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Certificate of Medical Necessity Form

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					    837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                              Segment/                                                               Mandatory/    Field       Field
             Record                       Field    Loop ID                                       Element Description                                                                                        Valid Values
                                                              Element                                                                Situational   Size        Type
                                                                                                                                         M
HEADER                            TPID            System     SYS_IDCO    Trading Partner ID                                              M          35         AN
                                                  Variable
HEADER                            ISA06                      ISA06       Interchange Sender ID                                           M          15         AN
HEADER                            GS06                       GS06        Group Control Number                                            M          9           N
HEADER                            GS08                       GS08        Version/Release/Industry Identifier Code                        M          12         AN
                                                             ST          Transaction Set Header                                          M
HEADER                            ST01                       ST01        Transaction Set Identifier Code                                 M                 3   ID      Automatically set to 837
HEADER                            ST02                       ST02        Transaction Set Control Number                                  M                 9   AN      Automatically generated.
                                                             BHT         Beginning of Hierarchical Transaction                           M
HEADER                            BHT01                      BHT01       Hierarchical Structure Code                                     M                 4    ID     0019 - Information Source, Subscriber, Dependent
HEADER                            BHT02                      BHT02       Transaction Set Purpose Code                                    M                 2    ID     00 - Original
                                                                                                                                                                       18 - Reissue
HEADER                            BHT03                      BHT03       Reference Identification                                        M               30    AN
HEADER                            BHT04                      BHT04       Date                                                            M                8    DT
HEADER                            BHT05                      BHT05       Time                                                            M                8    TM
HEADER                            BHT06                      BHT06       Transaction Type Code                                           M                2    ID      CH - Chargeable
                                                                                                                                                                       RP - Reporting
                                                             REF         Transmission Type Identification                                M
HEADER                            REF01                      REF01       Reference Identification Qualifier                              M                2    ID      87 - Functional Category
HEADER                            REF02                      REF02       Reference Identification                                        M               30    AN      004010X098DA1 - Testing
                                                                                                                                                                       004010X098A1 - Production
                                                  1000A      NM1         Submitter Name                                                  M
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     41 - Submitter
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                  M               35    AN
PROFILE                           NM104                      NM104       Name First                                                      S               25    AN
PROFILE                           NM105                      NM105       Name Middle                                                     S               25    AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                   M                2    ID      46 - Electronic Transmitter Identification Number (ETIN) established by a trading
                                                                                                                                                                       partner agreement.
PROFILE                           NM109                      NM109       Identification Code                                             M               80    AN
                                                  1000A      PER         Submitter EDI Contact Information                               M
CONTACT                           PER01                      PER01       Contact Function Code                                           M                2    ID      IC - Information Contact
CONTACT                           PER02                      PER02       Name                                                            M               60    AN
CONTACT                           PER03                      PER03       Communication Number Qualifier                                  M                2    ID      ED - Electronic Data Interchange Access Number
                                                                                                                                                                       EM - Electronic Mail
                                                                                                                                                                       FX - Facsimile
                                                                                                                                                                       TE - Telephone
CONTACT                           PER04                      PER04       Communication Number                                            M               80    AN
CONTACT                           PER05                      PER05       Communication Number Qualifier                                  S                2    ID      ED - Electronic Data Interchange Access Number
                                                                                                                                                                       EM - Electronic Mail
                                                                                                                                                                       EX - Telephone Extentsion
                                                                                                                                                                       FX - Facsimile
                                                                                                                                                                       TE - Telephone
CONTACT                           PER06                      PER06       Communication Number                                            S               80    AN
CONTACT                           PER07                      PER07       Communication Number Qualifier                                  S                2    ID      ED - Electronic Data Interchange Access Number
                                                                                                                                                                       EM - Electronic Mail
                                                                                                                                                                       EX - Telephone Extentsion
                                                                                                                                                                       FX - Facsimile
                                                                                                                                                                       TE - Telephone
CONTACT                           PER08                      PER08       Communication Number                                            S               80    AN
                                                  1000B      NM1         Receiver Name                                                   M
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                3    ID      40 - Receiver
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                1    ID      2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                  M               35    AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                   M                2    ID      46 - Electronic Transmitter Identification Number (ETIN) established by a trading
                                                                                                                                                                       partner agreement.
PROFILE                           NM109                      NM109       Identification Code                                             M               80    AN
                                                  2000A      HL          Billing/Pay-to Provider Hierarchical Level                      M
HIERARCHICALLEVEL                 HL01                       HL01        Hierarchical ID Number                                          M               12    AN      HL01 must begin with "1" and be incremented by one each time and HL is used in the
                                                                                                                                                                       transaction. Only numeric values are allowed in HL01.
HIERARCHICALLEVEL                 HL03                       HL03        Hierarchical Level Code                                         M                 2    ID     20 - Information Source
HIERARCHICALLEVEL                 HL04                       HL04        Hierarchical Child Code                                         M                 1    ID     1 - Additional Subordinate HL data segment in this hierarchical structure.




