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									                                                    Texas Clean Claim and eBill Companion Guide Revisions 01/07/2008
           Note: Page numbers omitted due to restructing of documents

Type       Chapter       Page Item                                     Issue/Comments                                         Change Implemented
                                                                       Stakeholder indicates the use of numerous excel
                                                                       spreadsheets create some confusion on required         The new companion guide is structured
                                                                       and optional transaction sets. Recommend               in a Chapter format with the tables
Clerical   All                    Complexity of document use           incorporating into a single source document.           incorporated into the appropriate chapter.
                                                                       The new structure eliminates the need for a Table of
Clerical   Chapter 1              Table of Contents                    Contents.                                              Table of Contents deleted.
                                                                       Background did not provide statutory requirement
                                                                       for insurance carriers to receive medical bills
                                                                       electronically. Audience omitted name of
Clerical   Chapter 1              Texas History                        Washington Publishing Company.                         Information added.

                                                                       Guide references UCF as the Phamacy Claim Form.
                                                                        The Division is currently engaging in rulemaking
Paper      Chapter 2              General Opening                      activities to retain the DWC-066 for the time being. Replaced UCF with DWC-066
                                                                                                                            Modified language to state new form
                                                                       Addresses NPI and form requirements in future        must be used for claims submitted
Paper      Chapter 2              CMS-1500 first paragraph             tense.                                               on/after July 1, 2007.
                                                                       The NUCC has indicated that not used fields should Change usage to "Optional" or include
                                  Fields 9, 12, 13, and 16, not used   be considered optional to avoid the rejection of     instructions that claims cannot be
Paper      Chapter 2              (CMS-1500)                           otherwise complete claims                            rejected if populated
                                                                       The IAIABC ProPay Subcommittee recommends
                                                                       modifing the requirements on taxonomy codes to
                                                                       align with HIPAA requirements. Other stakeholders
                                                                       pointed out that the current Division guides require Modified condition to state: Required
                                                                       this every time the rendering provider is a health   when the rendering provider NPI is not
                                                                       care provider even when the information can be       submitted on the paper claim or when
Paper      Chapter 2              Taxonomy Code in 10d (CMS-1500)      derived from the NPI number.                         required by CMS policy.
                                                                                                                            Modify usage to "Situational" with the
Paper      Chapter 2              Claim Number in box 11               Currently the claim number is optional               condition "If known."
                                                                                                                            Modified condition to cover situations
                                                                                                                            where a provider may not be eligible for
Paper      Chapter 2              NPI instruction in 17b (CMS-1500)    Requires NPI if referring provider populated         an NPI.
Paper      Chapter 2              Field 23 Preauthorization Number     Conditional field without a condition                Added condition.

                                                                                                                              Added additional language to condition to
                                                                                                                              address situations where a non-licensed
Paper      Chapter 2              NPI instruction in 24j (CMS-1500)    Requires NPI for rendering provider                    individual is the rendering provider.




Information Management Services                                               Page 1 of 23                                                      Proposed Revisions 20071212
Type      Chapter        Page Item                                        Issue/Comments                                        Change Implemented
                                                                          The NUCC has indicated that not used fields should
                                                                          be considered optional to avoid the rejection of
Paper     Chapter 2               Field 26, not used (CMS-1500)           otherwise complete claims                             Changed usage to "Optional"
Paper     Chapter 2               NPI instruction in 32a (CMS-1500)       Requires NPI for providers and facilities             Changed usage to "Optional"
                                                                                                                                Modified usage to "Required" for claims
Paper     Chapter 2               NPI instruction in 33A (CMS-1500)       Requires NPI for providers                            filed on and after May 23, 2008.
                                                                                                                                Modify language to state new form must
                                                                          Addresses NPI and form requirements in future         be used for claims submitted on/after
Paper     Chapter 2               UB-04 first paragraph                   tense.                                                May 23, 2007
                                                                          The NUBC has indicated that not used fields should
                                                                          be considered optional to avoid the rejection of
Paper     Chapter 2               Fields 15, 50, 51, 58, and 61, not used otherwise complete claims                             Changed usage to "Optional"
                                                                                                                                Changed usage to "Situational" if the
                                                                                                                                claim submitted on or after May 23, 2008
                                                                                                                                if billing provider is a health care provider
Paper     Chapter 2               NPI instruction in 56 (UB-04)           Requires NPI                                          eligible for a NPI.
Paper     Chapter 2               Field 63 Preauthorization Number        Conditional field without a condition                 Added condition.
                                                                                                                                Changed usage to "Situational" with
                                                                                                                                condition that ties requirement to CMS
Paper     Chapter 2               Field 67 ICD-9                          Current usage state "required" but it is situational. policy.

                                                                           Current required for admissions, observation says      Modify condition to state "Required for
Paper     Chapter 2               Admitting diagnosis code in 69           and emergency care and not required for outpatient     inpatient admissions"
                                                                           NUBC has stated that field 73 should be used to
Paper     Chapter 2               DRG in 75 (UB-04)                        report the DRG on institutional claims                 Require DRG to be reported in field 73
                                                                           Stakeholder raised questions on differences
Paper     Chapter 2               Field 74 procedure codes/dates           between prior instructions and CMS policy.             Modified conditions to mirror CMS policy.
                                                                                                                                  Changed usage to "Situational" and
                                                                                                                                  added condition: "Required for claims
                                                                                                                                  submitted on and after May 23, 2008 if
                                                                                                                                  claim includes any services other than
                                  Attending Physician information          Requires attending physician information (won't be     nonscheduled transportation services.
                                  (NPI/Name/State License) in 76 (UB-      applicable for home health or nonscheduled             For home health claims, this will be the
Paper     Chapter 2               04)                                      transportation services)                               NPI of the referring physician."
                                                                                                                                  Changed condition to: "required for
                                                                                                                                  claims submitted on and after May 23,
                                                                                                                                  2008 if a surgical procedure code is
                                                                           Requires operating physician NPI when surgical         listed on the claim (e.g., surgical services
Paper     Chapter 2               NPI instruction in 77                    services provided                                      provided).
Paper     Chapter 2               NPI instruction in 78 (UB-04)            Requires other physician NPI                           Changed usage to "Optional"
Paper     Chapter 2               NPI instruction in 79 (UB-04)            Requires other physician NPI                           Changed usage to "Optional"




Information Management Services                                                    Page 2 of 23                                                      Proposed Revisions 20071212
Type      Chapter        Page Item                                        Issue/Comments                                          Change Implemented
                                                                          The IAIABC ProPay Subcommittee recommends
                                                                          modifing the requirements on taxonomy codes to
                                                                          align with HIPAA requirements. Other stakeholders
                                                                          pointed out that the current Division guides require    Modified condition to state: Required
                                                                          this every time the rendering provider is a health      when the attending physician NPI is not
                                  Taxonomy Code in 80, 81A, 81b, 81c,     care provider even when the information can be          submitted on the paper claim or when
Paper     Chapter 2               and 81d (UB-04)                         derived from the NPI number.                            required per CMS policy.

                                                                          Stakeholders recommended retaining the use of the       Rulemaking in progress. Replaced UCF
                                                                          DWC-66 form instead of mandating the UCF for            instructions with DWC-066 instructions.
Paper     Chapter 2               NCPDP UCF Implementation                paper claims.                                           NPI implementation also addressed.

                                                                          Current instructions require the use of the NCPDP       Included instructions that the NPI will be
                                                                          number for the pharmacy and the DEA number for          required instead of the NCPDP or DEA
                                  DWC-66 Statement of Pharmacy            the physician. Health industry is currently moving to   number for claims submitted on and after
Paper     Chapter 2               Services: Provider Identification Codes requiring the NPI on and after May 23, 2008.            May 23, 2008.
                                                                          Stakeholder asked for additional information on
Paper     Chapter 2               ADA J515 First Paragraph                billing for professional services by dentists.          Additional info added.
                                                                          Suggestion to modify to optional similar to issue
Paper     Chapter 2               Not used fields (several)               raised by NUBC and NUCC.                                Changed usage to "Optional"
Paper     Chapter 2               Field 2 Preauthorization                Conditional field without a condition                   Added condition.
                                                                                                                                  Changed condition to state required for
                                                                                                                                  claims submitted on and after May 23,
Paper     Chapter 2               Field 49 and 52 NPI Number              Requires NPI number.                                    2008 provider is eligible for an NPI.
                                                                                                                                  Modified condition to state: Populate
                                                                                                                                  Provider Taxonomy Code if the NPI
Paper     Chapter 2               Field 52A Taxonomy Code                 Currently required on all claims                        number is not provided in Field 49.
                                                                                                                                  Modified condition to state: Populate
                                                                                                                                  Provider Taxonomy Code if required per
Paper     Chapter 2               Field 56A Taxonomy Code                 Currently required on all claims                        CMS policy.
                                                                                                                                  Modified to "Situational" and added a
Paper     Chapter 2               DWC-062 Field 15C Type of Service       Currently required without any description              little description.
                                                                                                                                  Added the following language: or other
                                  Interchange Control (ISA/IEA) FEIN      Stakeholders indicated need for other ETINs based       mutually agreed upon identification
HIPAA     Chapter 4               requirement for ETIN                    on business model.                                      numbers
                                                                                                                                  Added the following language: or other
                                  Functional Group (GS/GE) FEIN           Stakeholders indicated need for other ETINs based       mutually agreed upon identification
HIPAA     Chapter 4               requirement for ETIN                    on business model.                                      numbers




