HIPAA Trading Partner Agreement 837- Health Care Claim ...

Inbound 837P Companion GuideOffice of HIPAA ComplianceCHANGE LOGDate ofChange Page03/15/2007 4 , 5,603/15/2007 8, 9,60,63,68,79Loop/Txn2310A2310B2310D2420ASegment/ElementIDREF01REF02SegmentNameReferringProviderSecondary ID,RenderingProviderSecondary ID,ServiceFacilityLocationSecondary IDRenderingProviderSecondary ID,03/15/2007 27 2010AA NM108 BillingProvider Name03/15/2007 30 2010AA REF01 BillingProviderSecondaryIdentificationData Element/FieldName (Industry)ReferenceIdentificationIdentification CodeQualifierIdentification CodeQualifierDescription of ChangeUpdated Reviews and Approvers andadded EDI Team email address. Removedreferences to Marina Medical.Deleted REF01 and REF02 fields formsegments listing.Removed Qualifiers:24 Employer's Identification34 Number Social Security NumberRemoved Qualifier:1D Medicaid Provider NumberAdded Qualifiers:EI Employer's Identification NumberSY Social Security Number03/15/2007 59 2310A NM108 ReferringProvider Name03/15/2007 62 2310B NM108 RenderingProvider Name03/15/2007 65 2310D NM108 ServiceFacility03/15/2007LocationProvider Name78 2420A NM108 RenderingProvider Name03/15/2007 11,13,20,78Identification CodeQualifierIdentification CodeQualifierIdentification CodeQualifierIdentification CodeQualifierRemoved Qualifiers:24 Employer's Identification34 Number Social Security NumberRemoved Qualifiers:24 Employer's Identification34 Number Social Security NumberRemoved Qualifiers:24 Employer's Identification34 Number Social Security NumberRemoved Qualifiers:24 Employer's Identification34 Number Social Security NumberRemoved references to MarinaMedical because this companion guidewill be used for all inbound 837Psubmitter.03/15/2007 83 Removed references to Marina Medical.03/15/2007 84 Removed Aron Brewer as the contact forpayment question. Added Deb Antley.Removed Jerry Elder as the contact personfor the CMISP 837 P. Added Powell Tai.DHHS Sacramento County Page 3 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceDate ofChangePage06/16/2008 1, 5,6,Loop/TxnSegment/ElementIDSegmentNameData Element/FieldName (Industry)Description of ChangeAdded PEMS to the descriptionUpdated Reviews and Approvers andadded EDI Team email addressIntroduction information updated to includePEMS.06/23/2008 Updates to Introduction per EDI teammeeting 6/20/200809/09/2008 23,40,45,65,71,1000B,2300,2400Corrected incorrect NM109 code values,correction on character limit on CLM01,Addition of “Date – Accident,” correctionto character count for REF02, correction tofile examples, removal of note in appendix72,7409/19/2008 65 2400 REF02 Correction to position numbers and update10/07/2008 61,73to the example id.2400 DHHS note added for Procedure modifiersand reference link added for approvedMedi-Cal modifiers.DHHS Sacramento County Page 4 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceDOCUMENT CONTROL SHEETREVIEWERSDate Name TitleSrikanth SuriEdmond BlagdonEd DziukSue GuinnBiz Talk/DB DeveloperIT Project ManagerAccounting TechnicianAccounting ManagerAPPROVED BYDate Name TitleEd DziukSue GuinnPowell TaiJoe HowardDeb AntleyAccounting TechnicianAccounting ManagerEDI LeadITS ManagementProject SponsorPUBLISHING INFORMATIONNo Name Location / Website1 DHHS EDI Trading Partners http://www.sacdhhs.com/article.asp?ContentID=19042. DHHS HIPAA Web Site http://www.compliance.saccounty.net/default.htm3. Companion Guide http://www.sacdhhs.com/CMS/download/pdfs/HIP/CMISP837PCompanionGuide.pdfFor questions or comments, please contact:Sacramento County DHHS, EDI TeamEDI-dropbox@saccounty.netDHHS Sacramento County Page 5 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceCMISP 837 Health Care Claim: ProfessionalFunctional Group ID=HC1. INTRODUCTIONOVERVIEWThe Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation mandates that manyof the major health care electronic data exchanges, such as electronic claims and remittance advices, bestandardized into the same national format for all payers, providers, and clearinghouses, who submitgoverned data electronically to the Sacramento County Department of Health And Human Services(DHHS), must submit in the mandated HIPAA formats.HIPAA specifically names several electronic transactions that must be followed when certain health careinformation is exchanged. These transactions are published as National Electronic Data InterchangeTransaction Set Implementation Guides. They are commonly called Implementation Guides (IGs) and arereferred to as IGs throughout this document. Additionally, an addendum to each of the IGs has beenpublished and must be used to properly implement each transaction.TRANSACTION TYPEThis 837P companion document is provided by DHHS Sacramento County, Information TechnologyServices and Office of HIPAA Compliance for all payers, providers, and clearinghouses, sendingElectronic Data Interchange (EDI) 837 Professional Transaction to DHHS. This document shows howSacramento County DHHS uses the EDI ASC X12 837P Electronic Transactions, 004010X098A1 forcompliance with the federal HIPAA Regulations of 1996.SCOPEThe Companion guide covers data elements that are either required or situational to meet HIPAAvalidation & DHHS Business Requirements for 837P Claims Transaction Only.Note: Claim transactions for the purpose of the Coordination of Benefits (COB) are outside of the scopeof this companion guide. Information about how a particular claim is adjudicated by DHHS is also outsideof the scope of this companion guide.PROGRAM DESCRIPTIONS - CMISP / PEMSCMISPThe County Medically Indigent Services Program (CMISP) is a program of "last resort" designed to meetthe health care needs of individuals in our community who are not otherwise eligible for healthcareprograms such as Medi-Cal, Medicare or private health insurance, and who meet the County's "lastresort" socioeconomic eligibility standards. CMISP is a program mandated by the State of California, Title17 of the Welfare and Institutions Code, to provide access to medical care for medically indigent persons.The program is administered as a combined effort of the Sacramento County Departments of Health andHuman Services and Human Assistance. The Department of Health and Human Services includes theOffice of Medical Case Management under the direction of the Chief of Primary Health Services, MedicalCase Management is responsible for provider payments and patient billing in Accounting and FiscalServices for secondary and tertiary care.DHHS Sacramento County Page 6 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA CompliancePEMSThe Physicians Emergency Medical Services (PEMS) fund program is outlined in county code – TITLE 6HEALTH AND SANITATION, Chapter 6.105 EMERGENCY, OBSTETRIC, PEDIATRIC MEDICALSERVICES DISTRIBUTION OF PENALTY ASSESSMENT AND TOBACCO TAX FUNDS.PRIVACY AND SECURITY PROTECTIONThis companion guide does not specifically address privacy and security protection regarding the use ofthe system or application technology to send and receive a transaction set. For example, digitalcertificates, authentication, authorization, and other access restrictions are not addressed in thiscompanion guide. This document assumes that the transaction exchange will take place in a processingand communication environment that is secure at both ends for the senders and the receivers of data.DHHS Sacramento County Page 7 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA Compliance2. GETTING STARTEDPROVIDER REGISTRATIONAll payers, providers, and clearinghouses must complete a trading partner agreement form. The tradingpartner agreement form is used to communicate trading partner identifiers and to indicate whichtransactions they wish to exchange.Note: The form is available via County Web Site or email, EDI-Dropbox@SacCounty.net. Fill outseparate forms for Test and Production Submission. See the References and Links section onpage 73 for the information on where to download the forms.TESTING AND CERTIFICATION WITH DHHS837P transactions submitted to DHHS must pass test requirements before payers, providers, orclearinghouses are set up to send production transactions. Successful completion of transaction testingrequires an 837P transaction to pass HIPAA compliant validation (Level 1-2).DHHS will send a Certificate of Acceptance for production.Note: The County Testing and Activation Procedures Document is available via County Web Siteor up request email, EDI-Dropbox@SacCounty.net. See the References and Links Section on page73 for information on where to download the document.3. 837P CONTROL SEGMENTS/ENVELOPE STRUCTUREOVERVIEWAppendix A, Section A.1.1 of each X12N HIPAA Iplementation Guide (IG) provides details about the rulesfor ensuring integrity and maintaining the efficiency of data exchange. Data files are transmitted in anelectronic envelope. The communication envelope consists of an interchange envelope and functionalgroups. The interchange control structure is used for inbound and outbound files. An inbound interchangecontrol structure is the envelope that wraps all transaction data (ST-SE) sent to DHHS for processing.Examples include 837 and 997 transactions. An outbound interchange control structure wrapstransactions that are created by DHHS and returned to the respective payers, providers, orclearinghouses. Examples of outbound transactions include only 835 Remittance Advice, 997, and TA1Acknowledgements only.DHHS- SEGMENTS/LOOPS – TECHNICAL INFORMATIONa. The following list includes basic technical information for each transaction:• The following delimiters are used for all Inbound transactions:o * (asterisk) = data element separatoro : (colon) = sub element separatoro ~ (tilde) = segment terminatorb. DHHS will not accept claims at Patient Hierarchical level, 2000C Loop in 837P transaction.c. The maximum number of CLM Segments per Transaction set (ST-SE) is 5000.d. All monetary amounts and quantity fields have explicit decimals. The decimal point always appearsin the character stream if the decimal point is at any place other than the right end. If the value is anDHHS Sacramento County Page 8 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA Complianceinteger with the decimal point at the right end, the decimal point should be omitted. See the 837P/835IG for additional clarification.e. If one Claim within a transaction is noncompliant, the entire transaction (ST-SE) is rejected.f. DHHS accepts multiple ST-SE in one Functional Group.g. TA1 – interchange acknowledgment is generated when a functional group is rejected.h. 997 – Functional acknowledgment is generated in response to all inbound batch transactions.i. Send the transaction Data in Uppercase.HEADING, DETAIL AND SUMMARY TABLESThe following sections describe DHHS’s use of Header Interchange Control Segments (ISA-IEA),Functional Group (GS-GE) and Transaction Segments (ST-SE).The matrix on page 10 and 11 lists the segments required for submission per the 4010A version of the837P HIPAA Implementation Guideline noted under the X12 Standard column. Additionally, the matrixincludes a column DHHSStandard for DHHS requirements for the transaction. See the matrix below fordefinitions of the keys used for the X12 and DHHS standards.This implementation guideline identifies all required segments for 837P transactions. Failure to include arequired segment results in a compliance error. A situational segment is not required for every type oftransaction; however, a situational segment may be required under certain circumstances.The following sections contain a tabular representation of any segment required or situational for DHHSHIPAA implementation of the 837P.Code X12 Standard Code DHHS StardardM Mandatory Dep DependantO Optional M MandatoryMust Use Required for DHHSUsed Required for DHHSDHHS Sacramento County Page 9 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceHeading:Pos. Seg. X12 Standard DHHS Std LoopNo. ID Name Guide Status Max.Use