    11/12/2010                                                                                                                                                                                                                                              Page: 1
    837P - 4010 - Inbound - 000                                                                             State of Nebraska MMIS
                                                                                                       Mapping Specifications Spreadsheet



                                                              Segment/                                                              Mandatory/    Field       Field
             Record                       Field    Loop ID                                     Element Description                                                                                          Valid Values
                                                              Element                                                               Situational   Size        Type
                                                  2000A      PRV         Billing/Pay-to Provider Specialty Information                  S
HIERARCHICALLEVEL                 PRV01                      PRV01       Provider Code                                                  M                 3    ID     BI - Billing
                                                                                                                                                                      PT - Pay-to
HIERARCHICALLEVEL                 PRV02                      PRV02       Reference Identification Qualifier                             M             3       ID      ZZ - Mutually defined
HIERARCHICALLEVEL                 PRV03                      PRV03       Reference Identification                                       M            30       AN
                                                  2000A      CUR         Foreign Currency Information                                   S
HIERARCHICALLEVEL                 CUR01                      CUR01       Entity Identifier Code                                         M                 3    ID     85 - Billing Provider
HIERARCHICALLEVEL                 CUR02                      CUR02       Currency Code                                                  M                 3    ID
                                                  2010AA     NM1         Billing Provider Name                                          M
PROFILE                           NM101                      NM101       Entity ID Code                                                 M                 3    ID     85 - Billing Provider
PROFILE                           NM102                      NM102       Entity Type Qualifier                                          M                 1    ID     1 - Person
                                                                                                                                                                      2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM104                      NM104       Name First                                                     S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                    S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                    S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                  M             2       ID      24 - Employer's Identification Number
                                                                                                                                                                      34 - Social Security Number
                                                                                                                                                                      XX - Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                            M            80       AN
                                                  2010AA     N3          Billing Provider Address                                       M
PROFILE                           N301                       N301        Address Information                                            M            55       AN
PROFILE                           N302                       N302        Address Information                                            S            55       AN
                                                  2010AA     N4          Billing Provider City/State/Zip Code                           M
PROFILE                           N401                       N401        City Name                                                      M            30       AN
PROFILE                           N402                       N402        State or Province Code                                         M             2       ID
PROFILE                           N403                       N403        Postal Code                                                    M            15       ID
PROFILE                           N404                       N404        Country Code                                                   S             3       ID
                                                  2010AA     REF         Billing Provider Secondary Identification                      S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                             M                 3    ID     0B - State License Number
                                                                                                                                                                      1A - Blue Cross Provider Number
                                                                                                                                                                      1B - Blue Shield Provider Number
                                                                                                                                                                      1C - Medicare Provider Number
                                                                                                                                                                      1D - Medicaid Provider Number
                                                                                                                                                                      1G - Provider UPIN Number
                                                                                                                                                                      1H - CHAMPUS Identification Number
                                                                                                                                                                      1J - Facility ID Number
                                                                                                                                                                      B3 - Preferred Provider Organization Number
                                                                                                                                                                      BQ - Health Maintenance Organization Code Number
                                                                                                                                                                      EI - Employer's Identification Number
                                                                                                                                                                      FH - Clinic Number
                                                                                                                                                                      G2 - Provider Commercial Number
                                                                                                                                                                      G5 - Provider Site Number
                                                                                                                                                                      LU - Location Number
                                                                                                                                                                      SY - Social Security Number
                                                                                                                                                                      U3 - Unique Supplier Identification Number (USIN)
                                                                                                                                                                      X5 - State Industrial Accident Provider Number