Information Management Services                                                   Page 3 of 23                                                      Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                          Change Implemented

                                                                         Stakeholders have indicated issues with the
                                                                         statements that transactions containing "not used"
                                                                         data elements can be rejected by insurance carriers.
                                                                          Stakeholder indicated that if a transaction is         Modified the language to ensure that
                                                                         submitted consistent with the ANSI X12                  ANSI X12 compliant transactions are
                                                                         requirements, contain all data necessary to process     processed by insurance carriers if all
                                                                         the claim, the carrier should accept the transaction    other required data elements are
HIPAA      Chapter 5              HIPAA Not Used and W/C Not Used        and process the claim.                                  submitted.
                                                                         Other clarifications modified the HIPAA Gap             Updated the HIPAA Gap Analysis to
HIPAA      Chapter 5              HIPAA/WC Gap Analysis                  Analysis.                                               reflect changes in guides.
                                                                         Stakeholder indicated need to use other                 Added the following language: or other
                                                                         identification numbers for paper ID and other           mutually agreed upon identification
HIPAA      Chapter 5              Identification Numbers                 purposes.                                               numbers
                                                                         The IAIABC ProPay Subcommittee recommends               Modified instructions and components to
                                                                         modifing the instructions in this and other             incorporate IAIABC recommendation
                                                                         components of the guides. The purpose can be
                                                                         served by allowing an "other" code in the transaction
                                                                         and the "JX" codes to be the first two digits of the
                                                                         document ID. Current instructions require the use of
                                  PWK Information and attached           codes that are not contained in ANSI X12 4010.
HIPAA      Chapter 5              documentation
                                                                       Current language recommends using state reporting         Modified language to encourage carriers
                                                                       type edits which are not always applicable to bill        to consider bill processing issues and
Clerical   Chapter 5              Insurance carrier edits.             processing scenarios.                                     removed certain edits.
                                                                       Code set section did not address jurisdictional claim     Added.
Clerical   Chapter 5              Code sets                            adjustment reason codes.
                                                                       Stakeholder noted that this was a "not used"              Deleted references to CLM19 and
                                                                       element in ANSI X12 and HIPAA IG. Existing                explained current HIPAA IG use of
                                                                       codes, and new ones coming in December, are               CLM05-03 and ICN/DCN number.
HIPAA      Chapter 5              Reconsideration Requests and Appeals sufficient to convey information in CLM05.
                                                                       Current guides included language for rejecting            Modified language to ensure consistency
                                                                       claims that may not be considered consistent with         with Rule requirements.
HIPAA      Chapter 5              Reconsideration Requests and Appeals Rule 133.200.
                                                                       Stakeholder recommended adding Provider Type              Added License Type Codes.
                                                                       Prefix reference to Health Care Provider State
Clerical   Chapter 5              State License Number Section         License Number section.
                                                                                                                                 Deleted sentence. Instructions for NPI
                                                                         Language conveys requirement as broadly stated          numbers contained in form instructions
                                  NPI Number. States required for        and stakeholders have inquired on differences           for paper claims and in the companion
Clerical   Chapter 5              Texas billing in 2007                  between electronic requirements and paper billing.      guides for electronic submissions.




Information Management Services                                                 Page 4 of 23                                                      Proposed Revisions 20071212
Type       Chapter       Page Item                                   Issue/Comments                                           Change Implemented
                                                                                                                              Included language to allow the provider
                                                                     Stakeholders raised an issue regarding the need to       to populate 2300/CLM/CLM11-4 when
                                                                     identify the jurisdiction of the claim for editing       the claim is covered by a non-Texas
HIPAA      Chapter 5              Jurisdictional Identifier          purposes.                                                jurisdiction.
                                                                     The format provided was not presented in an              Included a NCPDP companion guide
                                                                     NCPDP 5.1 style. Information on NCPDP 5.1                following the format required by NCPDP
                                                                     segments and usage was either missing or difficult       5.1.
NCPDP      Chapter 8              Format Guides                      to understand.
                                                                     The Division has indicated that current rulemaking       References to the UCF have been
                                                                     initiatives are in progress to retain the DWC-066        removed.
Paper      Chapter 8              UCF References                     Statement of Pharmacy Services.
                                                                                                                              This language has been modified to
                                                                                                                              service date to ensure consistency with
                                                                                                                              the NCPDP 5.1 data names. In addition,
                                                                                                                              a conditional statement was added to
                                                                                                                              allow for other information to be
                                                                                                                              considered related to the date the
                                                                     The Billing Date section referred to the prescription    transaction was submitted to the carrier.
Clerical   Chapter 8              Billing date clarification         date as the bill date.
                                                                     Several places referenced the name of the data           Data element numbers and transaction
                                                                     element, but not the data element number or              segments added.
Clerical   Chapter 8              Data element references            transaction segment.
                                                                     Stakeholders raised issues regarding the use of the      Added additional language reflecting
                                                                     835 transaction and the sufficiency information in       Rules 133.500 and 133.501.
Clerical   Chapter 10             Second Paragraph                   Rule 133.240.
                                  Error in Claim Adjustment Reason   Reads “The Division accepts ANSI codes to were . . ”     Correct text to read "that were".
Clerical   Chapter 10             Code section text.
                                                                     IAIABC ProPay SubCommittee recommends                    Need to follow-up on this comment
                                  Claim Adjustment Reason Code       removing stated to eliminate anything that imply that
Clerical   Chapter 10             Language                           these codes will change over time.
                                                                     The current version of the companion guides              Modified list and information to align with
                                                                     requires data elements to be populated on                Rule 133.501.
                                                                     attachments that are different than the list contained
Other      Chapter 12             Data element requirements          in Rule 133.501.
                                                                     The IAIABC ProPay Subcommittee recommends                Added appropriate language to this effect.
                                                                     modifing the instructions in this and other
                                                                     components of the guides. The purpose can be
                                                                     served by allowing an "other" code in the transaction
                                                                     and the "JX" codes to be the first two digits of the
                                                                     document ID. Current instructions require the use of
                                                                     codes that are not contained in ANSI X12 4010.
HIPAA      Chapter 12             Documentation requirements




Information Management Services                                             Page 5 of 23                                                         Proposed Revisions 20071212
Type      Chapter        Page Item                                      Issue/Comments                                        Change Implemented
                                                                        Current code value only includes 00 and omits code    Deleted defined code to allow standard
HIPAA     837 Prof                Loop TS BHT BHT02                     18 for reissue due to transmission problem.           codes to be submitted.
                                                                        Current code value only includes 02 and omits code    Added code 01.
                                  Loop 1000A Sender Information NM1     01 for individual health care provider (person).
HIPAA     837 Prof                Submitter Name NM102
                                  Loop 1000A Sender Information NM1     Data element not included in companion guides.        Added NM104
HIPAA     837 Prof                Submitter Name NM104
                                  Loop 1000A Sender Information NM1     Data element not included in companion guides.        Added NM105
HIPAA     837 Prof                Submitter Name NM105
                                  Loop 2000A PRV Billing Provider      IAIABC ProPay SubCommittee recommends                  Modified usage from "J" to "S" as defined
                                  Taxonomy Code                        removing the jurisdictional requirement for taxonomy   in the ANSI X12 guides. Amended
                                                                       codes. The HIPAA IG language adequately covers         required comment to reflect situational
HIPAA     837 Prof                                                     the conditions.                                        requirement.
                                  Loop 2010AA Billing Provider REF     Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA     837 Prof                State License                        sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider REF      Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA     837 Prof                State License                        sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2000B Subscriber Detail SBR     Stakeholder points out that under the HIPAA IG this    Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment       data element is required if there is no group plan     in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator         number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA     837 Prof                                                     "S")
                                  Loop 2010BB Payer Identification REF Stakeholder points out that there may be situations    Added situational data segment.
                                  Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                       example, if the payer ID in Loop 2010BB NM1
                                                                       segment is a TPA and the insurance carrier
                                                                       identification is needed to process the claim, the
                                                                       secondary ID may be needed.
HIPAA     837 Prof
                                  Loop 2000C Patient Information HL     Stakeholder points out that under the HIPAA IG this   Modified usage from "J" to "S" as defined
                                  Segment                               data element is required if there the patient is      in the ANSI X12 guides.
                                                                        different than the policyholder, which makes it
                                                                        required for w/c. Recommend changing to match
HIPAA     837 Prof                                                      HIPAA IG ("J" to "S")
                                  Loop 2000C Patient Information PAT    Companion Guides did not include situational data     Added situational data element.
HIPAA     837 Prof                Segment PAT05                         elements for date of death.
                                  Loop 2000C Patient Information PAT    Companion Guides did not include situational data     Added situational data element.
HIPAA     837 Prof                Segment PAT06                         elements for date of death.
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Name NM108                            not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA     837 Prof