Repeat003 ISA Interchange Control Header O Used 1004 GS Functional Group Header O Used 1005 ST Transaction Set Header M M 1010 BHT Beginning of Hierarchical Transaction M M 1015 REF Transmission Type Identification O Must Use 1LOOP ID - 1000A 1020 NM1 Submitter Name O Must Use 1045 PER Submitter EDI Contact Information O Must Use 1LOOP ID - 1000B 1020 NM1 Receiver Name O Must Use 1Detail:Pos. Seg. X12 Standard DHHS Std LoopNo. ID Name Guide Status Max.Use RepeatLOOP ID - 2000A >1001 HL Billing/Pay-to Provider Hierarchical Level M M 1LOOP ID - 2010AA 1015 NM1 Billing Provider Name O Must Use 1025 N3 Billing Provider Address O Must Use 1030 N4 Billing Provider City/State/ZIP Code O Must Use 1035 REF Billing Provider Secondary Identification O Must Use 1LOOP ID - 2000B >1001 HL Subscriber Hierarchical Level M M 1005 SBR Subscriber Information O Must Use 1007 PAT Patient Information O Used 1LOOP ID - 2010BA 1015 NM1 Subscriber Name M M 1025 N3 Subscriber Address O Must Use 1030 N4 Subscriber City/State/ZIP Code O Must Use 1032 DMG Subscriber Demographic Information O Must Use 1035 REF Subscriber Secondary Identification O Used 4LOOP ID - 2010BB 1015 NM1 Payer Name O Must Use 1LOOP ID - 2300 5000130 CLM Claim Information O Used 1135 DTP Date - Onset of Current Illness/Symptom O Used 1135 DTP Date - Accident O Used 10135 DTP Date - Admission O Dep 1135 DTP Date - Discharge O Dep 1155 PWK Claim Supplemental Information O Used 1175 AMT Patient Amount Paid O Used 1180 REF Prior Authorization or Referral Number O Used 1190 NTE Claim Note O Dep 1231 HI Health Care Diagnosis Code O Must Use 1DHHS Sacramento County Page 10 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceLOOP ID - 2310A 2250 NM1 Referring Provider Name O Used 1LOOP ID - 2310B 1250 NM1 Rendering Provider Name O Used 1LOOP ID - 2310D 1250 NM1 Service Facility Location O Used 1265 N3 Service Facility Location Address O Must Use 1270 N4 Service Facility Location City/State/ZIP O Must Use 1LOOP ID - 2400 50365 LX Service Line O Must Use 1370 SV1 Professional Service O Must Use 1455 DTP Date - Service Date O Must Use 1470 REF Line Item Control Number O Must Use 1LOOP ID - 2420A 1500 NM1 Rendering Provider Name O Used 1Summary:Pos. Seg. X12 Standard DHHS Std LoopNo. ID Name Guide Status Max.Use Repeat555 SE Transaction Set Trailer M M 1565 GE Functional Group Trailer O Used 1575 IEA Interchange Control Trailer O Used 1DHHS Sacramento County Page 11 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: ISA Interchange Control HeaderPosition: 003Loop:Level: HeadingUsage: OptionalMax Use: 1Notes: The ISA is a fixed record length segment and all positions within each of the dataelements must be filled. The first element separator defines the element separator to beused through the entire interchange. The segment terminator used after the ISAdefines the segment terminator to be used throughout the entire interchange. Spacesin the example are represented by "." for clarity.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesISA01 I01 Authorization Information Qualifier M ID 2/2 MCode to identify the type of information in the Authorization Information00 No Authorization Information Present (No MeaningfulInformation in I02)ADVISED UNLESS SECURITY REQUIREMENTS MANDATEUSE OF ADDITIONAL IDENTIFICATION INFORMATION.ISA02 I02 Authorization Information M AN 10/10 MInformation used for additional identification or authorization of the interchange sender orthe data in the interchange; the type of information is set by the Authorization InformationQualifier (I01)ISA03 I03 Security Information Qualifier M ID 2/2 MCode to identify the type of information in the Security Information00 No Security Information Present (No Meaningful Information inI04)ADVISED UNLESS SECURITY REQUIREMENTS MANDATEUSE OF PASSWORD DATA.ISA04 I04 Security Information M AN 10/10 MThis is used for identifying the security information about the interchange sender or thedata in the interchange; the type of information is set by the Security Information Qualifier(I03)DHHS NOTE: Fill with (10) spaces.ISA05 I05 Interchange ID Qualifier M ID 2/2 MQualifier to designate the system/method of code structure used to designate the sender orreceiver ID element being qualifiedThis ID qualifies the Sender in ISA06.ZZMutually DefinedISA06 I06 Interchange Sender ID M AN 15/15 MIdentification code published by the sender for other parties to use as the receiver ID toroute data to them; the sender always codes this value in the sender ID elementDHHS NOTE: The "Sender ID" will be the vendor ID assigned by DHHS. This ID willbe provided to the trading partner upon initiation and certification of 837P submittals.Back fill with spaces to meet the minimum 15 character length.ISA07 I05 Interchange ID Qualifier M ID 2/2 MQualifier to designate the system/method of code structure used to designate the sender orreceiver ID element being qualifiedThis ID qualifies the Receiver in ISA08.ZZMutually DefinedISA08 I07 Interchange Receiver ID M AN 15/15 MIdentification code published by the receiver of the data; When sending, it is used by theDHHS Sacramento County Page 12 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA Compliancesender as their sending ID, thus other parties sending to them will use this as a receiving IDto route data to themDHHS NOTE: Use "SACCOUNTYHHSEDI"ISA09 I08 Interchange Date M DT 6/6 MDate of the interchangeThe date format is YYMMDD.ISA10 I09 Interchange Time M TM 4/4 MTime of the interchangeThe time format is HHMM.ISA11 I10 Interchange Control Standards Identifier M ID 1/1 MCode to identify the agency responsible for the control standard used by the message that isenclosed by the interchange header and trailerUU.S. EDI Community of ASC X12, TDCC, and UCSISA12 I11 Interchange Control Version Number M ID 5/5 MThis version number covers the interchange control segments00401 Draft Standards for Trial Use Approved for Publication by ASCX12 Procedures Review Board through October 1997ISA13 I12 Interchange Control Number M N0 9/9 MA control number assigned by the interchange senderThe Interchange Control Number, ISA13, must be identical to the associatedInterchange Trailer IEA02.DHHS NOTE: This number must remain unique for all claims throughout the lifetimeof our adjudication system.ISA14 I13 Acknowledgment Requested M ID 1/1 MCode sent by the sender to request an interchange acknowledgment (TA1)See Section A.1.5.1 for interchange acknowledgment information.0 No Acknowledgment Requested1 Interchange Acknowledgment RequestedISA15 I14 Usage Indicator M ID 1/1 MCode to indicate whether data enclosed by this interchange envelope is test, production orinformationPProduction DataTTest DataISA16 I15 Component Element Separator M AN 1/1 MType is not applicable; the component element separator is a delimiter and not a dataelement; this field provides the delimiter used to separate component data elements withina composite data structure; this value must be different than the data element separator andthe segment terminatorDHHS NOTE: Use a colon for this separator.DHHS Sacramento County Page 13 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: GS Functional Group HeaderPosition: 004Loop:Level: HeadingUsage: OptionalMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesGS01 479 Functional Identifier Code M ID 2/2 MCode identifying a group of application related transaction setsHC Health Care Claim (837)GS02 142 Application Sender's Code M AN 2/15 MCode identifying party sending transmission; codes agreed to by trading partnersUse this code to identify the unit sending the information.DHHS NOTE: The same vendor number used for ISA06 must be used without spaces.GS03 124 Application Receiver's Code M AN 2/15 MCode identifying party receiving transmission; codes agreed to by trading partnersUse this code to identify the unit receiving the information.DHHS NOTE: The same value used for ISA08 must be used "SACCOUNTYHHSEDI"GS04 373 Date M DT 8/8 MDate expressed as CCYYMMDDUse this date for the functional group creation date.GS05 337 Time M TM 4/8 MTime expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD,or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9)and DD = hundredths (00-99)Use this time for the creation time. The recommended format is HHMM.GS06 28 Group Control Number M N0 1/9 MAssigned number originated and maintained by the senderDHHS NOTE: This number should match the control number used for ISA13.GS07 455 Responsible Agency Code M ID 1/2 MCode used in conjunction with Data Element 480 to identify the issuer of the standardXAccredited Standards Committee X12GS08 480 Version / Release / Industry Identifier Code M AN 1/12 MCode indicating the version, release, subrelease, and industry identifier of the EDI standardbeing used, including the GS and GE segments; if code in DE455 in GS segment is X, thenin DE 480 positions 1-3 are the version number; positions 4-6 are the release andsubrelease, level of the version; and positions 7-12 are the industry or trade associationidentifiers (optionally assigned by user); if code in DE455 in GS segment is T, then otherformats are allowed004010X098A1Version/Release/Industry Indentifier CodeDraft Standards Approved for Publication by ASCX12 Procedures Review Board through October1997, as published in this implementation guide.1091 When using the X12N Health Care Claim:Professional Implementation Guide, originallyDHHS Sacramento County Page 14 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA Compliancepublished May 2000 as 004010X098 andincorporating the changes identified in the Addenda,the value used in GS08 must be "004010X098A1".DHHS Sacramento County Page 15 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: ST Transaction Set HeaderPosition: 005Loop:Level: HeadingUsage: MandatoryMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesST01 143 Transaction Set Identifier Code M ID 3/3 MCode uniquely identifying a Transaction SetThe only valid value within this transaction set for ST01 is 837.837 Health Care ClaimST02 329 Transaction Set Control Number M AN 4/9 MIdentifying control number that must be unique within the transaction set functional groupassigned by the originator for a transaction setThe Transaction Set Control Numbers in ST02 and SE02 must be identical. This uniquenumber also aids in error resolution research. Submitters could begin sendingtransactions using the number 0001 in this element and increment from there. Thenumber must be unique within a specific functional group (GS-GE) and interchange(ISA-IEA), but can repeat in other groups and interchanges.ALIAS: Transaction Set Control NumberDHHS Sacramento County Page 16 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: BHT Beginning of Hierarchical TransactionPosition: 010Loop:Level: HeadingUsage: MandatoryMax Use: 1Notes: The second example denotes the case where the entire transaction set containsENCOUNTERS.