REFERENCE                         REF02                      REF02       Reference Identification                                       M            30       AN
                                                  2010AA     REF         Credit/Debit Card Billing Information                          S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                             M                 3    ID     06 - System Number
                                                                                                                                                                      8U - Bank Assigned Security Identifier
                                                                                                                                                                      EM - Electronic Payment Reference Number
                                                                                                                                                                      IJ - Standard Industry Classification (SIC) Code
                                                                                                                                                                      LU - Location Number
                                                                                                                                                                      RB - Rate Code Number
                                                                                                                                                                      ST - Store Number
                                                                                                                                                                      TT - Terminal Code
REFERENCE                         REF02                      REF02       Reference Identification                                       M            30       AN
                                                  2010AA     PER         Billing Provider Contact Information                           S
CONTACT                           PER01                      PER01       Contact Function Code                                          M             2       ID      IC - Information Contact
CONTACT                           PER02                      PER02       Name                                                           M            60       AN
CONTACT                           PER03                      PER03       Communication Number Qualifier                                 M             2       ID      EM - Electronic Mail
                                                                                                                                                                      FX - Facsimile
                                                                                                                                                                      TE Telephone
CONTACT                           PER04                      PER04       Communication Number                                           M            80       AN




    11/12/2010                                                                                                                                                                                                                                 Page: 2
    837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                              Segment/                                                               Mandatory/    Field       Field
             Record                       Field    Loop ID                                    Element Description                                                                                              Valid Values
                                                              Element                                                                Situational   Size        Type
CONTACT                           PER05                      PER05       Communication Number Qualifier                                  S                 2    ID     EM - Electronic Mail
                                                                                                                                                                       EX - Telephone Extension
                                                                                                                                                                       FX - Facsimile
                                                                                                                                                                       TE Telephone
CONTACT                           PER06                      PER06       Communication Number                                            S            80       AN
CONTACT                           PER07                      PER07       Communication Number Qualifier                                  S             2       ID      EM - Electronic Mail
                                                                                                                                                                       EX - Telephone Extension
                                                                                                                                                                       FX - Facsimile
                                                                                                                                                                       TE Telephone
CONTACT                           PER08                      PER08       Communication Number                                            S            80       AN
                                                  2010AB     NM1         Pay-to Provider Name                                            S
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     87 - Pay-to Provider
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                  M            35       AN
PROFILE                           NM104                      NM104       Name First                                                      S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                     S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                     S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                   M             2       ID      24 - Employer's Identification Number
                                                                                                                                                                       34 - Social Security Number
                                                                                                                                                                       XX - Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                             M            80       AN
                                                  2010AB     N3          Pay-to Provider Address                                         M
PROFILE                           N301                       N301        Address Information                                             M            55       AN
PROFILE                           N302                       N302        Address Information                                             S            55       AN
                                                  2010AB     N4          Pay-to Provider City/State/Zip Code                             M
PROFILE                           N401                       N401        City Name                                                       M            30       AN
PROFILE                           N402                       N402        State or Province Code                                          M             2       ID
PROFILE                           N403                       N403        Postal Code                                                     M            15       ID
PROFILE                           N404                       N404        Country Code                                                    S             3       ID
                                                  2010AB     REF         Pay-to Provider Secondary Identification                        S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                              M                 3    ID     0B - State License Number
                                                                                                                                                                       1A - Blue Cross Provider Number
                                                                                                                                                                       1B - Blue Shield Provider Number
                                                                                                                                                                       1C - Medicare Provider Number
                                                                                                                                                                       1D - Medicaid Provider Number
                                                                                                                                                                       1G - Provider UPIN Number
                                                                                                                                                                       1H - CHAMPUS Identification Number
                                                                                                                                                                       1J - Facility ID Number
                                                                                                                                                                       B3 - Preferred Provider Organization Number
                                                                                                                                                                       BQ - Health Maintenance Organization Code Number
                                                                                                                                                                       EI - Employer's Identification Number
                                                                                                                                                                       FH - Clinic Number
                                                                                                                                                                       G2 - Provider Commercial Number
                                                                                                                                                                       G5 - Provider Site Number
                                                                                                                                                                       LU - Location Number
                                                                                                                                                                       SY - Social Security Number
                                                                                                                                                                       U3 - Unique Supplier Identification Number (USIN)
                                                                                                                                                                       X5 - State Industrial Accident Provider Number