Information Management Services                                                Page 6 of 23                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                      Issue/Comments                                        Change Implemented
                              Loop 2010CA Patient Information NM        HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                              Name NM109                                not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Prof
                                  2300 Claim Information CLM Segment    HIPAA IG shows this data element to be used when      Added situational data element.
                                  CLM16 Provider Agreement Code         a non-participating provider is submitting a claim.
                                                                        This may be needed for access plans in network
                                                                        settings and should be allowed as situational.
HIPAA      837 Prof
                                  2300 Claim Information CLM Segment    Stakeholder noted that this was a "not used"          HIPAA "not used" data element deleted.
                                  CLM19 Bill Submission Reason Code     element in ANSI X12 and HIPAA IG. Existing
                                                                        codes, and new ones coming in December, are
HIPAA      837 Prof                                                     sufficient to convey information in CLM05.
                                  2300 Claim Information CLM Segment    HIPAA IG includes a delay reason code situational     Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code               data element.                                         "S" as defined in the ANSI X12 guides.
Question   837 Prof
                                  2300 Claim Information PWK Segment    IAIABC ProPay recommended change in approach          Modified usage from "J" to "S" as defined
HIPAA      837 Prof               PWC05                                 to align with HIPAA IG ("J" to "S")                   in the ANSI X12 guides.
                                  2300 Claim Information PWK Segment    IAIABC ProPay recommended change in approach          Modified usage from "J" to "S" as defined
HIPAA      837 Prof               PWC06                                 to align with HIPAA IG ("J" to "S")                   in the ANSI X12 guides.
                                  2300 Claim Information CN1 Contract   HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Information Segment CN102             not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Prof
                                  2310A Referring Provider NM1          Companion Guides did not include situational data     Added NM107 as "S" as defined in ANSI
HIPAA      837 Prof               Provider Name Segment                 element for suffix.                                   X12 guides.
                                  2310A Referring Provider NM1          HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Provider Name Segment NM108           not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Prof
                                  2310A Referring Provider NM1          HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Provider Name Segment NM109           not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Prof
                                  Loop 2310A Referring Provider REF     Stakeholder indicates HIPAA conditions are            Modifed usage from "J" to "S" as defined
HIPAA      837 Prof               State License                         sufficient and suggests changing the "J" to an "S"    in the ANSI X12 guides.
                                  Loop 2310B Rendering Provider REF     Stakeholder indicates HIPAA conditions are            Modified usage from "J" to "S" as defined
HIPAA      837 Prof               State License                         sufficient and suggests changing the "J" to an "S"    in the ANSI X12 guides.
                                  Look 2310D NM1 Facility Service       Stakeholder indicates HIPAA conditions are            Modified usage from "R" to "S" as
HIPAA      837 Prof               Location Name NM103                   sufficient and suggests changing the "R" to an "S"    defined in the ANSI X12 guides.
                                  Loop 2310D NM1 Facility Service       Spreadsheet indicates HIPAA usage for this data       Modified HIPAA and wc usage from "R"
                                  Location Name NM108 Identification    element is Required, HIPAA IG indicates segment is    to "S" as defined in ANSI X12 guides.
HIPAA      837 Prof               Code Qualifier                        Situational.
                                  Loop 2310D NM1 Facility Service       Spreadsheet indicates HIPAA usage for this data       Modified HIPAA and wc usage from "R"
                                  Location Name NM109 Identification    element is Required, HIPAA IG indicates segment is    to "S" as defined in ANSI X12 guides.
HIPAA      837 Prof               Code                                  Situational.




Information Management Services                                                Page 7 of 23                                                     Proposed Revisions 20071212
Type      Chapter        Page Item                                       Issue/Comments                                        Change Implemented
                              Loop 2310B Rendering Provider PRV          Spreadsheet indicates HIPAA usage for this data       Deleted comment and modified usage to
                              Provider Specialty Code                    element is Required, but HIPAA IG indicates           situational as defined in the ANSI X12
                                                                         segment is Situational with the condition of when     guides.
                                                                         adjudication requires taxonomy code. Comment in
                                                                         Division guides and w/c usage shows it is Required.
                                                                         Stakeholders recommend changing usage to
HIPAA     837 Prof                                                       Situational and deleting comment.
                                  Loop 2410D Facility/Service Location   HIPAA IG shows segment is situational, but DWC        Modified usage from "J" to "S" consistent
                                  REF State License Number               companion guides show jurisdictionally situational    with the ANSI X12 guides.
HIPAA     837 Prof                                                       without a condition.
                                  Loop 2400 SV1 Professional Service     Companion Guide did not include the emergency         Added situational data element.
                                  SV109 Emergency Indicator              indicator. This indicator is important to prevent
                                                                         unnecessary denials of claims for lack of
HIPAA     837 Prof                                                       preauthorization.
                                  Loop 2400 SV5 Durable Medical          IAIABC ProPay SubCommittee recommends                 Modify usage from "N" to "S" and "R" as
                                  Equipment                              removing the not-used usage in order to align the     defined in the ANSI X12 guides
HIPAA     837 Prof                                                       companion guides with the HIPAA IG
                                  Loop 2400 Service Line Information     Stakeholder indicates that the SV5 segment is the     Modified w/c usage from "N" to "S" and
                                  SV5 DME                                segment used in the submission of DME items in the    "N" to "R" as defined in the ANSI X12
                                                                         industry. Failure to use this loop/segment is a       guides.
                                                                         significant deviation from the ANSI X12 standards.
HIPAA     837 Prof
                                  Loop 2410 Drug Identification          HIPAA IG shows that this segment can be repeated, Modified comment to recommendation to
                                                                         but note says w/c implementation does not repeat. help ensure consistency with HIPAA IG.
HIPAA     837 Prof
                                  Loop 2420A Rendering Line Provider     Companion guide did not include this situational      Added situational data element.
HIPAA     837 Prof                NM Provider Name Segment NM105         data element.
                                  Loop 2420A Rendering Line Provider     Companion guide did not include this situational      Added situational data element.
HIPAA     837 Prof                NM Provider Name Segment NM107         data element.
                                  Loop 2420A Rendering Line Provider     Stakeholder indicates that the HIPAA Condition        Modify usage from "J" to "S" as defined
HIPAA     837 Prof                REF State License                      meets w/c needs for reporting.                        in the ANSI X12 guides.
                                  Loop 2420A Rendering Line Provider     HIPAA IG allows different tax ID numbers,             Added code for either FEIN or SSN as
                                  REF Tax ID Number                      companion guide limits to Social Security Number.     defined in the ANSI X12 guides.
                                                                         Providers may have either a FEIN or SSN.
HIPAA     837 Prof
                                                                         Current code value only includes 00 and omits code Deleted defined code to allow standard
HIPAA     837 Dental              Loop TS BHT BHT02                      18 for reissue due to transmission problem.        codes to be submitted.
                                                                         Current code value only includes 02 and omits code Added code 01.
                                  Loop 1000A Sender Information NM1      01 for individual health care provider (person).
HIPAA     837 Dental              Submitter Name NM102
                                  Loop 1000A Sender Information NM1      Data element not included in companion guides.        Added NM104
HIPAA     837 Dental              Submitter Name NM104