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesBHT01 1005 Hierarchical Structure Code M ID 4/4 MCode indicating the hierarchical application structure of a transaction set that utilizes theHL segment to define the structure of the transaction set0019 Information Source, Subscriber, DependentBHT02 353 Transaction Set Purpose Code M ID 2/2 MCode identifying purpose of transaction setBHT02 is intended to convey the electronic transmission status of the 837 batchcontained in this ST-SE envelope. The terms "original" and "reissue" refer to theelectronic transmission status of the 837 batch, not the billing status.ALIAS: Transaction Set Purpose CodeDHHS NOTE: CMISP and PEMS will treat every transaction as an original. Use "00"00 OriginalBHT03 127 Reference Identification O AN 1/30 M/UReference information as defined for a particular Transaction Set or as specified by theReference Identification QualifierThe inventory file number of the tape or transmission assigned by the submitter's system.This number operates as a batch control number. It may or may not be identical to thenumber carried in ST02.BHT04 373 Date O DT 8/8 M/UDate expressed as CCYYMMDDIdentifies the date that the submitter created the file.BHT05 337 Time O TM 4/8 M/UTime expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD,or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9)and DD = hundredths (00-99)Use this time to identify the time of day that the submitter created the file.BHT06 640 Transaction Type Code O ID 2/2 M/UCode specifying the type of transactionAlthough this element is required, submitters are not necessarily required to accuratelybatch claims and encounters at this level. Generally CH is used for claims and RP isused for encounters. However, if an ST-SE envelope contains both claims andencounters use CH. Some trading partner agreements may specify using only one code.ALIAS: Claim or Encounter IndicatorCHChargeableUse this code when the transaction contains only fee-for-serviceclaims or claims with at least one chargeable line item. If it is notclear whether a transaction contains claims or encounters, or ifthe transaction contains a mix of claims and encounters, theDHHS Sacramento County Page 17 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA Compliancedevelopers of this implementation guide recommend using codeCH.DHHS Sacramento County Page 18 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: REF Transmission Type IdentificationPosition: 015Loop:Level: HeadingUsage: Optional (Must Use)Max Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesREF01 128 Reference Identification Qualifier M ID 2/3 MCode qualifying the Reference Identification87 Functional CategoryREF02 127 Reference Identification X AN 1/30 M/UReference information as defined for a particular Transaction Set or as specified by theReference Identification QualifierWhen piloting the transaction set, this value is 004010X098DA1. When sending thetransaction set in a production mode, this value is 004010X098A1.004010X098A1Production ID004010X098DA1Pilot NumberDHHS Sacramento County Page 19 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Submitter NamePosition: 020Loop: 1000A Optional (Must Use)Level: HeadingUsage: Optional (Must Use)Max Use: 1Notes: The example in this NM1 and the subsequent N2 demonstrate how a name that is morethan 35 characters long could be handled between the NM1 and N2 segments.See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about usingLoop ID-1000. Ignore the Set Notes below.Because this is a required segment, this is a required loop. See Appendix A for furtherdetails on ASC X12 syntax rules.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individual41 SubmitterNM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entityDHHS NOTE: Use Non-Person Entity , Value 22 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Submitter NameDHHS NOTE: This name must remain the same once established as stated in thetrading partner agreement.NM104 1036 Name First O AN 1/25 UsedIndividual first nameRequired if NM102=1 (person).ALIAS: Submitter NameNM105 1037 Name Middle O AN 1/25 UsedIndividual middle name or initialRequired if NM102=1 and the middle name/initial of the person is known.ALIAS: Submitter NameNM108 66 Identification Code Qualifier X ID 1/2 M/UCode designating the system/method of code structure used for Identification Code (67)INDUSTRY: Identification Code Qualifier46 Electronic Transmitter Identification Number (ETIN)Established by trading partner agreement.NM109 67 Identification Code X AN 2/80 M/UCode identifying a party or other codeALIAS: Submitter Primary Identification NumberDHHS NOTE: The submitter ID will be the vendor ID assigned by DHHS. This ID willbe provided to the trading partner upon initiation and certification of 837P submittals.This is the same vendor ID that is used in ISA06 and GS02.DHHS Sacramento County Page 20 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: PER Submitter EDI Contact InformationPosition: 045Loop: 1000A Optional (Must Use)Level: HeadingUsage: Optional (Must Use)Max Use: 1Notes: When the communication number represents a telephone number in the United Statesand other countries using the North American Dialing Plan (for voice, data, fax, etc.),the communication number should always include the area code and phone numberusing the format AAABBBCCCC where AAA is the area code, BBB is the telephonenumber prefix, and CCCC is the telephone number (e.g., (534) 224-2525 would berepresented as 5342242525). The extension, when applicable, should be included in thecommunication number immediately after the telephone number.The contact information in this segment should point to the person in the submitterorganization who deals with data transmission issues. If data transmission problemsarise, this is the person to contact in the submitter organization.There are 2 repetitions of the PER segment to allow for six possible combination ofcommunication numbers including extensions.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesPER01 366 Contact Function Code M ID 2/2 MCode identifying the major duty or responsibility of the person or group namedICInformation ContactPER02 93 Name O AN 1/60 M/UFree-form nameUse this data element when the name of the individual to contact is not already definedor is different than the name within the prior name segment (e.g. N1 or NM1).PER03 365 Communication Number Qualifier X ID 2/2 M/UCode identifying the type of communication numberTETelephonePER04 364 Communication Number X AN 1/80 M/UComplete communications number including country or area code when applicableDHHS NOTE: AAABBBCCCC format, no hyphens. Please use the phone numbersubmitted on your application.Example - 9168268888PER05 365 Communication Number Qualifier X ID 2/2 UsedCode identifying the type of communication numberUsed at the discretion of the submitter.EXTelephone ExtensionPER06 364 Communication Number X AN 1/80 UsedComplete communications number including country or area code when applicableUsed at the discretion of the submitter.PER07 365 Communication Number Qualifier X ID 2/2 UsedCode identifying the type of communication numberUsed at the discretion of the submitter.EMElectronic MailPER08 364 Communication Number X AN 1/80 UsedDHHS Sacramento County Page 21 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceComplete communications number including country or area code when applicableUsed at the discretion of the submitter.DHHS Sacramento County Page 22 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Receiver NamePosition: 020Loop: 1000B Optional (Must Use)Level: HeadingUsage: Optional (Must Use)Max Use: 1Notes: Because this is a required segment, this is a required loop. See Appendix A for furtherdetails on ASC X12 syntax rules.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individual40 ReceiverNM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity2 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Receiver NameDHHS NOTE: Use either "PEMS" or "CMISP" according to the type of claims beingsubmitted.CMISP CMISPPEMS PEMSNM108 66 Identification Code Qualifier X ID 1/2 M/UCode designating the system/method of code structure used for Identification Code (67)46 Electronic Transmitter Identification Number (ETIN)NM109 67 Identification Code X AN 2/80 M/UCode identifying a party or other codeALIAS: Receiver Primary Identification NumberDHHS NOTE: Populate as follows for CMISP and PEMS"01" - for CMISP"16" - for PEMS01 CMISP16 PEMSDHHS Sacramento County Page 23 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: HL Billing/Pay-to Provider Hierarchical LevelPosition: 001Loop: 2000A MandatoryLevel: DetailUsage: MandatoryMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesHL01 628 Hierarchical ID Number M AN 1/12 MA unique number assigned by the sender to identify a particular data segment in ahierarchical structureHL01 must begin with "1" and be incremented by one each time an HL is used in thetransaction. Only numeric values are allowed in HL01.HL03 735 Hierarchical Level Code M ID 1/2 MCode defining the characteristic of a level in a hierarchical structure20 Information SourceHL04 736 Hierarchical Child Code O ID 1/1 M/UCode indicating if there are hierarchical child data segments subordinate to the level beingdescribed1 Additional Subordinate HL Data Segment in This HierarchicalStructure.DHHS Sacramento County Page 24 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Billing Provider NamePosition: 015Loop: 2010AA Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Notes: Although the name of this loop/segment is "Billing Provider" the loop/segment reallyidentifies the billing entity. The billing entity does not have to be a health care providerto use this loop. However, some payers do not accept claims from non-provider billingentities.Because this is a required segment, this is a required loop. See Appendix A for furtherdetails on ASC X12 syntax rules.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individual85 Billing ProviderUse this code to indicate billing provider, billing submitter, andencounter reporting entity.NM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity1 Person2 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Billing Provider NameNM104 1036 Name First O AN 1/25 UsedIndividual first nameRequired if NM102=1 (person).ALIAS: Billing Provider NameNM105 1037 Name Middle O AN 1/25 UsedIndividual middle name or initialRequired if NM102=1 and the middle name/initial of the person is known.ALIAS: Billing Provider NameNM107 1039 Name Suffix O AN 1/10 UsedSuffix to individual nameRequired if known.ALIAS: Billing Provider NameNM108 66 Identification Code Qualifier X ID 1/2 M/UCode designating the system/method of code structure used for Identification Code (67)DHHS NOTE: "Employer's Identification Number (Tax Id)" of the provider must becarried in the REF in this loop.XXHealth Care Financing Administration National ProviderIdentifierNM109 67 Identification Code X AN 2/80 M/UCode identifying a party or other codeALIAS: Billing Provider Primary Identification NumberDHHS Sacramento County Page 25 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: N3 Billing Provider AddressPosition: 025Loop: 2010AA Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesN301 166 Address Information M AN 1/55 MAddress informationALIAS: Billing Provider Address 1N302 166 Address Information O AN 1/55 UsedAddress informationRequired if a second address line exists.ALIAS: Billing Provider Address 2DHHS Sacramento County Page 26 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: N4 Billing Provider City/State/ZIP CodePosition: 030Loop: 2010AA Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesN401 19 City Name O AN 2/30 M/UFree-form text for city nameALIAS: Billing Provider's CityN402 156 State or Province Code O ID 2/2 M/UCode (Standard State/Province) as defined by appropriate government agencyALIAS: Billing Provider's StateN403 116 Postal Code O ID 3/15 M/UCode defining international postal zone code excluding punctuation and blanks (zip codefor United States)ALIAS: Billing Provider's Zip CodeDHHS Sacramento County Page 27 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: REF Billing Provider Secondary IdentificationPosition: 035Loop: 2010AA Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Notes: Required when a secondary identification number is necessary to identify the entity.The primary identification number should be carried in NM108/9 in this loop.If the reason the number is being used in this REF can be met by the NPI, carried inthe NM108/09 of this loop, then this REF is not used.DHHS NOTE: If "code XX - NPI" is used in the NM108/09 of this loop, then theEmployer's Identification Number of the provider must be carried in this REF. Thenumber sent is the one which is used on the 1099.