Atypical Providers2010BB | REF2310B | REF (Claim Level)*2420A | REF (Service Line Level)**837P OnlySegment NameBilling Provider Secondary IdentificationRendering Provider Secondary IdentificationRendering Provider Secondary Identification©Blue Cross Blue Shield of Massachusetts, January 2013 24

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE10.4. 837 Institutional - Type of Bill ConventionBCBSMA recognizes all NUBC approved Type of Bill (TOB) values. However, the majority ofclaims for our Facility partners require only a limited set of these codes. BCBSMA uses the firstand second position of the TOB as a secondary qualifier to a provider’s NPI. This value isobtained from the submitted claim in the CLM05-1 (Facility Code Value) element of the 837Ilocated in Loop 2300.For services provided in this area of thehospitalSubmit this value in the1 st position of the TOBSubmit this value in the2 nd position of the TOBInpatient Hospital 1 1Outpatient Hospital 1 3Hospital-based Community Health Center 7 9Surgical Day Care 8 310.5. 837 Institutional/Professional - Provider Taxonomy CodesBCBSMA does not require the use of Taxonomy Codes for the majority of claims submitted.However, in certain limited conditions, the taxonomy code is used as a secondary qualifier tothe provider’s NPI. If you have been instructed to use a specific taxonomy code by BCBSMA,provide this data in order for proper claims adjudication.Additional information and the most up-to-date billing instructions are available on ourBlueLinks for Providers© website at www.bluecrossma.com/provider. Once logged in,navigate to: Resource Center>Admin Guidelines & Info, then select Blue Books and choose thesubject of interest.10.6. 837 Institutional - Revenue Codes10.6.1. Vent Bends & Complex Rehabilitation StaysBCBSMA has issued special billing instructions when billing for Vent Beds or ComplexRehabilitation Stays:For this serviceSubmit this Revenue CodeSNF Vent Bed 0129Complex Rehabilitation Stays 013910.6.2. ASC & Observation ServicesWhen billing revenue codes for ASC or Observation Services, BCBSMA requires that thecharge amount for the service must be greater than zero ($0).Additional information and the most up-to-date billing instructions are available on ourBlueLinks for Providers© website at www.bluecrossma.com/provider. Once logged in,navigate to: Resource Center>Admin Guidelines & Info, then select Blue Books and choose thesubject of interest.©Blue Cross Blue Shield of Massachusetts, January 2013 25

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE10.7. 837 Professional - Early Intervention ProvidersPrior to the implementation of HIPAA 5010, specific providers were instructed by BCBSMA toinclude the Special Program indicator value of “01” in the CLM12 element of Loop 2300 if theywere a contracted Early Intervention Provider. This value (CLM12 = “01”) no longer exists andsubsequently, those contracted Early Intervention Providers have been instructed by BCBSMAto obtain a new NPI. Please use this NPI when billing Early Intervention services.Additional information and the most up-to-date billing instructions are available on ourBlueLinks for Providers© website at www.bluecrossma.com/provider. Once logged in,navigate to: Resource Center>Admin Guidelines & Info, then select Blue Books and choose thesubject of interest.10.8. 837 Professional - Procedure Code Modifiers for CMHCBCBSMA requires that a Community Mental Health Center (CMHC) submit a Procedure CodeModifier specific to the specialty of the Rendering Provider on each line of the claim in elementSV101 within Loop 2400.ModifierAFAHAJHAHEHOHRTDBCBSMA Fee SchedulePsychiatristPsychologistLicensed Independent Clinical Social WorkerChild PsychiatristPsychiatric Nurse PractitionerLicensed Mental Health CounselorLicensed Marriage & Family TherapistClinical Nurse SpecialistAdditional information and the most up-to-date billing instructions are available on ourBlueLinks for Providers© website at www.bluecrossma.com/provider. Once logged in,navigate to: Resource Center>Admin Guidelines & Info, then select Blue Books and choose thesubject of interest.10.9. 837 Professional - Professional/Technical Components for Radiology ServicesThe following billing guidelines are for providers contracted by BCBSMA to perform Radiologyservices using the modifiers of 26 (Professional) and/or TC (Technical). Please note thatproviders may be contracted to render/bill Technical services with an Individual NPI or BillingNPI.When billing for… Put this on Rendering Provider line Modifier RequiredProfessional Component NPI of Rendering Provider 26Technical Component NPI of provider contracted to render TechnicalServicesTC©Blue Cross Blue Shield of Massachusetts, January 2013 26

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEFor providers that prepare separate bills (one bill for Professional Services and another forTechnical Services):On the Professional Component Service Bill (Modifier 26)1. Submit NPI and Tax ID of the Billing Provider in Loop 2010AA.2. Submit NPI of the Rendering Provider in Loop 2310B.3. If another provider within the group has rendered another service, submit theNPI of the Rendering provider for that particular service in Loop 2420A.On the Technical Component Service Bill (Modifier TC)1. Submit NPI and Tax ID of the Billing Provider in Loop 2010AA.2. If the Billing Provider NPI is contracted with BCBSMA to perform the TechnicalService, no other Provider Loops are required*.3. If the Billing Provider NPI is not contracted with BCBSMA to perform theTechnical Service, Submit the NPI of the provider contracted to perform the TechnicalService in Loop 2310B.Note: In order to correctly adjudicate the Technical Component Service, you must identify theprovider contracted with BCBSMA to perform the Technical Service.*If your software requires it, you may resubmit the NPI of the Billing Provider in Loop 2310B.For providers that prepare a single bill that includes both Professional and TechnicalComponent(s):Option 1* – Identify the contracted Technical Component provider in Loop 2310B1. Submit NPI and Tax ID of the Billing Provider in Loop 2010AA.2. Submit NPI of the provider contracted with BCBSMA to perform the TechnicalService in Loop 2310B.3. For each Service other than the Technical Component service, submit the NPI ofthe Rendering provider for that particular service in Loop 2420A.Option 2 – Identify the Professional Component provider in Loop 2310B1. Submit NPI and Tax ID of the Billing Provider in Loop 2010AA.2. Submit NPI of the provider rendering the Profession Component in Loop 2310B.3. For the Technical Component, submit the NPI of the provider contracted withBCBSMA to perform the Technical Service in Loop 2420A.Note: In order to correctly adjudicate the Technical Component Service, you must identify theprovider contracted with BCBSMA to perform the Technical Service.*The ANSI Standard allows you to submit the Rendering provider NPI in Loop 2310B. TheStandard applies that Rendering provider NPI to all services. Remember, the TechnicalComponent Service will only adjudicate correctly if the Rendering provider is contracted withBCBSMA to provide the Technical Service.©Blue Cross Blue Shield of Massachusetts, January 2013 27