Information Management Services                                                 Page 8 of 23                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                         Change Implemented
                              Loop 1000A Sender Information NM1          Data element not included in companion guides.         Added NM105
HIPAA      837 Dental         Submitter Name NM105
                              Loop 2000A PRV Billing Provider            IAIABC ProPay SubCommittee recommends                  Modified usage from "J" to "S" as defined
                              Taxonomy Code                              removing the jurisdictional requirement for taxonomy   in the ANSI X12 guides. Amended
                                                                         codes. The HIPAA IG language adequately covers         required comment to reflect situational
HIPAA      837 Dental                                                    the conditions.                                        requirement.
                                  Loop 2000A Billing/Pay to Provider     Incorrect qualifier for Taxonomy Code referenced in    Corrected qualifier to "ZZ".
                                  Loop PRV Provider Taxonomy Code        field PRV02.
Clerical   837 Dental             Segment
                                  Loop 2010AA Billing Provider NM1       Data element not included in companion guides.      Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                                 X12 guides.
                                  Loop 2010AA Billing Provider REF TaxCodes are not inclusive of those allowed in HIPAA      Deleted code values to allow appropriate
HIPAA      837 Dental             ID REF01                            implementation guides.                                 code to be used.
                                  Loop 2010AA Billing Provider REF    Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" and
                                  Segment Dentist State License Numbersufficient and suggests changing the "J" to an "S".    deleted second segment as defined in
                                                                      In addition, current spreadsheet indicates a           the ANSI X12 guides. The code values
                                                                      jurisdictional requirement for Texas and two different used will define the license type, if
HIPAA      837 Dental                                                 segments for the same type of data.                    needed.
                                  Loop 2010AA Billing Provider PER    This data segment is not included in the HIPAA         Deleted segment.
HIPAA      837 Dental             Contact Information Segment         implementation guides.
                                  Loop 2010AB Pay to Provider NM1     Data element not included in companion guides.         Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                                 X12 guides.
                                  Loop 2010AB Pay to Provider REF Tax Codes are not inclusive of those allowed in HIPAA      Deleted code values to allow appropriate
HIPAA      837 Dental             ID REF01                            implementation guides.                                 code to be used.
                                  Loop 2010AB Pay to Provider         Field REF01 was omitted from Excel spreadsheet.        Added field.
                                  Information REF State License
Clerical   837 Dental             Number Segment
                                  Loop 2010AB Pay to Provider REF     Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License                       sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider PER                                                            Deleted segment.
                                  Contact Information Segment         Stakeholder recommends deletion of this data
                                                                      segment that is not used in the ANSI X12 837d
                                                                      transaction set. Spreadsheet shows segment is not
HIPAA      837 Dental                                                 used in HIPAA, but jurisdictionally required in w/c.
                                  Loop 2010BA N302 Employer Address                                                          Modified mapping to show source from
                                                                      Spreadsheet shows employer address coming from Box 12 (Policyholder name and address).
Clerical   837 Dental                                                 Box 7 on the ADA form (which is gender).
                                  Loop 2000B Subscriber Detail SBR    Stakeholder points out that under the HIPAA IG this Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment      data element is required if there is no group plan     in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator        number, which makes it required for w/c.
                                                                      Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Dental                                                 "S")




Information Management Services                                                 Page 9 of 23                                                      Proposed Revisions 20071212
Type      Chapter        Page Item                                 Issue/Comments                                            Change Implemented
                              Loop 2010BB Payer Identification REF Stakeholder points out that there may be situations       Added situational data segment.
                              Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                   example, if the payer ID in Loop 2010BB NM1
                                                                   segment is a TPA and the insurance carrier
                                                                   identification is needed to process the claim, the
                                                                   secondary ID may be needed.
HIPAA     837 Dental
                                  Loop 2000C Patient Information HL   Stakeholder points out that under the HIPAA IG this    Modified usage from "J" to "S" as defined
                                  Segment                             data element is required if there the patient is       in the ANSI X12 guides.
                                                                      different than the policyholder, which makes it
                                                                      required for w/c. Recommend changing to match
HIPAA     837 Dental                                                  HIPAA IG ("J" to "S")
                                  Loop 2010CA Patient Information NM1 HIPAA implementation guide shows this data             Modified usage from "R" to "S" as
                                  Name NM108                          element as situational, as opposed to the required     defined in the ANSI X12 guides and
                                                                      usage listed in the companion guides. In addition,     deleted code.
                                                                      Code MI is for member identification, and SSN may
HIPAA     837 Dental                                                  be used in workers' compensation.
                                  Loop 2010CA Patient Information NM1 HIPAA implementation guide shows this data             Modified usage from "R" to "S" as
                                  Name NM109                          element as situational, as opposed to the required     defined in the ANSI X12 guides and
                                                                      usage listed in the companion guides. In addition,     changed name to identification code.
HIPAA     837 Dental                                                  data element name is incorrect.
                                  Loop 2300 Claim Information CLM     HIPAA implementation guide shows this data             Modified data type.
                                  Claim Segment CLM05-1               element as "AN" not "ID" as contained in companion
HIPAA     837 Dental                                                  guide.
                                  Loop 2300 Claim Information CLM     Companion Guide lists only "A" as a valid code         Deleted code value to allow appropriate
HIPAA     837 Dental              Claim Segment CLM07                 value, HIPAA IG allows other code values.              code to be used.
                                  Loop 2300 Claim Information CLM     Companion Guide lists only "I" as a valid code         Deleted code value to allow appropriate
                                  Claim Segment CLM09                 value, HIPAA IG shows only "Y" and "N" as valid        code to be used.
HIPAA     837 Dental                                                  code values.
                                  Loop 2300 Claim Information CLM                                                            Added CLM12 to companion guides with
                                  Claim Segment CLM12                 Situational data element omitted from companion        "S" as defined in the ANSI X12 guides.
HIPAA     837 Dental                                                  guides.
                                  Loop 2300 Claim Information CLM     Stakeholder noted that this was a "not used"           Modified HIPAA usage from "N" to "S"
                                  Claim Segment CLM19                 element in ANSI X12 and HIPAA IG. Additional           and w/c usage from "J" to "S" and
                                                                      investigation reveals that the CLM19 segment is a      modified code value as defined in the
                                                                      "situational" data element in the HIPAA IG, but does   ANSI X12 guides.
                                                                      not contain the code values for the usage
HIPAA     837 Dental                                                  contemplated in the companion guides.
                                  2300 Claim Information CLM Segment HIPAA IG includes a delay reason code situational       Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code             data element.                                          "S" as defined in the ANSI X12 guides.
HIPAA     837 Dental




Information Management Services                                               Page 10 of 23                                                    Proposed Revisions 20071212
Type       Chapter       Page Item                                     Issue/Comments                                         Change Implemented
                              2300 Claim Information DTP Date of       Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Dental         Service                                  sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                              Loop 2300 DTP Date of Service            Spreadsheet shows date of service coming from          Modified mapping to show source from
                                                                       Box 41 on the ADA form (which is date appliance        Box 24
Clerical   837 Dental                                                  placed).
                                  Loop 2300 Claim Information DN1                                                             Modified data type.
                                  Orthodontic Information DN101 and    These data elements show the data type as "N" as
Clerical   837 Dental             DN102                                opposed to "R" in the HIPAA IG
                                  2300 Claim Information PWK Segment   IAIABC ProPay recommended change in approach           Modified usage from "R" to "S" as
HIPAA      837 Dental             PWC05                                to align with HIPAA IG ("R" to "S")                    defined in the ANSI X12 guides.
                                  2300 Claim Information PWK Segment   IAIABC ProPay recommended change in approach           Modified usage from "R" to "S" as
HIPAA      837 Dental             PWC06                                to align with HIPAA IG ("R" to "S")                    defined in the ANSI X12 guides.
                                  2300 Claim Information AMT Amount    Stakeholder recommends removing the "not used"         Modify usage from "N" to "S" as defined
                                  Paid Segment                         workers' compensation usage, while generally not       in the ANSI X12 guides.
                                                                       found in workers' compensation, this will align with
HIPAA      837 Dental                                                  HIPAA IG.
                                  Loop 2310A Referring Provider NM1    HIPAA IG shows additional code values used in          Deleted single code value to allow
HIPAA      837 Dental             Name NM101                           certain situations.                                    appropriate code to be used.
                                  Loop 2310A Referring Provider NM1    HIPAA IG shows additional code values used in          Deleted single code value to allow
                                  Name NM102                           certain situations.                                    appropriate code to be used and added
HIPAA      837 Dental                                                                                                         data element name.
                                  Loop 2310A Referring Provider NM1    Data element not included in companion guides.         Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                                  X12 guides.
                                  Loop 2310A Referring Provider NM1                                                           Modified usage from "R" to "S" as
                                  Name NM108                           HIPAA implementation guide shows this data             defined in the ANSI X12 guides and
                                                                       element as situational, as opposed to the required     deleted code.
                                                                       usage listed in the companion guides. In addition,
HIPAA      837 Dental                                                  companion guide only lists one code value.
                                  Loop 2310A Referring Provider NM1    HIPAA implementation guide shows this data             Modified usage from "R" to "S" as
                                  Name NM109                           element as situational, as opposed to the required     defined in the ANSI X12 guides and
                                                                       usage listed in the companion guides. In addition,     changed name to identification code.
HIPAA      837 Dental                                                  data element name is incorrect.
                                  Loop 2310A Referring Provider REF    Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License                        sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2310B Rendering Provider NM1    HIPAA IG shows additional code values used in          Deleted single code value to allow
                                  Name NM102                           certain situations.                                    appropriate code to be used and added
HIPAA      837 Dental                                                                                                         data element name.
                                  Loop 2310B Rendering Provider NM1    Data element not included in companion guides.         Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                                  X12 guides.
                                  Loop 2310B Rendering Provider NM1                                                           Deleted code to allow use of appropriate
HIPAA      837 Dental             Name NM108                           Companion guide only lists one code value.             code.