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesREF01 128 Reference Identification Qualifier M ID 2/3 MCode qualifying the Reference IdentificationDHHS NOTE: Only use EIN.EIEmployer's Identification NumberREF02 127 Reference Identification X AN 1/30 M/U AN 9/9Reference information as defined for a particular Transaction Set or as specified by theReference Identification QualifierALIAS: Billing Provider Secondary Identification NumberDHHS NOTE: This is required by DHHS.DHHS Sacramento County Page 28 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: HL Subscriber Hierarchical LevelPosition: 001Loop: 2000B MandatoryLevel: DetailUsage: MandatoryMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesHL01 628 Hierarchical ID Number M AN 1/12 MA unique number assigned by the sender to identify a particular data segment in ahierarchical structureHL02 734 Hierarchical Parent ID Number O AN 1/12 M/UIdentification number of the next higher hierarchical data segment that the data segmentbeing described is subordinate toHL03 735 Hierarchical Level Code M ID 1/2 MCode defining the characteristic of a level in a hierarchical structure22 SubscriberHL04 736 Hierarchical Child Code O ID 1/1 M/UCode indicating if there are hierarchical child data segments subordinate to the level beingdescribedThe claim loop (Loop ID-2300) can be used both when HL04 has no subordinate levels(HL04 = 0) or when HL04 has subordinate levels indicated (HL04 = 1).In the first case (HL04 = 0), the subscriber is the patient and there are no dependentclaims. The second case (HL04 = 1) happens when claims/encounters for both thesubscriber and a dependent of theirs are being sent under the same billing provider HL(e.g., a father and son are both involved in the same automobile accident and are treatedby the same provider). In that case, the subscriber HL04 = 1 because there is a dependentto this subscriber, but the 2300 loop for the subscriber/patient (father) would begin afterthe subscriber HL. The dependent HL (son) would then be run and the 2300 loop for thedependent/patient would be run after that HL. HL04=1 would also be used when aclaim/encounter for a only a dependent is being sent.0 No Subordinate HL Segment in This Hierarchical Structure.DHHS Sacramento County Page 29 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: SBR Subscriber InformationPosition: 005Loop: 2000B MandatoryLevel: DetailUsage: Optional (Must Use)Max Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesSBR01 1138 Payer Responsibility Sequence Number Code M ID 1/1 MCode identifying the insurance carrier's level of responsibility for a payment of a claimALIAS: Payer Responsibility Sequence Number CodePPrimarySBR02 1069 Individual Relationship Code O ID 2/2 M/UCode indicating the relationship between two individuals or entitiesRequired when the subscriber is the same person as the patient. If the subscriber is notthe same person as the patient, do not use this element.ALIAS: Relationship Code18 SelfSBR03 127 Reference Identification O AN 1/30 UsedReference information as defined for a particular Transaction Set or as specified by theReference Identification QualifierRequired if the subscriber's payer identification includes Group or Plan Number. Thisdata element is intended to carry the subscriber's Group Number, not the number thatuniquely identifies the subscriber (Subscriber ID, Loop 2010BA-NM109).ALIAS: Group or Policy NumberSBR09 1032 Claim Filing Indicator Code O ID 1/2 UsedCode identifying type of claimRequired prior to mandated used of PlanID. Not used after PlanID is mandated.ALIAS: Claim Filing Indicator CodeMCMedicaidCA0-23.0 (D), DA0-05.0 (D)DHHS Sacramento County Page 30 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: PAT Patient InformationPosition: 007Loop: 2000B MandatoryLevel: DetailUsage: OptionalMax Use: 1Notes: Required if the subscriber is the same person as the patient (Loop ID-2000BSBR02=18), and information in this PAT segment (date of death, and/or patientweight) is necessary to file the claim/encounter (see PAT05, 06, 07, and 08).Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesPAT05 1250 Date Time Period Format Qualifier X ID 2/3 UsedCode indicating the date format, time format, or date and time formatRequired if patient is known to be deceased and the date of death is available to theprovider billing system.D8Date Expressed in Format CCYYMMDDPAT06 1251 Date Time Period X AN 1/35 UsedExpression of a date, a time, or range of dates, times or dates and timesRequired if patient is known to be deceased and the date of death is available to theprovider billing system.ALIAS: Date of DeathPAT07 355 Unit or Basis for Measurement Code X ID 2/2 UsedCode specifying the units in which a value is being expressed, or manner in which ameasurement has been takenRequired when PAT08 is used.01 Actual PoundsPAT08 81 Weight X R 1/10 UsedNumeric value of weightRequired on (1) claims/encounters involving EPO (epoetin) for patients on dialysis (2)Medicare Durable Medical Equipment Regional Carriers certificate of medical necessity(DMERC CMN) 02.03 and 10.02.ALIAS: Patient WeightPAT09 1073 Yes/No Condition or Response Code O ID 1/1 UsedCode indicating a Yes or No condition or responseRequired when mandated by law. The determination of pregnancy should be completedin compliance with applicable law. The "Y" code indicates that the patient is pregnant. IfPAT09 is not used it means the patient is not pregnant.ALIAS: Pregnancy IndicatorYYesDHHS Sacramento County Page 31 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Subscriber NamePosition: 015Loop: 2010BA MandatoryLevel: DetailUsage: MandatoryMax Use: 1Notes: In worker's compensation or other property and casualty claims, the "subscriber" maybe a non-person entity (i.e., the employer). However, this varies by state.Because this is a required segment, this is a required loop. See Appendix A for furtherdetails on ASC X12 syntax rules.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individualILInsured or SubscriberNM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity1 PersonNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Subscriber Last NameNM104 1036 Name First O AN 1/25 UsedIndividual first nameRequired if NM102=1 (person).ALIAS: Subscriber First NameNM105 1037 Name Middle O AN 1/25 UsedIndividual middle name or initialRequired if NM102=1 and the middle name/initial of the person is known.ALIAS: Subscriber Middle NameNM107 1039 Name Suffix O AN 1/10 UsedSuffix to individual nameRequired if known.Examples: I, II, III, IV, Jr, SrALIAS: Subscriber GenerationNM108 66 Identification Code Qualifier X ID 1/2 M/UCode designating the system/method of code structure used for Identification Code (67)Required if NM102 = 1 (person)MIMember Identification NumberThe code MI is intended to be the subscriber's identificationnumber as assigned by the payer. Payers use differentterminology to convey the same number. Therefore the 837Professional Workgroup recommends using MI - MemberIdentification Number to convey the following terms: Insured'sID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.MI is also intended to be used in claims submitted to the IndianHealth Service/Contract Health Services (IHS/CHS) FiscalDHHS Sacramento County Page 32 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceIntermediary for the purpose of reporting the Tribe ResidencyCode (Tribe County State).In the event that a Social Security Number is also available onan IHS/CHS claim, put the SSN in REF02.NM109 67 Identification Code X AN 2/80 M/UCode identifying a party or other codeRequired if the Subscriber is the patient. If the subscriber is not thepatient, use if known. An identifier must be present in either thesubscriber or the patient loop.DHHS NOTE: If Subscriber Information Not available please use " 0000000" asDefault. Mandatory to Populate NM109 Field. Do not send the SSN here.DHHS Sacramento County Page 33 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: N3 Subscriber AddressPosition: 025Loop: 2010BA MandatoryLevel: DetailUsage: Optional (Must Use)Max Use: 1Notes: Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18 (self)).DHHS NOTE: IF patient Information Not Available , populate N301, Address lineField with"UNKNOWN"Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesN301 166 Address Information M AN 1/55 MAddress informationALIAS: Subscriber Address 1DHHS NOTE: If the patient is homeless, put "HOMELESS in this field.N302 166 Address Information O AN 1/55 UsedAddress informationRequired if a second address line exists.ALIAS: Subscriber Address 2DHHS Sacramento County Page 34 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: N4 Subscriber City/State/ZIP CodePosition: 030Loop: 2010BA MandatoryLevel: DetailUsage: Optional (Must Use)Max Use: 1Notes: Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18 (self)).DHHS NOTE: If the patient is homeless use the city, state, and zip code of the billingprovider. Must Populate this segmentData Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesN401 19 City Name O AN 2/30 M/UFree-form text for city nameALIAS: Subscriber City NameN402 156 State or Province Code O ID 2/2 M/UCode (Standard State/Province) as defined by appropriate government agencyALIAS: Subscriber State CodeN403 116 Postal Code O ID 3/15 M/U ID 5/9Code defining international postal zone code excluding punctuation and blanks (zip codefor United States)ALIAS: Subscriber Zip CodeDHHS Sacramento County Page 35 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: DMG Subscriber Demographic InformationPosition: 032Loop: 2010BA MandatoryLevel: DetailUsage: Optional (Must Use)Max Use: 1Notes: Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18 (self)).DHHS Note: if patient DOB information Not available, Default to valid date.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesDMG01 1250 Date Time Period Format Qualifier X ID 2/3 M/UCode indicating the date format, time format, or date and time formatD8Date Expressed in Format CCYYMMDDDMG02 1251 Date Time Period X AN 1/35 M/U AN 8/8Expression of a date, a time, or range of dates, times or dates and timesALIAS: Patient Birth DateDate of Birth - PatientDMG03 1068 Gender Code O ID 1/1 M/UCode indicating the sex of the individualALIAS: Patient Gender CodeGender - PatientFMFemaleMaleDHHS Sacramento County Page 36 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: REF Subscriber Secondary IdentificationPosition: 035Loop: 2010BA MandatoryLevel: DetailUsage: OptionalMax Use: 4Notes: Required when a secondary identification number is necessary to identify the entity.The primary identification number should be carried in NM109 in this loop.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesREF01 128 Reference Identification Qualifier M ID 2/3 MCode qualifying the Reference Identification1WMember Identification NumberIf NM108 = M1 do not use this code.SYSocial Security NumberThe social security number may not be used for Medicare.REF02 127 Reference Identification X AN 1/30 M/UReference information as defined for a particular Transaction Set or as specified by theReference Identification QualifierDHHS Sacramento County Page 37 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Payer NamePosition: 015Loop: 2010BB Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Notes: This is the destination payer.Because this is a required segment, this is a required loop. See Appendix A for furtherdetails on ASC X12 syntax rules.DHHS NOTE: DHHS uses field NM103 of this loop to appropriately differentiatebetween the CMISP and PEMS claim types. The payer name is required forProcessing.