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE11. FACILITY CODE REQUIREMENTS FOR 837PThe Service Facility Location Name Loop (2310C) is required when the location of health care serviceis different than that carried in Loop 2010AA (Billing Provider). The Service Facility Location NameLoop supplies information of where care was delivered to the BCBSMA member. It is not requiredfor services delivered in the patient’s home or for Laboratory services.The following segments need to be completed for proper BCBSMA claims adjudication:Segment Description ExampleNM1 Service Facility Location Name NM1*77*2*GENERALHOSPITAL*****XX*1234567890~N3 Service Facility Location Address N3*123 ANY ST~N4 Service Facility Location City, State, Zip Code N4*ANYTOWN*MA*12345~12. APPENDICESAppendix A - Interchange Acknowledgment (TA1)ISA*00* *00* *ZZ*00200 *ZZ*EFENEPREDI*110917*1631*^*00501*000000001*0*P*:~TA1*000001252*101021*0251*A*000~IEA*0*000000001~Appendix B - Health Care Claim Acknowledgment (277CA)ISA*00* *00* *ZZ*00200 *ZZ*EFENEPREDI*110917*1631*^*00501*000000001*0*P*:~GS*HN*00200*EFENEPREDI*20110917*1631*1*X*005010X214~ST*277*0001*005010X214~BHT*0085*08*F9D4438CE16B11E0B569E41F13399968*20110917*1631*TH~HL*1**20*1~NM1*PR*2*BLUE CROSS OF MA*****46*00200~TRN*1*F9D44B16E16B11E0B569E41F13399968~DTP*050*D8*20110917~DTP*009*D8*20110917~HL*2*1*21*1~NM1*41*2*ACME SUBMITTER*****46*EFENEPREDI~TRN*2*000002269~STC*A1:19:PR*20110917*WQ*1790~QTY*90*1~AMT*YU*1790~HL*3*2*19*1~NM1*85*2*ACME PROVIDER*****XX*1112223330~TRN*1*F9D48AE0E16B11E0B569E41F13399968~STC*A1:19:PR**WQ*1790~©Blue Cross Blue Shield of Massachusetts, January 2013 28

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEQTY*QA*1~AMT*YU*1790~HL*4*3*PT~NM1*QC*1*DOE*JOHN****MI*XXA987654321~TRN*2*1111221090~STC*A1:19:PR*20110917*WQ*1790~REF*1K*8511257001663~DTP*472*RD8*20101018-20101018~SE*26*0001~GE*1*1~IEA*1*000000001~©Blue Cross Blue Shield of Massachusetts, January 2013 29

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEAppendix C - Implementation Acknowledgment for Health Care Insurance (999)ISA*00* *00* *ZZ*00200 *ZZ*EFENEPREDI*110917*1631*^*00501*000000001*0*P*:~GS*FA*00200*EFENEPREDI*20110917*1631*1*X*005010X231A1~ST*999*0001*005010X231A1~AK1*HC*393341*005010X222A1~AK2*837*0002*005010X222A1~IK5*A~AK9*A*1*1*1~SE*6*0001~GE*1*1~IEA*1*000000001~©Blue Cross Blue Shield of Massachusetts, January 2013 30

837 P,I,D BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDEAppendix D - Revision HistoryRevision Number Date Section Notes1.01 09/30/11 Cover Replaced “HIPAA Transaction” with “Health Care Claim”1.10 11/01/11 8.1 Corrected “Loop 2320” to “Loop 2430” for Line DeductibleAmount and Line Co-insurance Amount Items in BCBSMACOB Quick Reference table.5.4 Added NEW section 5.4 Delimiters1.2 02/03/12 6 Added new section 6 – BCBSMA Identification NumberRequirements7.1 Loop Specific Data – Added note to Loop 2310B (RenderingProvider Name) with specific instructions.7.2 Loop Specific Data – Added new Loop 2310D (RenderingProvider Name) with specific instructions.7.2 Loop Specific Data – HI Segment updated with language toinclude DTP segment (DTP01 = 435) if Patient’s Reason forVisit is submitted on transaction7.2 Loop Specific Data – HI Segment (Present on Admission)added to clarify differences between 4010 and 5010submission.10.1 Added new section 10.1 – Medicare as Primary Payer1.2.1 5/15/12 7.2 Loop Specific Data – 2010BA NM1 updated with newverbiage for clarification.10.2 Reworded paragraph to provide clarification regardingSubmitter vs. Dependent claims.1.2.2 1/21/13 9 Updated to include the requirement of Remaining LiabilityAmount (AMT*EAF) segment when Line Level adjudicationinformation is not included.©Blue Cross Blue Shield of Massachusetts, January 2013 31