Information Management Services                                              Page 11 of 23                                                      Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                        Change Implemented
                              Loop 2310B Rendering Provider NM1                                                                Changed name to identification code.
HIPAA      837 Dental         Name NM109                                 Data name indicates only NPI to be used.
                              Loop 2310B Rendering Provider PRV          Spreadsheet indicates HIPAA usage for this data       Deleted comment and modified usage to
                              Provider Specialty Code                    element is Required, but HIPAA IG indicates           situational as defined in the ANSI X12
                                                                         segment is Situational with the condition of when     guides.
                                                                         adjudication requires taxonomy code. Comment in
                                                                         Division guides and w/c usage shows it is Required.
                                                                         Stakeholders recommend changing usage to
HIPAA      837 Dental                                                    Situational and deleting comment.
                                  Loop 2310B Rendering Provider REF      Stakeholder indicates HIPAA conditions are            Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License                          sufficient and suggests changing the "J" to an "S"    in the ANSI X12 guides.
                                  Loop 2310C NM1 Segment Individual      Stakeholder indicates HIPAA conditions are            Modified usage from "J" to "S" as defined
HIPAA      837 Dental             or Org Name                            sufficient and suggests changing the "J" to an "S"    in the ANSI X12 guides.
                                  Loop 2310C Facility/Service Location   Companion Guide shows HIPAA usage is "S" when         Modified usage from "S" to "R" as
HIPAA      837 Dental             NM1 Name NM103                         HIPAA IG shows usage is "R"                           defined in ANSI X12 guides.
                                  Loop 2310C Facility/Service Location                                                         Deleted segment.
                                  REF Segment State License Number       HIPAA Implementation Guide does not contain a
HIPAA      837 Dental                                                    REF Segment for the facility state license number.
                                  Loop 2310D Assisting Surgeon PRV       Comment in companion guides indicates this is         Deleted comment since the HIPAA
HIPAA      837 Dental             Provider Specialty Code                required.                                             defined condition is sufficient.
                                  Loop 2310D Assisting Surgeon REF       Companion guide shows jurisdictionally required       Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License Number                   with "J" but no defined Texas condition.              in the ANSI X12 guides.
                                  Loop 2320 Other Subscriber Info SBR    SBR04 is defined as the Policy or Plan Name in the    Modified name.
                                  Other Subscriber Info SBR04            HIPAA IG, as a Group or Plan Name in the
Clerical   837 Dental                                                    Companion Guides.
                                  Loop 2320 Other Subscriber Info SBR                                                          Deleted SBR05.
HIPAA      837 Dental             Other Subscriber Info SBR05            HIPAA IG shows this is a "not used" data element.
                                  Loop 2320 Other Subscriber             Companion guide shows only allowed value is "WC"      Deleted "WC" code value to allow
                                  Information SBR Segment SBR09          for workers' compensation, however, the other claim   appropriate code to be used. Modified
                                                                         referenced in this loop may not have been workers'    "J" to "S" as defined in the ANSI X12
                                                                         compensation. In addition, companion guide shows      guides.
                                                                         as "J" with comment that it is a required field.
HIPAA      837 Dental
                                  Loop 2330A Other Subscriber Name       Data element not included in companion guides.        Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             NM1 Name NM107                                                                               X12 guides.
                                  Loop 2400 Service Lines SV3 Dental     HIPAA IG shows data type is "ID" not "AN" as in       Corrected data type.
HIPAA      837 Dental             Service SV305                          companion guides.
                                  Loop 2400 Service Lines DTP Service    Companion guides show data/time/period qualifier      Corrected code value.
Clerical   837 Dental             Date DTP02                             as "RD8", HIPAA IG shows "D8"
                                  Loop 2420A Rendering Line Provider     HIPAA IG shows additional code values used in         Deleted single code value to allow
                                  NM1 Name NM102                         certain situations.                                   appropriate code to be used and added
HIPAA      837 Dental                                                                                                          data element name.




Information Management Services                                                Page 12 of 23                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                    Issue/Comments                                         Change Implemented
                              Loop 2420A Rendering Line Provider                                                             Deleted code value to allow appropriate
HIPAA      837 Dental         NM1 Name NM108                          Companion guide only lists one code value.             code to be used.
                              Loop 2420A Rendering Line Provider                                                             Corrected data element name.
HIPAA      837 Dental         NM1 Name NM109                          Data element name is incorrect.
                              Loop 2420A Rendering Line Provider                                                             Corrected data type.
HIPAA      837 Dental         PRV Specialty Code PRV02                Data type incorrect (lists "AN" not "ID").
                              Loop 2420A Rendering Line Provider      Stakeholder indicates that the HIPAA Condition         Modified usage from "J" to "S" as defined
HIPAA      837 Dental         REF State License                       meets w/c needs for reporting.                         in the ANSI X12 guides.
                              Loop 2420C Assistant Surgeon NM1        HIPAA IG shows this data element as required, not      Modified usage from "S" to "R" as
HIPAA      837 Dental         Name NM108                              situational as noted in companion guide.               defined in ANSI X12 guides.
                              Loop 2420C Assistant Surgeon NM1        HIPAA IG shows this data element as required, not      Modified usage from "S" to "R" as
HIPAA      837 Dental         Name NM109                              situational as noted in companion guide.               defined in ANSI X12 guides.
                              Loop 2420C Assistant Surgeon REF        Companion guide shows this segment as                  Modified usage from "J" to "S" as defined
HIPAA      837 Dental         State License Number                    jurisdictionally required without a Texas condition.   in the ANSI X12 guides.
                                                                      Current code value only includes 00 and omits code     Deleted defined code to allow standard
HIPAA      837 Inst               Loop TS BHT BHT02                   18 for reissue due to transmission problem.            codes to be submitted.
                                                                      Current code value only includes 02 and omits code     Added code 01.
                                  Loop 1000A Sender Information NM1   01 for individual health care provider (person).
HIPAA      837 Inst               Submitter Name NM102
                                  Loop 1000A Sender Information NM1   Data element not included in companion guides.         Added NM104
HIPAA      837 Inst               Submitter Name NM104
                                  Loop 1000A Sender Information NM1   Data element not included in companion guides.         Added NM105
HIPAA      837 Inst               Submitter Name NM105
                                  Loop 2000A PRV Billing Provider     IAIABC ProPay SubCommittee recommends                  Modified usage from "J" to "S" as defined
                                  Taxonomy Code                       removing the jurisdictional requirement for taxonomy   in the ANSI X12 guides. Amended
                                                                      codes. The HIPAA IG language adequately covers         required comment to reflect situational
HIPAA      837 Inst                                                   the conditions.                                        requirement.
                                  Loop 2010AA Billing Provider        Situational language was ambiguous.                    Modify language to indicate hospital
                                  Information Segment REF Provider                                                           Billing Provider State License Number is
                                  Identification Number                                                                      submitted if the billing entity is a health
                                                                                                                             care provider and if provider has a state
Clerical   837 Inst                                                                                                          license.
                                  Loop 2010AA Billing Provider REF    Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Inst               State License                       sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider REF     Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Inst               State License                       sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2000B Subscriber Detail SBR    Spreadsheet showed code value but not data             Added data element name.
                                  Subscriber Information Segment      element name.
Clerical   837 Inst               SBR01
                                  Loop 2000B Subscriber Detail SBR    SBR03 fields was inadvertently omitted from the        Added field.
Clerical   837 Inst               Subscriber Information Segment      837I Excel spreadsheet.




Information Management Services                                             Page 13 of 23                                                       Proposed Revisions 20071212
Type       Chapter       Page Item                                     Issue/Comments                                         Change Implemented
                              Loop 2000B Subscriber Detail SBR         Stakeholder points out that under the HIPAA IG this    Modified usage from "J" to "S" as defined
                              Subscriber Information Segment           data element is required if there is no group plan     in the ANSI X12 guides.
                              SBR04 Employer Name                      number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Inst                                                    "S")
                                  Loop 2000B Subscriber Detail SBR     Stakeholder points out that under the HIPAA IG this    Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment       data element is required if there is no group plan     in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator         number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Inst                                                    "S")
                                  Loop 2010BC Payer Identification REF Stakeholder points out that there may be situations    Added situational data segment.
                                  Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                       example, if the payer ID in Loop 2010BC NM1
                                                                       segment is a TPA and the insurance carrier
                                                                       identification is needed to process the claim, the
                                                                       secondary ID may be needed.
HIPAA      837 Inst
                                  Loop 2000C Patient Information HL     Stakeholder points out that under the HIPAA IG this   Modified usage from "J" to "S" as defined
                                  Segment                               data element is required if there the patient is      in the ANSI X12 guides.
                                                                        different than the policyholder, which makes it
                                                                        required for w/c. Recommend changing to match
HIPAA      837 Inst                                                     HIPAA IG ("J" to "S")
                                  Loop 2010CA Patient Information NM    Sutuational data element NM107 omitted from           Added NM107 as "S" as defined in ANSI
HIPAA      837 Inst               Name NM107                            companion guides.                                     X12 guides.
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Name NM108                            not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Inst
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Name NM109                            not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Inst
                                  Loop 2010CA Patient Information N4    Companion guide contains typo showing N404 as         Corrected typo.
Clerical   837 Inst               City State Zip                        N403.
                                  2300 Claim Information CLM Segment    Stakeholder noted that this was a "not used"          HIPAA "not used" data element deleted.
                                  CLM19 Bill Submission Reason Code     element in ANSI X12 and HIPAA IG. Existing
                                                                        codes, and new ones coming in December, are
HIPAA      837 Inst                                                     sufficient to convey information in CLM05.
                                  2300 Claim Information CLM Segment    HIPAA IG includes a delay reason code situational     Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code               data element.                                         "S" as defined in the ANSI X12 guides.
HIPAA      837 Inst
                                  2300 Claim Information PWK Segment IAIABC ProPay recommended change in approach             Modified usage from "R" to "S" as
HIPAA      837 Inst               PWC05                              to align with HIPAA IG ("R" to "S")                      defined in the ANSI X12 guides.