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individualPRPayerNM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity2 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Payer NameDHHS NOTE: Please Use following Names OnlyCMISP:"CMISP" - for all CMISP claimsPEMS:"PEMSES" - for Charity Care/Emergency physicians"PEMSOB" - for Charity Care/Obstetrics"PEMSPE" - for Charity Care/PediatricsNM108 66 Identification Code Qualifier X ID 1/2 M/UCode designating the system/method of code structure used for Identification Code (67)PIPayor IdentificationNM109 67 Identification Code X AN 2/80 M/UCode identifying a party or other codeALIAS: Payer Primary IdentifierDHHS NOTE: Use "SACCOUNTYHHSEDI"DHHS Sacramento County Page 38 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: CLM Claim InformationPosition: 130Loop: 2300 OptionalLevel: DetailUsage: OptionalMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesCLM01 1028 Claim Submitter's Identifier M AN 1/38 M AN 1/21Identifier used to track a claim from creation by the health care provider through paymentThe number that the submitter transmits in this position is echoed back to the submitterin the 835 and other transactions. This permits the submitter to use the value in this fieldas a key in the submitter's system to match the claim to the payment informationreturned in the 835 transaction. The two recommended identifiers are either the PatientAccount Number or the Claim Number in the billing submitter's patient managementsystem. The developers of this implementation guide strongly recommend that submittersuse completely unique numbers for this field for each individual claim.The maximum number of characters to be supported for this field is '21'. A provider maysubmit fewer characters depending upon their needs. However, the HIPAA maximumrequirement to be supported by any responding system is '21'. Characters beyond 20 arenot required to be stored nor returned by any 837-receiving system.ALIAS: Patient Account NumberDHHS NOTE: Populate as follows for CMISP and PEMSPosition (1) - C (CMISP) (1)P (PEMS) (1)Position (2-10) - Unique Number (9)Position (11-15) - Batch Number (ST02) (5) zero fill when necessaryPosition (16-21) - HHMMSS (6) use 24 hour clockExample: "P00008821700026130120" - 21 bytesCLM02 782 Monetary Amount O R 1/10 M/U R 1/9Monetary amountFor encounter transmissions, zero (0) may be a valid amount.ALIAS: Total Submitted ChargesCLM05 C023 Health Care Service Location Information O M/UTo provide information that identifies the place of service or the type of bill related to thelocation at which a health care service was renderedCLM05 applies to all service lines unless it is over written at the line level.ALIAS: Place of Service CodeC02301 1331 Facility Code Value M AN 1/2 MCode identifying the type of facility where services were performed; the first and secondpositions of the Uniform Bill Type code or the Place of Service code from the ElectronicMedia Claims National Standard FormatUse this element for codes identifying a place of service from code source 237. As acourtesy, the codes are listed below, however, the code list is thought to be complete atthe time of publication of this implementation guideline. Since this list is subject toDHHS Sacramento County Page 39 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA Compliancechange, only codes contained in the document available from code source 237 are to besupported in this transaction and take precedence over any and all codes listed here.11 Office12 Home21 Inpatient Hospital22 Outpatient Hospital23 Emergency Room - Hospital24 Ambulatory Surgical Center25 Birthing Center26 Military Treatment Facility31 Skilled Nursing Facility32 Nursing Facility33 Custodial Care Facility34 Hospice41 Ambulance - Land42 Ambulance - Air or Water51 Inpatient Psychiatric Facility52 Psychiatric Facility Partial Hospitalization53 Community Mental Health Center54 Intermediate Care Facility/Mentally Retarded55 Residential Substance Abuse Treatment Facility56 Psychiatric Residential Treatment Center50 Federally Qualified Health Center60 Mass Immunization Center61 Comprehensive Inpatient Rehabilitation Facility62 Comprehensive Outpatient Rehabilitation Facility65 End Stage Renal Disease Treatment Facility71 State or Local Public Health Clinic72 Rural Health Clinic81 Independent Laboratory99 Other Unlisted FacilityALIAS: Facility Type CodeC02303 1325 Claim Frequency Type Code O ID 1/1 M/UCode specifying the frequency of the claim; this is the third position of the Uniform BillingClaim Form Bill TypeDHHS NOTE: use Claim Frequency Code "1"1 DHHS County Frequency CodeCLM06 1073 Yes/No Condition or Response Code O ID 1/1 M/UCode indicating a Yes or No condition or responseALIAS: Provider Signature on FileNNoYYesCLM07 1359 Provider Accept Assignment Code O ID 1/1 M/UCode indicating whether the provider accepts assignmentCLM07 indicates whether the provider accepts Medicare assignment.The NSF mapping to FA0-59.0 occurs only in payer-to-payer COB situations.ALIAS: Medicare Assignment CodeAAssignedBAssignment Accepted on Clinical Lab Services OnlyCNot AssignedPPatient Refuses to Assign BenefitsCLM08 1073 Yes/No Condition or Response Code O ID 1/1 M/UDHHS Sacramento County Page 40 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceCode indicating a Yes or No condition or responseALIAS: Assignment of Benefits IndicatorNNoYYesCLM09 1363 Release of Information Code O ID 1/1 M/UCode indicating whether the provider has on file a signed statement by the patientauthorizing the release of medical data to other organizationsALIAS: Release of Information CodeAAppropriate Release of Information on File at Health CareService Provider or at Utilization Review OrganizationIInformed Consent to Release Medical Information forConditions or Diagnoses Regulated by Federal StatutesMThe Provider has Limited or Restricted Ability to Release DataRelated to a ClaimNNo, Provider is Not Allowed to Release DataOOn file at Payor or at Plan SponsorYYes, Provider has a Signed Statement Permitting Release ofMedical Billing Data Related to a ClaimCLM10 1351 Patient Signature Source Code O ID 1/1 UsedCode indicating how the patient or subscriber authorization signatures were obtained andhow they are being retained by the providerCLM10 is required except in cases where code "N" is used in CLM09.ALIAS: Patient Signature Source CodeBSigned signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on fileCSigned HCFA-1500 Claim Form on fileMSigned signature authorization form for HCFA-1500 ClaimForm block 13 on filePSignature generated by provider because the patient was notphysically present for servicesSSigned signature authorization form for HCFA-1500 ClaimForm block 12 on fileCLM11 C024 Related Causes Information O UsedTo identify one or more related causes and associated state or country informationCLM11-1, CLM11-2, or CLM11-3 are required when the condition being reported isaccident or employment related. If CLM11-1, CLM11-2, or CLM11-3 equals AP, thenmap Yes to EA0-09.0.If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required.ALIAS: Accident/Employment/Related CausesC02401 1362 Related-Causes Code M ID 2/3 MCode identifying an accompanying cause of an illness, injury or an accidentAAAuto AccidentAPAnother Party ResponsibleEMEmploymentOAOther AccidentC02402 1362 Related-Causes Code O ID 2/3 UsedCode identifying an accompanying cause of an illness, injury or an accidentUsed if more than one code applies.DHHS Sacramento County Page 41 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceAAAuto AccidentAPAnother Party ResponsibleEMEmploymentOAOther AccidentC02403 1362 Related-Causes Code O ID 2/3 UsedCode identifying an accompanying cause of an illness, injury or an accidentUsed if more than one code applies.AAAuto AccidentAPAnother Party ResponsibleEMEmploymentOAOther AccidentC02404 156 State or Province Code O ID 2/2 UsedCode (Standard State/Province) as defined by appropriate government agencyRequired if CLM11-1, -2, or -3 = AA to identify the state in which the automobileaccident occurred. Use state postal code (CA = California, UT = Utah, etc).C02405 26 Country Code O ID 2/3 UsedCode identifying the countryRequired if the automobile accident occurred out of the United States to identify thecountry in which the accident occurred.DHHS Sacramento County Page 42 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: DTP Date - Onset of Current Illness/SymptomPosition: 135Loop: 2300 OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTPsegment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTPin Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.Required when information is available and if different than the date of service. If notused, claim/service date is assumed to be the date of onset of illness/symptoms.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesDTP01 374 Date/Time Qualifier M ID 3/3 MCode specifying type of date or time, or both date and time431 Onset of Current Symptoms or IllnessDTP02 1250 Date Time Period Format Qualifier M ID 2/3 MCode indicating the date format, time format, or date and time formatD8Date Expressed in Format CCYYMMDDDTP03 1251 Date Time Period M AN 1/35 M AN 8/8Expression of a date, a time, or range of dates, times or dates and timesDHHS Sacramento County Page 43 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: DTP Date - AccidentPosition: 135Loop: 2300 OptionalLevel: DetailUsage: OptionalMax Use: 10Notes: Required if CLM11-1, CLM11-2, or CLM11-3 = AA, AP or OA.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesDTP01 374 Date/Time Qualifier M ID 3/3 MCode specifying type of date or time, or both date and time439 AccidentDTP02 1250 Date Time Period Format Qualifier M ID 2/3 MCode indicating the date format, time format, or date and time formatD8Date Expressed in Format CCYYMMDDDTDate and Time Expressed in Format CCYYMMDDHHMMRequired if accident hour is known.DTP03 1251 Date Time Period M AN 1/35 MExpression of a date, a time, or range of dates, times or dates and timesDHHS NOTE: Use format CCYYMMDDhhmmss. Zero fill for hours, minutes, andseconds when unavailable.DHHS Sacramento County Page 44 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: DTP Date - AdmissionPosition: 135Loop: 2300 OptionalLevel: DetailUsage: Optional (Dependent)Max Use: 1Notes: Required on all ambulance claims/encounters when the patient was known to beadmitted to the hospital. Also required on inpatient medical visits claims/encounters.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesDTP01 374 Date/Time Qualifier M ID 3/3 MCode specifying type of date or time, or both date and time435 AdmissionDTP02 1250 Date Time Period Format Qualifier M ID 2/3 MCode indicating the date format, time format, or date and time formatD8Date Expressed in Format CCYYMMDDDTP03 1251 Date Time Period M AN 1/35 M AN 8/14Expression of a date, a time, or range of dates, times or dates and timesDHHS NOTE: Use format CCYYMMDDhhmmss. Zero fill for hours, minutes, andseconds when unavailable.DHHS Sacramento County Page 45 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: DTP Date - DischargePosition: 135Loop: 2300 OptionalLevel: DetailUsage: Optional (Dependent)Max Use: 1Notes: Required for inpatient claims when the patient was discharged from the facility and thedischarge date is known.DHHS NOTE: For CMISP only DTP Discharge is REQUIRED, if CLM05-1/FacilityType Code equals 21, 31, 32, 51, 55, 56, or 61.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesDTP01 374 Date/Time Qualifier M ID 3/3 MCode specifying type of date or time, or both date and time096 DischargeDTP02 1250 Date Time Period Format Qualifier M ID 2/3 MCode indicating the date format, time format, or date and time formatD8Date Expressed in Format CCYYMMDDDTP03 1251 Date Time Period M AN 1/35 M AN 8/14Expression of a date, a time, or range of dates, times or dates and timesDHHS NOTE: Use format CCYYMMDDhhmmss. Zero fill for hours, minutes, andseconds when unavailable.DHHS Sacramento County Page 46 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: PWK Claim Supplemental InformationPosition: 155Loop: 2300 OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: The PWK segment is required if there is paper documentation supporting this claim.The PWK segment should not be used if the information related to the claim is beingsent within the 837 ST-SE envelope.The PWK segment is required to identify attachments that are sent electronically(PWK02 = EL) but are transmitted in another functional group (e.g., 275) rather thanby paper. PWK06 is used to identify the attached electronic documentation. Thenumber in PWK06 would be carried in the TRN of the electronic attachment.The PWK segment can be used to identify paperwork that is being held at theprovider's office and is available upon request by the payer (or appropriate entity), butthat is not being sent with the claim. Use code AA in PWK02 to convey this specific useof the PWK segment. See code note under PWK02, code AA.