Information Management Services                                                Page 14 of 23                                                    Proposed Revisions 20071212
Type       Chapter       Page Item                                     Issue/Comments                                         Change Implemented
                              2300 Claim Information PWK Segment       IAIABC ProPay recommended change in approach           Modified usage from "R" to "S" as
HIPAA      837 Inst           PWC06                                    to align with HIPAA IG ("R" to "S")                    defined in the ANSI X12 guides.
                              2300 Claim Information REF Segment       Companion Guide placed segment in different            Moved to same location as HIPAA IG.
                              Original Reference Number (ICN/DCN)      location than HIPAA IG.
Clerical   837 Inst
                                  2300 Claim Information REF Segment   Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Inst               Medical Record Number                sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  2300 Claim Information HI Segment    Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
                                  DRG Information                      sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides and added
                                                                                                                              comment that it is required for inpatient
HIPAA      837 Inst                                                                                                           admissions.
                                  2300 Claim Information HI Segment    Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Inst               Occurance Codes and Dates            sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not           Modified usage from "N" to "S" as
                                  Covered Days                         used" usage to the HIPAA "S" usage. This will          defined in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not           Modified usage from "N" to "S" as
                                  Non Covered Days                     used" usage to the HIPAA "S" usage. This will          defined in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not           Modified usage from "N" to "S" as
                                  Co Insured Days                      used" usage to the HIPAA "S" usage. This will          defined in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not           Modified usage from "N" to "S" as
                                  Lifetime Reserved Days               used" usage to the HIPAA "S" usage. This will          defined in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  Loop 2310 Attending Provider         Companion guide only lists person as an option and     Deleted code value to allow appropriate
                                  Information NM1 Individual Name      HIPAA IG allows person or organization.                code to be used.
HIPAA      837 Inst               NM102 Entity Type Qualifier
                                  Loop 2310 Attending Provider         Stakeholder points out that HIPAA usage dictates       Modified usage from "J" to "S" as defined
                                  Information NM1 Individual Name      this as required for hospital admissions, which        in the ANSI X12 guides.
                                  NM104                                meets w/c usage needs. Recommend changing
HIPAA      837 Inst                                                    from "J" to "S".
                                  Loop 2310 Attending Provider         Companion guide lists this data element as "Title"     Modified name of data element as
                                  Information NM1 Individual Name      and HIPAA IG shows this data element as "Name          defined in the ANSI X12 guides.
Clerical   837 Inst               NM107                                Suffix".
                                  Loop 2310A Attending Provider                                                               Modified usage from "J" to "S" as defined
                                  Information REF Segment State        Stakeholder indicates HIPAA conditions are             in the ANSI X12 guides.
HIPAA      837 Inst               License Number                       sufficient and suggests changing the "J" to an "S"




Information Management Services                                              Page 15 of 23                                                      Proposed Revisions 20071212
Type      Chapter        Page Item                                       Issue/Comments                                          Change Implemented
                              Loop 2310B Operating Physician PRV                                                                 Deleted non-standard segment.
                              Segment Provider Specialty Code           This segment is not contained in the HIPAA
HIPAA     837 Inst                                                      implementation guide.
                                  Loop 2310B Operating Physician REF Stakeholder indicates HIPAA conditions are                  Modified usage from "J" to "S" as defined
HIPAA     837 Inst                Segment State License Number          sufficient and suggests changing the "J" to an "S"       in the ANSI X12 guides.
                                  Loop 2310C Other Provider Name        Companion Guide allows use of "ZZ" which is not          Deleted code value.
HIPAA     837 Inst                NM1 Name NM101                        contained in HIPAA implementation guide.
                                  Loop 2310C Other Provider Name        Companion guide only lists person as an option and       Deleted code value to allow appropriate
HIPAA     837 Inst                NM1 Name NM102                        HIPAA IG allows person or organization.                  code to be used.
                                  Loop 2310C Other Provider Name        HIPAA implementation guide usage is situational.         Modified usage from "R" to "S" as
HIPAA     837 Inst                NM1 Name NM104                        Companion guides show as required.                       defined in the ANSI X12 guides.
                                  Loop 2310C Other Provider PRV         This segment is not contained in the HIPAA               Deleted non-standard segment.
HIPAA     837 Inst                Segment Provider Specialty Code       implementation guide.
                                  Loop 2310C Other Provider REF         Stakeholder indicates HIPAA conditions are               Modified usage from "J" to "S" as defined
HIPAA     837 Inst                Segment State License Number          sufficient and suggests changing the "J" to an "S"       in the ANSI X12 guides.
                                  Loop 2310D                            Loop 2310D does not exist in the HIPAA                   Deleted loop.
HIPAA     837 Inst                                                      implementation guide.
                                  Loop 2310E Facility/Service Location  Stakeholder indicates HIPAA condition requires this      Modified usage from "J" to "S" as defined
                                  NM1 Individual Name NM108             loop only when location is different than billing        in the ANSI X12 guides.
                                                                        provider or pay-to-provider loops. HIPAA condition
HIPAA     837 Inst                                                      meets w/c needs, modify from "J" to "S"
                                  Loop 2310E Facility/Service Location  Stakeholder indicates HIPAA condition requires this      Modified usage from "J" to "S" as defined
                                  NM1 Individual Name NM109             loop only when location is different than billing        in the ANSI X12 guides.
                                                                        provider or pay-to-provider loops. HIPAA condition
HIPAA     837 Inst                                                      meets w/c needs, modify from "J" to "S"
                                  Loop 2310E Facility/Service REF State Current companion guide shows as "J" without a           Modified usage from "J" to "S" as defined
                                  License Number                        Texas specific condition.                                in the ANSI X12 guides and added
                                                                                                                                 condition if the facility is a licensed health
HIPAA     837 Inst                                                                                                               care facility.
                                  Loop 2310F Referring Provider          Stakeholder indicates ANSI X12 4010 does not            Deleted loop.
                                                                         contain this loop, but the guides present it as a
                                                                         situational application in the implementation guides.
                                                                         This loop is not supported in the ANSI X12 4010A1
HIPAA     837 Inst                                                       version.
                                  Loop 2320 Other Subscriber             HIPAA implementation guide shows this data              Deleted HIPAA "not used" data element.
                                  Information SBR Segment SBR08          element is "not used". Companion guide shows it
HIPAA     837 Inst                                                       jurisdictionally required.
                                  Loop 2320 Other Subscriber             HIPAA implementation guide shows this data              Deleted HIPAA "not used" data element.
                                  Information SBR Segment SBR09          element is situational but companion guide shows it
HIPAA     837 Inst                                                       jurisdictionally required.




Information Management Services                                                Page 16 of 23                                                         Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                           Change Implemented
                              Loop 2320 Other Subscriber                 Companion guide shows only allowed value is "WC"         Deleted "WC" code value to allow
                              Information SBR Segment SBR09              for workers' compensation, however, the other claim      appropriate code to be used.
                                                                         referenced in this loop may not have been workers'
HIPAA      837 Inst                                                      compensation.
                                  Loop 2320 Other Subscriber AMT         This segment in the HIPAA implementation guide is        Modified segement as defined in the
                                  Coordination of Benefits (COB) Payer the Payer Prior Payment with some differences in           ANSI X12 guides.
HIPAA      837 Inst               Paid Amount                            code value.
                                  Loop 2320 Other Subscriber AMT         This segment is not contained in the HIPAA               Deleted non-standard (per HIPAA) data
                                  Coordination of Benefits (COB) Patient implementation guide.                                    segment.
HIPAA      837 Inst               Paid Amount
                                  Loop 2330A Other Subscriber Name       This situational data element was not contained in       Added data element and usage as
HIPAA      837 Inst               NM Name NM 107                         the companion guides.                                    defined in the ANSI X12 guides.
                                  Loop 2330A Other Subscriber REF        The HIPAA implementation guides permit several           Modified name in companion guide and
                                  Secondary Information                  codes and identification numbers to be used. The         deleted code value to allow appropriate
                                                                         companion guide restricts usage to Social Security       codes and identification numbers to be
                                                                         Number, which may not be applicable in all               used as defined in the ANSI X12 guides.
HIPAA      837 Inst                                                      situations.
                                  Loop 2400 Service Line Information     Stakeholder indicates that the HIPAA Condition           Modified usage from "J" to "S" as defined
                                  DTP Service Date                       requires this on outpaitent claims when revenue,         in the ANSI X12 guides.
                                                                         procedure or other codes are reported in the SV2
                                                                         segement. This condition meets w/c needs for
HIPAA      837 Inst                                                      reporting.
                                  Loop 2410 Drug Identification CTP      Condition in description segment contains incorrect      Deleted condition, HIPAA implementation
                                  Drug Pricing CTP03                     reference to SV102.                                      guides contain sufficient instructions.
Clerical   837 Inst
                                  Loop 2410 Drug Identification CTP      Condition in description segment contains incorrect      Deleted condition, HIPAA implementation
                                  Drug Pricing CTP03                     reference to SV104.                                      guides contain sufficient instructions.
Clerical   837 Inst
                                  Loop 2410 Drug Identification CTP      Stakeholder indicates that the spreadsheet shows         Modify usage from "S" to "R" as defined
                                  Drug Pricing CTP03-CTP05               data elements are situational, but the situation is at   in the ANSI X12 guides.
                                                                         the segment level, not the data element level.
HIPAA      837 Inst
                                                                         Current code value only includes 00 and omits code       Deleted defined code to allow standard
HIPAA      837 Rx                 Loop TS BHT BHT02                      18 for reissue due to transmission problem.              codes to be submitted.
                                                                         Companion guide only listed code "2" for company,        Deleted defined code to allow standard
                                  Loop 1000A Sender Information NM1      HIPAA allows individuals and organizations to            codes to be submitted.
HIPAA      837 Rx                 Name NM102                             submit transactions.
                                  Loop 1000A Sender Information NM1      NM104 and NM105 not contained in companion               Added data elements.
HIPAA      837 Rx                 Name NM104 and NM105                   guides but do exist in HIPAA IG.