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesPWK01 755 Report Type Code M ID 2/2 MCode indicating the title or contents of a document, report or supporting itemALIAS: Attachment Report Type Code77 Support Data for VerificationREFERRAL. Use this code to indicate a completed referral form.ASAdmission SummaryB2PrescriptionB3Physician OrderB4Referral FormCTCertificationDADental ModelsDGDiagnostic ReportDSDischarge SummaryEBExplanation of Benefits (Coordination of Benefits or MedicareSecondary Payor)MTModelsNNNursing NotesOBOperative NoteOZSupport Data for ClaimPNPhysical Therapy NotesPOProsthetics or Orthotic CertificationPZPhysical Therapy CertificationRBRadiology FilmsRRRadiology ReportsRTReport of Tests and Analysis ReportPWK02 756 Report Transmission Code O ID 1/2 M/UCode defining timing, transmission method or format by which reports are to be sentALIAS: Attachment Transmission CodeDHHS Sacramento County Page 47 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceAAAvailable on Request at Provider SiteThis means that the paperwork is not being sent with the claim atthis time. Instead, it is available to the payer (or appropriateentity) at their request.BMBy MailELElectronically OnlyUse to indicate that attachment is being transmitted in a separateX12 functional group.EME-MailFXBy FaxPWK05 66 Identification Code Qualifier X ID 1/2 UsedCode designating the system/method of code structure used for Identification Code (67)Required if PWK02 = "BM", "EL", "EM" or "FX".ACAttachment Control NumberPWK06 67 Identification Code X AN 2/80 UsedCode identifying a party or other codeRequired if PWK02 = "BM", "EL", "EM" or "FX".ALIAS: Attachment Control NumberDHHS NOTE: The attachment control number should be in for following format:County Medical Record Number + Date of Service (i.e., 12345612312003)Example - "123456MMDDCCYY" 123456 equals Couny MRN (NM109)+MMDDCCYY equals Service Date (DTP03)DHHS Sacramento County Page 48 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: AMT Patient Amount PaidPosition: 175Loop: 2300 OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: Required when patient has made payment specifically toward this claim.Patient Amount Paid refers to the sum of all amounts paid on the claim by the patientor his/her representative(s).Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesAMT01 522 Amount Qualifier Code M ID 1/3 MCode to qualify amountF5Patient Amount PaidAMT02 782 Monetary Amount M R 1/10 MMonetary amountDHHS Sacramento County Page 49 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: REF Prior Authorization or Referral NumberPosition: 180Loop: 2300 OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: Numbers at this position apply to the entire claim unless they are overridden in theREF segment in Loop ID-2400. A reference identification is considered to beoverridden if the value in REF01 is the same in both the Loop ID-2300 REF segmentand the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies onlyto that specific line.Required where services on this claim were preauthorized or where a referral isinvolved. Generally, preauthorization/referral numbers are those numbers assigned bythe payer/UMO to authorize a service prior to its being performed. The UMO(Utilization Management Organization) is generally the entity empowered to make adecision regarding the outcome of a health services review or the owner ofinformation. The referral or prior authorization number carried in this REF is specificto the destination payer reported in the 2010BB loop. If other payers have similarnumbers for this claim, report that information in the 2330 loop REF which holds thatpayer's information.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesREF01 128 Reference Identification Qualifier M ID 2/3 MCode qualifying the Reference IdentificationG1Prior Authorization NumberREF02 127 Reference Identification X AN 1/30 M/U AN 1/7Reference information as defined for a particular Transaction Set or as specified by theReference Identification QualifierDHHS Sacramento County Page 50 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NTE Claim NotePosition: 190Loop: 2300 OptionalLevel: DetailUsage: Optional (Dependent)Max Use: 1Notes: Information in the NTE segment in Loop ID-2300 applies to the entire claim unlessoverridden by information in the NTE segment in Loop ID-2400. Information isconsidered to be overridden when the value in NTE01 in Loop ID-2400 is the same asthe value in NTE01 in Loop ID-2300.The developers of this implementation guide discourage using narrative informationwithin the 837. Trading partners who require narrative information with claims areencouraged to codify that information within the ASC X12 environment.Required when: (1) State regulations mandate information not identified elsewherewithin the claim set or (2) in the opinion of the provider, the information is needed tosubstantiate the medical treatment and is not supported elsewhere within the claimdata set.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNTE01 363 Note Reference Code O ID 3/3 M/UCode identifying the functional area or purpose for which the note appliesADDAdditional InformationNTE02 352 Description M AN 1/80 M AN 1/25A free-form description to clarify the related data elements and their contentDHHS NOTE: Refer to note segment table Appendix A, for positioning of data collectedin this field.DHHS Sacramento County Page 51 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: HI Health Care Diagnosis CodePosition: 231Loop: 2300 OptionalLevel: DetailUsage: Optional (Must Use)Max Use: 1Notes: Required on all claims/encounters except claims for which there are no diagnoses (e.g.,taxi claims).Do not transmit the decimal points in the diagnosis codes. The decimal point isassumed.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesHI01 C022 Health Care Code Information M MTo send health care codes and their associated dates, amounts and quantitiesWith a few exceptions, it is not recommended to put E codes in HI01. E codes may be putin any other HI element using BF as the qualifier.The diagnosis listed in this element is assumed to be the principal diagnosis.ALIAS: Principal DiagnosisC02201 1270 Code List Qualifier Code M ID 1/3 MCode identifying a specific industry code listBKPrincipal DiagnosisICD-9 CodesC02202 1271 Industry Code M AN 1/30 M AN 3/5Code indicating a code from a specific industry code listHI02 C022 Health Care Code Information O UsedTo send health care codes and their associated dates, amounts and quantitiesRefer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.Required if needed to report an additional diagnoses and if the preceeding HI dataelements have been used to report other diagnoses.ALIAS: DiagnosisC02201 1270 Code List Qualifier Code M ID 1/3 MCode identifying a specific industry code listBFDiagnosisICD-9 CodesC02202 1271 Industry Code M AN 1/30 M AN 3/50Code indicating a code from a specific industry code listDHHS Sacramento County Page 52 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Referring Provider NamePosition: 250Loop: 2310A OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: Information in Loop ID-2310 applies to the entire claim unless overridden on a serviceline by the presence of Loop ID-2420 with the same value in NM101.When there is only one referral on the claim, use code "DN - Referring Provider".When more than one referral exists and there is a requirement to report the additionalreferral, use code DN in the first iteration of this loop to indicate the referral receivedby the rendering provider on this claim. Use code "P3 - Primary Care Provider" in thesecond iteration of the loop to indicate the initial referral from the primary careprovider or whatever provider wrote the initial referral for this patient's episode of carebeing billed/reported in this transaction.Because the usage of this segment is "Situational" this is not a syntactically requiredloop. If this loop is used, then this segment is a "Required" segment. See Appendix Afor further details on ASC X12 syntax rules.Required if claim involved a referral.When reporting the provider who ordered services such as diagnostic and lab utilizethe 2310A loop at the claim level. For ordered services such as DMERC utilize the2420E Loop at the line level.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individualThe entity identifier in NM101 applies to all segments in this Loop ID-2310.DNReferring ProviderUse on first iteration of this loop. Use if loop is used only once.NM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity1 Person2 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Referring Provider Last NameNM104 1036 Name First O AN 1/25 UsedIndividual first nameRequired if NM102=1 (person).ALIAS: Referring Provider First NameNM105 1037 Name Middle O AN 1/25 UsedIndividual middle name or initialRequired if NM102=1 and the middle name/initial of the person is known.ALIAS: Referring Provider Middle NameNM107 1039 Name Suffix O AN 1/10 UsedDHHS Sacramento County Page 53 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSuffix to individual nameRequired if known.ALIAS: Referring Provider GenerationNM108 66 Identification Code Qualifier X ID 1/2 UsedCode designating the system/method of code structure used for Identification Code (67)Required if Employer's Identification/Social Security number (Tax ID) or NationalProvider Identifier is known.XXHealth Care Financing Administration National ProviderIdentifierNM109 67 Identification Code X AN 2/80 UsedCode identifying a party or other codeRequired if Employer's Identification/Social Security number (Tax ID) or NationalProvider Identifier is known.ALIAS: Referring Provider Primary IdentifierDHHS Sacramento County Page 54 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Rendering Provider NamePosition: 250Loop: 2310B OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: Information in Loop ID-2310 applies to the entire claim unless overridden on a serviceline by the presence of Loop ID-2420 with the same value in NM101.Because the usage of this segment is "Situational" this is not a syntactically requiredloop. If this loop is used, then this segment is a "Required" segment. See Appendix Afor further details on ASC X12 syntax rules.Required when the Rendering Provider NM1 information is different than that carriedin either the Billing Provider NM1 or the Pay-to Provider NM1 in the 2010AA/ABloops respectively.Used for all types of rendering providers including laboratories. The RenderingProvider is the person or company (laboratory or other facility) who rendered the care.In the case where a subsitute provider (locum tenans) was used, that person should beentered here.