Information Management Services                                                 Page 17 of 23                                                       Proposed Revisions 20071212
Type       Chapter       Page Item                                      Issue/Comments                                         Change Implemented
                              Loop 2000A PRV Billing Provider           IAIABC ProPay SubCommittee recommends                  Modified usage from "J" to "S" as defined
                              Taxonomy Code                             removing the jurisdictional requirement for taxonomy   in the ANSI X12 guides. Deleted
                                                                        codes. The HIPAA IG language adequately covers         required comment.
HIPAA      837 Rx                                                       the conditions.
                                  Loop 2010AA Billing Provider          Spreadsheet indicates data element is Situational,     Modified usage to Required.
                                  Information NM108 Identification Code HIPAA IG indicates segment is Required.
Clerical   837 Rx                 Qualifier
                                  Loop 2010AA Billing Provider          Spreadsheet indicates data element is Situational,     Modified usage to Required.
                                  Information NM109 Identification Code HIPAA IG indicates segment is Required.
Clerical   837 Rx
                                  Loop 2010AA Billing Provider REF     Companion guides show usage as "J" and HIPAA            Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 State License                        IG shows usage as "S"                                   in the ANSI X12 guides.
                                  Loop 2010AA Billing Provider PER     Companion guides show usage as "J" and HIPAA            Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 Contact Information Segment          IG shows usage as "S"                                   in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider REF      Companion guides show usage as "J" and HIPAA            Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 State License                        IG shows usage as "S"                                   in the ANSI X12 guides.
                                  Loop 2000B Subscriber Detail SBR     Stakeholder points out that under the HIPAA IG this     Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment       data element is required if there is no group plan      in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator         number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Rx                                                      "S")
                                  Loop 2010BB Payer Identification REF Stakeholder points out that there may be situations     Added situational data segment.
                                  Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                       example, if the payer ID in Loop 2010BB NM1
                                                                       segment is a TPA and the insurance carrier
                                                                       identification is needed to process the claim, the
                                                                       secondary ID may be needed.
HIPAA      837 Rx
                                  Loop 2000C Patient Information HL      Stakeholder points out that under the HIPAA IG this   Modified usage from "J" to "S" as defined
                                  Segment                                data element is required if there the patient is      in the ANSI X12 guides.
                                                                         different than the policyholder, which makes it
                                                                         required for w/c. Recommend changing to match
HIPAA      837 Rx                                                        HIPAA IG ("J" to "S")
                                  Loop 2100CA Patient Information        Spreadsheet shows patient information as 2100CA,      Modified loop to 2010CA
Clerical   837 Rx                                                        the proper loop is 2010CA
                                  Loop 2010CA Patient Information NM     HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Name NM108                             not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Rx
                                  Loop 2010CA Patient Information NM     HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Name NM109                             not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Rx




Information Management Services                                                Page 18 of 23                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                         Issue/Comments                                        Change Implemented
                              2300 Claim Information CLM Segment           HIPAA IG shows this data element to be used when      Added situational data element.
                              CLM16 Provider Agreement Code                a non-participating provider is submitting a claim.
                                                                           This may be needed for access plans in network
                                                                           settings and should be allowed as situational.
HIPAA      837 Rx
                                  2300 Claim Information CLM Segment       Stakeholder noted that this was a "not used"          HIPAA "not used" data element deleted.
                                  CLM19 Bill Submission Reason Code        element in ANSI X12 and HIPAA IG. Existing
                                                                           codes, and new ones coming in December, are
HIPAA      837 Rx                                                          sufficient to convey information in CLM05.
                                  2300 Claim Information CLM Segment       HIPAA IG includes a delay reason code situational     Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code                  data element.                                         "S" as defined in the ANSI X12 guides.
HIPAA      837 Rx
                                  2300 Claim Information PWK Segment       IAIABC ProPay recommended change in approach          Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 PWC05                                    to align with HIPAA IG ("J" to "S")                   in the ANSI X12 guides.
                                  2300 Claim Information PWK Segment       IAIABC ProPay recommended change in approach          Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 PWC06                                    to align with HIPAA IG ("J" to "S")                   in the ANSI X12 guides.
                                  2300 Claim Information CN1 Contract      HIPAA IG shows this data element as situational,      Modified HIPAA and wc usage from "R"
                                  Information Segment CN102                not required as noted in companion guide.             to "S" as defined in ANSI X12 guides.
HIPAA      837 Rx
                                  2300 Claim Information AMT Amount        Patient amount paid shows "J" instead of "S" as       Modified usage from "J" to "S" as defined
                                  Paid Segment                             defined in the HIPAA guides. This is a situational    in the ANSI X12 guides.
HIPAA      837 Rx                                                          field that is only populated when it is applicable.
                                  Loop 2310 Facility/Service Location      Comments referring to "in REF Segment"                Removed comments.
Clerical   837 Rx                 Information NM1 Name Segment
                                  Loop 2310D NM1 Facility Service          Spreadsheet indicates HIPAA usage for this data       Modified HIPAA and wc usage from "R"
                                  Location Name NM108 Identification       element is Required, HIPAA IG indicates segment is    to "S" as defined in ANSI X12 guides.
HIPAA      837 Rx                 Code Qualifier                           Situational.
                                  Loop 2310D NM1 Facility Service          Spreadsheet indicates HIPAA usage for this data       Modified HIPAA and wc usage from "R"
                                  Location Name NM109 Identification       element is Required, HIPAA IG indicates segment is    to "S" as defined in ANSI X12 guides.
HIPAA      837 Rx                 Code                                     Situational.
                                  Loop 2410 Drug Identification LIN Item   Spreadsheet indicates data element is Required,       Modified HIPAA and workers'
                                  Identification Segment                   HIPAA IG indicates segment is Situational.            compensation usage to situational -- the
                                                                                                                                 HIPAA implementation notes show that
                                                                                                                                 this is required when NDC is needed,
                                                                                                                                 which would make it "required" for any
HIPAA      837 Rx                                                                                                                RX transaction.
                                  Loop 2410 Drug Identification REF        Spreadsheet indicates segment is Required, HIPAA      Modified HIPAA and workers'
                                  Prescription Number Segment              IG indicates segment is Situational.                  compensation usage to situational -- the
                                                                                                                                 HIPAA implementation notes show that
                                                                                                                                 this is required when drug dispensing is
                                                                                                                                 done with an assigned RX number.
HIPAA      837 Rx