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individualThe entity identifier in NM101 applies to all segments in this Loop ID-2310.82 Rendering ProviderNM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity1 Person2 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Rendering Provider Last NameNM104 1036 Name First O AN 1/25 UsedIndividual first nameRequired if NM102=1 (person).ALIAS: Rendering Provider First NameNM105 1037 Name Middle O AN 1/25 UsedIndividual middle name or initialRequired if NM102=1 and the middle name/initial of the person is known.ALIAS: Rendering Provider Middle NameNM107 1039 Name Suffix O AN 1/10 UsedSuffix to individual nameRequired if known.ALIAS: Rendering Provider GenerationNM108 66 Identification Code Qualifier X ID 1/2 M/UCode designating the system/method of code structure used for Identification Code (67)DHHS Sacramento County Page 55 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceFA0-57.0 crosswalk is only used in Medicare COB payer-to-payer claims.XXHealth Care Financing Administration National ProviderIdentifierNM109 67 Identification Code X AN 2/80 M/UCode identifying a party or other codeFA0-58.0 crosswalk is only used in Medicare COB payer-to-payer claims.ALIAS: Rendering Provider Primary IdentifierDHHS Sacramento County Page 56 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Service Facility LocationPosition: 250Loop: 2310D OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: Information in Loop ID-2310 applies to the entire claim unless overridden on a serviceline by the presence of Loop ID-2420 with the same value in NM101.Because the usage of this segment is "Situational" this is not a syntactically requiredloop. If this loop is used, then this segment is a "Required" segment. See Appendix Afor further details on ASC X12 syntax rules.This loop is required when the location of health care service is different than thatcarried in the 2010AA (Billing Provider) or 2010AB (Pay-to Provider) loops.Required if the service was rendered in a Health Professional Shortage Area (QB orQU modifier billed) and the place of service is different than the HPSA billing address.The purpose of this loop is to identify specifically where the service was rendered. Incases where it was rendered at the patient's home, do not use this loop. In that case, theplace of service code in CLM05-1 should indicate that the service occurred in thepatient's home.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individualFAFacilityLIIndependent LabNM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity2 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameRequired except when service was rendered in the patient's home.ALIAS: Laboratory/Facility NameNM108 66 Identification Code Qualifier X ID 1/2 UsedCode designating the system/method of code structure used for Identification Code (67)Required if either Employer's Identification/Social Security Number or NationalProvider Identifier is known.XXHealth Care Financing Administration National ProviderIdentifierNM109 67 Identification Code X AN 2/80 UsedCode identifying a party or other codeRequired if either Employer's Identification/Social Security Number or NationalProvider Identifier is known.ALIAS: Laboratory/Facility Primary IdentifierDHHS Sacramento County Page 57 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: N3 Service Facility Location AddressPosition: 265Loop: 2310D OptionalLevel: DetailUsage: Optional (Must Use)Max Use: 1Notes: If service facility location is in an area where there are no street addresses, enter adescription of where the service was rendered (e.g., "crossroad of State Road 34 and45" or "Exit near Mile marker 265 on Interstate 80".)Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesN301 166 Address Information M AN 1/55 MAddress informationALIAS: Laboratory/Facility Address 1N302 166 Address Information O AN 1/55 UsedAddress informationRequired if a second address line exists.ALIAS: Laboratory/Facility Address 2DHHS Sacramento County Page 58 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: N4 Service Facility Location City/State/ZIPPosition: 270Loop: 2310D OptionalLevel: DetailUsage: Optional (Must Use)Max Use: 1Notes: If service facility location is in an area where there are no street addresses, enter thename of the nearest town, state and zip of where the service was rendered.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesN401 19 City Name O AN 2/30 M/UFree-form text for city nameALIAS: Laboratory/Facility CityN402 156 State or Province Code O ID 2/2 M/UCode (Standard State/Province) as defined by appropriate government agencyALIAS: Laboratory/Facility StateN403 116 Postal Code O ID 3/15 M/UCode defining international postal zone code excluding punctuation and blanks (zip codefor United States)ALIAS: Laboratory/Facility Zip CodeDHHS Sacramento County Page 59 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: LX Service LinePosition: 365Loop: 2400 Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Notes: The Service Line LX segment begins with 1 and is incremented by one for eachadditional service line of a claim. The LX functions as a line counter.The datum in the LX is not usually returned in the 835 (Remittance Advice)transaction. LX01 may be used as a line item control number by the payer in the 835 ifa line item control number has not been submitted on the service line. See that REF formore information.LX01 is used to indicate bundling/unbundling in SVC06. See Section 1.4.3 for moreinformation on bundling and unbundling.Because this is a required segment, this is a required loop. See Appendix A for furtherdetails on ASC X12 syntax rules.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesLX01 554 Assigned Number M N0 1/6 MNumber assigned for differentiation within a transaction setThe service line number incremented by 1 for each service line.ALIAS: Line CounterDHHS Sacramento County Page 60 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: SV1 Professional ServicePosition: 370Loop: 2400 Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesSV101 C003 Composite Medical Procedure Identifier M MTo identify a medical procedure by its standardized codes and applicable modifiersALIAS: Procedure identifierC00301 235 Product/Service ID Qualifier M ID 2/2 MCode identifying the type/source of the descriptive number used in Product/Service ID(234)The NDC number is used for reporting prescribed drugs and biologics when required bygovernment regulation, or as deemed by the provider to enhance claimreporting/adjudication processes. The NDC number is reported in the LIN segment ofLoop ID-2410 only.HCHealth Care Financing Administration Common ProceduralCoding System (HCPCS) CodesBecause the AMA's CPT codes are also level 1 HCPCS codes,they are reported under HC.C00302 234 Product/Service ID M AN 1/48 M AN 1/15Identifying number for a product or serviceC00303 1339 Procedure Modifier O AN 2/2 UsedThis identifies special circumstances related to the performance of the service, as definedby trading partnersUse this modifier for the first procedure code modifier.Required when a modifier clarifies/improves the reporting accuracy of the associatedprocedure code.DHHS NOTE: Only Modifiers currently approved by Medi-cal will be accepted. Referto references and list for details.ALIAS: Procedure Modifier 1C00304 1339 Procedure Modifier O AN 2/2 UsedThis identifies special circumstances related to the performance of the service, as definedby trading partnersUse this modifier for the second procedure code modifier.Required when a modifier clarifies/improves the reporting accuracy of the associatedprocedure code.ALIAS: Procedure Modifier 2C00305 1339 Procedure Modifier O AN 2/2 UsedThis identifies special circumstances related to the performance of the service, as definedby trading partnersUse this modifier for the third procedure code modifier.Required when a modifier clarifies/improves the reporting accuracy of the associatedprocedure code.DHHS Sacramento County Page 61 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceALIAS: Procedure Modifier 3C00306 1339 Procedure Modifier O AN 2/2 UsedThis identifies special circumstances related to the performance of the service, as definedby trading partnersUse this modifier for the fourth procedure code modifier.Required when a modifier clarifies/improves the reporting accuracy of the associatedprocedure code.ALIAS: Procedure Modifier 4SV102 782 Monetary Amount O R 1/10 M/U R 1/9Monetary amountFor encounter transmissions, zero (0) may be a valid amount.ALIAS: Submitted charge amountSV103 355 Unit or Basis for Measurement Code X ID 2/2 M/UCode specifying the units in which a value is being expressed, or manner in which ameasurement has been takenFA0-50.0 is only used in Medicare COB payer-to-payer situations.UNUnitSV104 380 Quantity X R 1/15 M/U R 1/5Numeric value of quantityNote: If a decimal is needed to report units, include it in this element, e.g., "15.6".ALIAS: Units or MinutesSV105 1331 Facility Code Value O AN 1/2 UsedCode identifying the type of facility where services were performed; the first and secondpositions of the Uniform Bill Type code or the Place of Service code from the ElectronicMedia Claims National Standard FormatRequired if value is different than value carried in CLM05-1 in Loop ID-2300.Use this element for codes identifying a place of service from code source 237. As acourtesy, the codes are listed below, however, the code list is thought to be complete atthe time of publication of this implementation guideline. Since this list is subject tochange, only codes contained in the document available from code source 237 are to besupported in this transaction and take precedence over any and all codes listed here.11 Office12 Home21 Inpatient Hospital22 Outpatient Hospital23 Emergency Room - Hospital24 Ambulatory Surgical Center25 Birthing Center26 Military Treatment Facility31 Skilled Nursing Facility32 Nursing Facility33 Custodial Care Facility34 Hospice41 Ambulance - Land42 Ambulance - Air or Water50 Federally Qualified Health Center51 Inpatient Psychiatric Facility52 Psychiatric Facility Partial Hospitalization53 Community Mental Health Center54 Intermediate Care Facility/Mentally RetardedDHHS Sacramento County Page 62 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA Compliance55 Residential Substance Abuse Treatment Facility56 Psychiatric Residential Treatment Center60 Mass Immunization Center61 Comprehensive Inpatient Rehabilitation Facility62 Comprehensive Outpatient Rehabilitation Facility65 End Stage Renal Disease Treatment Facility71 State or Local Public Health Clinic72 Rural Health Clinic81 Independent Laboratory99 Other Unlisted FacilityALIAS: Place of Service CodeSV107 C004 Composite Diagnosis Code Pointer O UsedTo identify one or more diagnosis code pointersRequired if HI segment in Loop ID-2300 is used.ALIAS: Diagnosis Code PointerC00401 1328 Diagnosis Code Pointer M N0 1/2 MA pointer to the claim diagnosis code in the order of importance to this serviceUse this pointer for the first diagnosis code pointer (primary diagnosis for this serviceline). Use remaining diagnosis pointers in declining level of importance to service line.Acceptable values are 1 through 8, inclusive.12C00402 1328 Diagnosis Code Pointer O N0 1/2 UsedA pointer to the claim diagnosis code in the order of importance to this serviceUse this pointer for the second diagnosis code pointer.Required if the service relates to that specific diagnosis and is needed to substantiate themedical treatment. Acceptable values are 1 through 8, inclusive.12C00403 1328 Diagnosis Code Pointer O N0 1/2 UsedA pointer to the claim diagnosis code in the order of importance to this serviceUse this pointer for the third diagnosis code pointer.Required if the service relates to that specific diagnosis and is needed to substantiate themedical treatment. Acceptable values are 1 through 8, inclusive.C00404 1328 Diagnosis Code Pointer O N0 1/2 UsedA pointer to the claim diagnosis code in the order of importance to this serviceUse this pointer for the fourth diagnosis code pointer.Required if the service relates to that specific diagnosis and is needed to substantiate themedical treatment. Acceptable values are 1 through 8, inclusive.SV109 1073 Yes/No Condition or Response Code O ID 1/1 UsedCode indicating a Yes or No condition or responseRequired when the service is known to be an emergency by the provider.Emergency definition: The patient requires immediate medical intervention as a result ofsevere, life threatening, or potentially disabling conditions.ALIAS: Emergency IndicatorYYesDHHS Sacramento County Page 63 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: DTP Date - Service DatePosition: 455Loop: 2400 Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Notes: The total number of DTP segments in the 2400 loop cannot exceed 15.In cases where a drug is being billed on a service line, the Date of Service DTP may beused to indicate the range of dates through which the drug will be used by the patient.Use RD8 for this purpose.In cases where a drug is being billed on a service line, the Date of Service DTP is usedto indicate the date the prescription was written (or otherwise communicated by theprescriber if not written).Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesDTP01 374 Date/Time Qualifier M ID 3/3 MCode specifying type of date or time, or both date and time472 ServiceUse RD8 in DTP02 to indicate begin/end or from/to dates.DTP02 1250 Date Time Period Format Qualifier M ID 2/3 MCode indicating the date format, time format, or date and time formatD8Date Expressed in Format CCYYMMDDDTP03 1251 Date Time Period M AN 1/35 MExpression of a date, a time, or range of dates, times or dates and timesDHHS Sacramento County Page 64 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: REF Line Item Control NumberPosition: 470Loop: 2400 Optional (Must Use)Level: DetailUsage: Optional (Must Use)Max Use: 1Notes: Required if it is necessary to send a line control or inventory number. Providers areSTRONGLY encouraged to routinely send a unique line item control number on allservice lines, particularly if the provider automatically posts their remittance advice.Submitting a unique line item control number gives providers the capability toautomatically post by service line. The line item control number should be uniquewithin a patient control number (CLM01). Payers are required to return this numberin the remittance advice transaction (835) if the providers sends it to them in the 837.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesREF01 128 Reference Identification Qualifier M ID 2/3 MCode qualifying the Reference Identification6RProvider Control NumberREF02 127 Reference Identification X AN 1/30 M/U AN 1/25Reference information as defined for a particular Transaction Set or as specified by theReference Identification QualifierDHHS NOTE: Populate as follows for CMISP and PEMSPosition (1) - C (CMISP) (1)P (PEMS) (1)Position (2-10) - Unique Number (9)Position (11-15) - Batch Number (ST02) (5)Position (16-21) - HHMMSS (6) Use 24 hour clockPosition (22-25) - Service Line Number (4) {Zero fill when necessary for this number}Example: "P0000882170002613012000001" - 25 bytesDHHS Sacramento County Page 65 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: NM1 Rendering Provider NamePosition: 500Loop: 2420A OptionalLevel: DetailUsage: OptionalMax Use: 1Notes: Because the usage of this segment is "Situational" this is not a syntactically requiredloop. If this loop is used, then this segment is a "Required" segment. See Appendix Afor further details on ASC X12 syntax rules.Required if the Rendering Provider NM1 information is different than that carried inthe 2310B (claim) loop, or if the Rendering provider information is carried at theBilling/Pay-to Provider loop level (2010AA/AB) and this particular service line has adifferent Rendering Provider that what is given in the 2010AA/AB loop. Theidentifying payer-specific numbers are those that belong to the destination payeridentified in loop 2010BB.Used for all types of rendering providers including laboratories. The RenderingProvider is the person or company (laboratory or other facility) who rendered the care.In the case where a subsitute provider (locum tenans) was used, that person should beentered here.Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesNM101 98 Entity Identifier Code M ID 2/3 MCode identifying an organizational entity, a physical location, property or an individualThe entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.82 Rendering ProviderNM102 1065 Entity Type Qualifier M ID 1/1 MCode qualifying the type of entity1 Person2 Non-Person EntityNM103 1035 Name Last or Organization Name O AN 1/35 M/UIndividual last name or organizational nameALIAS: Rendering Provider Last NameNM104 1036 Name First O AN 1/25 UsedIndividual first nameRequired if NM102=1 (person).ALIAS: Rendering Provider First NameNM105 1037 Name Middle O AN 1/25 UsedIndividual middle name or initialRequired if NM102=1 and the middle name/initial of the person is known.ALIAS: Rendering Provider Middle NameNM107 1039 Name Suffix O AN 1/10 UsedSuffix to individual nameRequired if known.ALIAS: Rendering Provider GenerationNM108 66 Identification Code Qualifier X ID 1/2 M/UCode designating the system/method of code structure used for Identification Code (67)DHHS Sacramento County Page 66 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceXXHealth Care Financing Administration National ProviderIdentifierNM109 67 Identification Code X AN 2/80 M/UCode identifying a party or other codeALIAS: Rendering Provider Primary IdentifierDHHS Sacramento County Page 67 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: SE Transaction Set TrailerPosition: 555Loop:Level: SummaryUsage: MandatoryMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesSE01 96 Number of Included Segments M N0 1/10 MTotal number of segments included in a transaction set including ST and SE segmentsALIAS: Segment CountSE02 329 Transaction Set Control Number M AN 4/9 MIdentifying control number that must be unique within the transaction set functional groupassigned by the originator for a transaction setThe Transaction Set Control Numbers in ST02 and SE02 must be identical. TheTransaction Set Control Number is assigned by the originator and must be unique withina functional group (GS-GE) and interchange (ISA-IEA). This unique number also aidsin error resolution research.DHHS NOTE: ST02 and SE02 must match.DHHS Sacramento County Page 68 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: GE Functional Group TrailerPosition: 565Loop:Level: SummaryUsage: OptionalMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesGE01 97 Number of Transaction Sets Included M N0 1/6 MTotal number of transaction sets included in the functional group or interchange(transmission) group terminated by the trailer containing this data elementGE02 28 Group Control Number M N0 1/9 MAssigned number originated and maintained by the senderDHHS Sacramento County Page 69 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSegment: IEA Interchange Control TrailerPosition: 575Loop:Level: SummaryUsage: OptionalMax Use: 1Data Element SummaryRef. Data Base UserDes. Element Name Attributes AttributesIEA01 I16 Number of Included Functional Groups M N0 1/5 MA count of the number of functional groups included in an interchangeIEA02 I12 Interchange Control Number M N0 9/9 MA control number assigned by the interchange senderDHHS Sacramento County Page 70 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceSAMPLE 837P TRANSACTION DATACMISPISA*00* *00**ZZ*DHHSEDIEXAMPLES*ZZ*SACCOUNTYHHSEDI*051020*1200*U*00401*000000005*0*T*:~GS*HC* DHHSEDIEXAMPLES *SACCOUNTYHHSEDI*20051020*1200*5*X*004010X098A1~ST*837*0001~BHT*0019*00*3920394930203*20051115*1615*CH~REF*87*004010X098A1~NM1*41*2*JOHNSON*BARBARA*T***46* DHHSEDIEXAMPLES ~PER*IC*ARTHUR JONES*TE*9168767214*EX*9163613311*EM*BILL@ DHHSEDIEXAMPLES.COM~NM1*40*2*CMISP*****46*01~HL*1**20*1~NM1*85*1*JONES*MUFFY*M**M.D.*XX*9012345918~N3*PO BOX 123*157 WEST 57TH STREET~N4*SACRAMENTO*CA*95825~REF*EI*680000055~HL*2*1*22*0~SBR*P*18*500******MC~PAT*****D8*20051010*01*12345678*Y~NM1*IL*1*JOHNSON*BARBARA*T**PH.D*MI*0000000~N3*1708 PLUTO WAY~N4*SACRAMENTO*CA*95864~DMG*D8*19570424*M~REF*SY*845789652~NM1*PR*2*CMISP*****PI*SACCOUNTYHHSEDI~CLM*C00008821700026130120*100.00***21::1*N*A*Y*A*B~DTP*431*D8*20050401~DTP*439*D8*20050401~DTP*435*D8*20050401~DTP*096*D8*20050401~PWK*77*AA***AC*123456121222005~AMT*F5*50.00~REF*G1*3920394930203~NTE*ADD*No Message~HI*BK:3102*BF:87342*BF:E9600~NM1*DN*2*JONES*MUFFY*M**M.D.*XX*1111222333~NM1*82*1*JOHNSON*BARBARA*T**PH.D*XX*2222112222~NM1*FA*2*SMITH*****XX*9012345918~N3*2801 L STREET~N4*SACRAMENTO*CA*95816~LX*1~SV1*HC:ASSEMBLY:12:AA:A2:12*665.75*UN*100*NH**1:1:5:12**Y~DTP*472*D8*20050401~REF*6R* C00008821700026130120~NM1*82*2*JONES*MUFFY*M**M.D.*XX*1112223330~SE*39*0001~GE*1*5~IEA*1*000000005~DHHS Sacramento County Page 71 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA CompliancePEMSISA*00* *00**ZZ*DHHSEDIEXAMPLES*ZZ*SACCOUNTYHHSEDI*051020*1200*U*00401*000000005*0*T*:~GS*HC* DHHSEDIEXAMPLES *SACCOUNTYHHSEDI*20051020*1200*5*X*004010X098A1~ST*837*0001~BHT*0019*00*3920394930203*20051115*1615*CH~REF*87*004010X098A1~NM1*41*2*JOHNSON*BARBARA*T***46* DHHSEDIEXAMPLES ~PER*IC*ARTHUR JONES*TE*9168767214*EX*9163613311*EM*BILL@ DHHSEDIEXAMPLES.COM~NM1*40*2*PEMS*****46*16~HL*1**20*1~NM1*85*1*JONES*MUFFY*M**M.D.*XX*9012345918~N3*PO BOX 123*157 WEST 57TH STREET~N4*SACRAMENTO*CA*95825~REF*EI*680000055~HL*2*1*22*0~SBR*P*18*500******MC~PAT*****D8*20051010*01*12345678*Y~NM1*IL*1*JOHNSON*BARBARA*T**PH.D*MI*0000000~N3*1708 PLUTO WAY~N4*SACRAMENTO*CA*95864~DMG*D8*19570424*M~REF*SY*845789652~NM1*PR*2*PEMSES*****PI*SACCOUNTYHHSEDI~CLM*P00008821700026130120*100.00***23::1*N*A*Y*A*B~DTP*431*D8*20050401~DTP*439*D8*20050401~DTP*435*D8*20050401~DTP*096*D8*20050401~PWK*77*AA***AC*123456121222005~AMT*F5*50.00~REF*G1*3920394930203~NTE*ADD*No Message~HI*BK:3102*BF:87342*BF:E9600~NM1*DN*2*JONES*MUFFY*M**M.D.*XX*1111222333~NM1*82*1*JOHNSON*BARBARA*T**PH.D*XX*2222112222~NM1*FA*2*SMITH*****XX*9012345918~N3*2801 L STREET~N4*SACRAMENTO*CA*95816~LX*1~SV1*HC:ASSEMBLY:12:AA:A2:12*665.75*UN*100*NH**1:1:5:12**Y~DTP*472*D8*20050401~REF*6R* P00008821700026130120~NM1*82*2*JONES*MUFFY*M**M.D.*XX*1112223330~SE*39*0001~GE*1*5~IEA*1*000000005~DHHS Sacramento County Page 72 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceREFERENCES & LINKSHIPAA Implementation Guideswww.wpc-edi.comCounty HIPAA Websitehttp://www.compliance.saccounty.net/default.htmCMISP 837P Companion Documenthttp://www.sacdhhs.com/CMS/download/pdfs/HIP/CMISP837PCompanionGuide.pdfCMISP Test Procedure Documenthttp://www.sacdhhs.com/CMS/download/pdfs/HIP/TestingandActivation.pdfCMISP Registration Documenthttp://www.sacdhhs.com/CMS/download/pdfs/HIP/TradingPartnerRegistration.pdfMedi-Calhttp://files.medi-cal.ca.gov/pubsdoco/publications/Masters-MTP/Part2/modifapp_m00o02o03o04o07o09o11a02a04a05a06a08v00.docCONTACT INFORMATIONProvider RegistrationNancy GilbertiPhone - 916 875 9755Email - GilbertiN@saccounty.netPayment QuestionsEd DziukPhone - 916 876 5092Email – DziukEd@saccounty.netCMISP 837P Transaction Testing & Production QuestionsEmail - EDI-Dropbox@SacCounty.netDHHS Sacramento County Page 73 of 74 Version 1.8 10/07/2008

Inbound 837P Companion GuideOffice of HIPAA ComplianceAPPENDIX ATable – NOTE Text. Please use this complete format when submitting note.Example - “ 0491687672141100055000”Field Name Description Size From To Valid ValuesBPCC Bill Processing Condition Code 2 1 2MICR MICRS Form Y/N 1 3 3ETHN Patient’s Race or Ethnic Origin 2 4 5 01 = CAUCASIAN02 = BLACK03 = MEXICAN AMERICAN04 = AMERICAN INDIAN/ALASKAN05 = CHINESE06 = JAPANESE07 = FILIPINO08 = VIETNAMESE27 = OTHERARCD Telephone Area Code 3 6 8PHON Telephone Number 7 9 15FSRI Family Income Source 1 16 16 1 = EARNED2 = DISABILITY3 = RETIREMENT4 = GENERAL ASSISTANCE5 = OTHER6 = NONE7 = UNKNOWNFPTEEmployment Type Primary WageEarnerFSIZ Family Size 4 18 21FMIC Family Monthly Income 4 22 251 17 17 1 = UNEMPLOYED2 = AGRICULTURE3 = SERVICE/SALES4 = LABOR/PRODUCTION/TRANSPORT5 = PROFESSIONAL/TECHNICAL6 = UNKNOWNDHHS Sacramento County Page 74 of 74 Version 1.8 10/07/2008