Information Management Services                                                  Page 19 of 23                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                         Issue/Comments                                          Change Implemented
                              Loop 2410 Service Payment                    Stakeholder noted this includes an invalid              Modified to "ZZ"
                              Information REF Segment Prescription         code…change "XZ" to "ZZ"
Clerical   837 Rx             Number REF02
                              Loop 2420E Ordering Provider Name          Spreadsheet indicates HIPAA usage for this data           Modified HIPAA usage to required.
                              N104 First Name                            element is Situational, HIPAA IG indicates segment
Clerical   837 Rx                                                        is Required.
                                  Loop 2420E Ordering Provider Name      Spreadsheet indicates HIPAA usage for this data           Modified usage to situational.
                                  N108 Identification Code Qualifier and element is Required, HIPAA IG indicates segment is
HIPAA      837 Rx                 NM109                                  Situational.
                                  Loop TS BPR Financial Information      HIPAA IG usage is "R", companion guide shows as           Modified usage from "S" to "R" as
HIPAA      835                    BPR16                                  "S"                                                       defined in ANSI X12 guides.
                                  Loop TS DTM Production Date            HIPAA IG usage is "S", companion guide shows as           Modified usage from "R" to "S" as
HIPAA      835                    Segment                                "R"                                                       defined in the ANSI X12 guides.
                                  Loop 1000A Payer Identification N1     Stakeholder indicates HIPAA condition requires if         Modified usage from "R" to "S" as
                                  Payer Name                             the National Plan ID isn't populated, which basically     defined in the ANSI X12 guides.
HIPAA      835                                                           makes it required for w/c submissions.
                                  Loop 1000A Payer Identification REF    Stakeholder indicates HIPAA condition requires if         Modified usage from "J" to "S" as defined
                                  Payer Identification                   the National Plan ID is implemented, which basically      in the ANSI X12 guides.
                                                                         makes it required for w/c submissions with the same
HIPAA      835                                                           conditions.
                                  Loop 1000B Payee Identification NI     Stakeholder indicates that HIPAA requires this only       Modified usage from "R" to "S" as
                                  Payee Name                             when NPI is not submitted in the N104 field.              defined in the ANSI X12 guides.
                                                                         Otherwise, it isn't required to be sent in the 835 (NPI
HIPAA      835                                                           provides same information).
                                  Loop 1000B Payee Identification REF Stakeholder indicates HIPAA condition sufficent for          Modified usage from "J" to "S" as defined
HIPAA      835                    State License Number                   w/c usage.                                                in the ANSI X12 guides.
                                  Loop 2100 Bill Payment Information     Stakeholder indicates HIPAA condition sufficent for       Modified usage from "R" to "S" as
                                  NM1 Insured Name NM108 and NM109 w/c usage. It is required when the patient isn't the            defined in the ANSI X12 guides.
HIPAA      835                                                           insured.
                                  Loop 2100 Bill Payment Information     Stakeholder indicates HIPAA condition sufficent for       Modified usage from "R" to "S" as
                                  NM1 Insured Name NM103                 w/c usage. It is required when the patient isn't the      defined in the ANSI X12 guides.
HIPAA      835                    Organization Name                      insured.
                                  Loop 2100 Bill Payment Information     HIPAA IG usage shows as "S", but companion guide          Modified usage from "R" to "S" as
HIPAA      835                    NM1 Service Provider Name NM103        shows usage as "R".                                       defined in the ANSI X12 guides.
                                  Loop 2100 Bill Payment Information     HIPAA IG usage shows as multiple code values, but         Added "FI" to the code list in the
                                  NM1 Service Provider Name NM108        companion guides only list State License or NPI.          companion guides.
                                                                         HIPAA IG advises preference for use of the "FI"
HIPAA      835                                                           Federal Tax Identification Number.
                                  2100 Bill Payment Information REF      Stakeholder indicates we currently list this as a         Modified code from "Y4" to "F8" and
                                  Reference Identification (workers'     jurisdiction requirement with the use of a "Y4" code.     modified usage from "J" to "S" as defined
                                  compensation claim no.)                Questions use of the code and indicates it is             in the ANSI X12 guides.
HIPAA      835                                                           situational in the HIPAA IG.




Information Management Services                                                  Page 20 of 23                                                       Proposed Revisions 20071212
Type       Chapter       Page Item                                         Issue/Comments                                        Change Implemented
                              2100 Bill Payment Information DTM            Stakeholder indicates this is not used in HIPAA IG    Deleted HIPAA "not used" data segment.
                              Date of Accident                             and questions the need to include the date of injury
                                                                           on 835 transactions when other data elements (such
                                                                           as dates of service) provide sufficient data to match
                                                                           remittance advice to original claim.
HIPAA      835
                                  2100 Bill Payment Information DTM Bill Stakeholder indicates HIPAA IG allows this to be       Modify usage from "J" to "S" as defined
HIPAA      835                    Received Date                          submitted and provides some conditions.                in the ANSI X12 guides.
                                  2100 Bill Payment Information PER Bill Stakeholder indicates HIPAA IG outlines conditions     Modify usage from "J" to "S" as defined
                                  Contact Infromation                    which would make it applicable and suggests            in the ANSI X12 guides.
HIPAA      835                                                           changing "J" to "S".
                                  2100 Bill Payment Information PER Bill Stakeholder indicates HIPAA IG outlines conditions     Modify usage from "R" to "S" as defined
                                  Contact Infromation PER03              which would make it applicable and suggests            in the ANSI X12 guides. Also removed
                                                                         changing "R" to "S".                                   code value to allow appropriate code to
HIPAA      835                                                                                                                  be used.
                                  2100 Bill Payment Information PER Bill Stakeholder indicates HIPAA IG outlines conditions     Modify usage from "R" to "S" as defined
                                  Contact Infromation PER04              which would make it applicable and suggests            in the ANSI X12 guides.
HIPAA      835                                                           changing "R" to "S".
                                  2110 Service Payment Inormation REF Stakeholder recommends using the CLP01 to return Removed segment to align with HIPAA
                                  Prescription Number                    the prescription number instead of this ANSI X12     IG.
                                                                         "not used" segment. Even if the Rx number is not
                                                                         sent in the CLP01 field, the receiving entity should
                                                                         be able to match the paid amount on a claim with
                                                                         the other identification elements without deviating
                                                                         from the ANSI X12 format.
HIPAA      835
Clerical   Acks                   Multiple in Acknowledgment Formats       Segment usage not listed.                            Added segment usage.
                                  997 TS ST Transaction Set Header         The data elements did not contain the data element   Added data element numbers.
Clerical   Acks                                                            number.




Information Management Services                                                  Page 21 of 23                                                    Proposed Revisions 20071212
                                             Texas Clean Claim and eBill Companion Guide Revision Tracking 06/21/20

Chapter      Page    Issue                                   Comments
837D                 Loop 2300 REF Original Reference        Inadvertently omitted
Excel                Number (ICN/DCN) Segments are
                     missing
837D                 Loop 2320 AMT Coordination of           Payer loop referenced Patient
Excel                Benefits Payer Paid Amount Field
837I Excel           Loop 2320 AMT Coordination of           Payer loop referenced Patient
                     Benefits Payer Paid Amount Field
837I Excel           Loop 2300 REF Prior Authorization       Inadvertently omitted
                     Number Segment is missing
837I Excel           Loop 2300 REF Medical Record            Inadvertently omitted
                     Number Segment is missing
837P                 Loop 2300 REF Original Reference        Inadvertently omitted
Excel                Number (ICN/DCN) Segments are
                     missing
837P                 Loop 2320 AMT Coordination of           Payer loop referenced Patient
Excel                Benefits Payer Paid Amount Field
Chapter 2 8          CMS-1500 Instructions                   Boxes 11b Employer' Name and 11c Insurance
                                                             Plan Name omitted
Chapter 2 21,22      ADA revised form to support NPI and     Add fields
                     taxonomy codes.
Chapter 5 32         Loop 2300 CLM Claim Information         Omitted reference in Gap Analysis
                     Segment CLM19 field
Chapter 5 46         Incorrect reference to Chapter 7        Reference should state Chapter 8
                     Companion Guide Pharmacy
Chapter 5 47         Change AP to 30
Chapter 5 30, 47     Qualifier AP is used for                Correct value is 30
                     Appeal/Reconsideration transactions
                     where valid value is defined as 30

Chapter 5 41, 48     Reconsideration instructions does not   Language appears to require the same PWK
                     provide specific direction on PWK       segment on the reconsideration that was on the
                     Segment                                 original bill
Chapter 7 50         SBR08 Employment Status Code            Reference in Companion Guide Excel
                                                             removed, SBR08 no longer required
Chapter      59      Use of the term "header" of a           Remove the term header
12                   document caused confusion with the
                     use of header in electronic
                     transactions
Chapter      60      Methods of exchanging electronic        Companion Guide did not include language to
12                   documentation and HL7 formats           indicate a participant is not required to support
                                                             all three methods or direction on the use of HL7
                                                             attachment formats
Multiple     Mult.   Incorrect reference to ANSI format      Reference should state 004010A1
                     version 00410A1
Revision Tracking 06/21/2007

            Resolution
            Added to spreadsheet, line 289


            Corrected reference, line 411

            Corrected reference, line 681

            Added to spreadsheet, line 268

            Added to spreadsheet, line 272

            Added to spreadsheet, line 290


            Corrected reference, line 415

            Added to CMS-1500 instructions

            Added field 52A for Billing Provider and 56A for Rendering
            Provider taxonomy Codes.
            Added to Gap Analysis

            Corrected reference


            Replaced all AP occurrences with 30



            Change language to indicate PWK Segment information may be
            different on the reconsideration transaction

            Removed reference in Companion Guide Word document

            Instructions changed to read "top part of each pager of the
            document, left justified"


            Added language to clarify issue



            Corrected multiple references

								
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