REFERENCE                         REF02                      REF02       Reference Identification                                        M            30       AN
                                                  2000B      HL          Subscriber Hierarchical Level                                   M
HIERARCHICALLEVEL                 HL01                       HL01        Hierarchical ID Number                                          M            12       AN      HL01 must begin with "1" and be incremented by one each time and HL is used in the
                                                                                                                                                                       transaction. Only numeric values are allowed in HL01.
HIERARCHICALLEVEL                 HL02                       HL02        Hierarchical Parent ID Number                                   M            12       AN      HL02 identifies the hierarchical ID number of the HL segment to which the current HL
                                                                                                                                                                       is subordinate
HIERARCHICALLEVEL                 HL03                       HL03        Hierarchical Level Code                                         M                 2    ID     22 - Subscriber
HIERARCHICALLEVEL                 HL04                       HL04        Hierarchical Child Code                                         M                 1    ID     0 - No Subordinate
                                                                                                                                                                       1 - Additional Subordinate HL data segment in this hierarchical structure
                                                  2000B      SBR         Subscriber Information                                          M
HIERARCHICALLEVEL                 SBR01                      SBR01       Payer Responsibility Sequence Number Code                       M                 1    ID     P - Primary
                                                                                                                                                                       S - Secondary
                                                                                                                                                                       T - Tertiary - use to indicate "payer of last resort"
HIERARCHICALLEVEL                 SBR02                      SBR02       Individual Relationship Code                                    S             2       ID      18 - Self
HIERARCHICALLEVEL                 SBR03                      SBR03       Reference Identification                                        S            30       AN
HIERARCHICALLEVEL                 SBR04                      SBR04       Name                                                            S            60       AN




    11/12/2010                                                                                                                                                                                                                                                Page: 3
    837P - 4010 - Inbound - 000                                                                             State of Nebraska MMIS
                                                                                                       Mapping Specifications Spreadsheet



                                                              Segment/                                                              Mandatory/    Field       Field
             Record                       Field    Loop ID                                     Element Description                                                                                        Valid Values
                                                              Element                                                               Situational   Size        Type
HIERARCHICALLEVEL                 SBR05                      SBR05       Insurance Type Code                                            S                 3    ID     12 - Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group
                                                                                                                                                                      Health Plan
                                                                                                                                                                      13 - Medicare Secondary End-stage Renal Disease Beneficiary in the 12 month
                                                                                                                                                                      coordination period with an employer's group health plan
                                                                                                                                                                      14 - Medicare Secondary, No-fault Insurance including Auto is Primary
                                                                                                                                                                      15 - Medicare Secondary Worker's Compensation
                                                                                                                                                                      16 - Medicare Secondary Public Health Service or Other Federal Agency
                                                                                                                                                                      41 - Medicare Secondary Blank Lung
                                                                                                                                                                      42 - Medicare Secondary Veteran's Administrationz
                                                                                                                                                                      43 - Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health
                                                                                                                                                                      Plan (LGHP)
                                                                                                                                                                      47 - Medicare Secondary, Other Liability Insurance is Primary
HIERARCHICALLEVEL                 SBR09                      SBR09       Claim Filing Indicator Code                                    S                 2    ID     09 - Self-pay
                                                                                                                                                                      10 - Central Certification (K)
                                                                                                                                                                      11 - Other Non-federal Programs
                                                                                                                                                                      12 - Preferred Provider Organization (PPO)
                                                                                                                                                                      13 - Point of Service (POS)
                                                                                                                                                                      14 - Exclusive Provider Organization (EPO)
                                                                                                                                                                      15 - Indemnity Insurance
                                                                                                                                                                      16 - Health Maintenance Organization (HMO) Medicare Risk
                                                                                                                                                                      AM - Automobile Medical
                                                                                                                                                                      BL - Blue Cross/Blue Shield
                                                                                                                                                                      CH - Champus
                                                                                                                                                                      CI - Commercial Insurance Co.
                                                                                                                                                                      DS - Disability
                                                                                                                                                                      HM - Health Maintenance Organization
                                                                                                                                                                      LI - Liability
                                                                                                                                                                      LM - Liability Medical
                                                                                                                                                                      MB - Medicare Part B
                                                                                                                                                                      MC - Medicaid
                                                                                                                                                                      OF - Other Frederal Program
                                                                                                                                                                      TV - Titile V
                                                                                                                                                                      VA - Veterans Administration Plan
                                                                                                                                                                      WC - Worker's Compensation Health Claim
                                                                                                                                                                      ZZ - Mutually Defined

                                                  2000B      PAT         Patient Information                                            S
HIERARCHICALLEVEL                 PAT05                      PAT05       Date Time Period Format Qualifier                              S             3       ID      D8 - Date expressed in format CCYYMMDD
HIERARCHICALLEVEL                 PAT06                      PAT06       Date Time Period                                               S            35       AN
HIERARCHICALLEVEL                 PAT07                      PAT07       Unit or Basis for Measurement Code                             S             2       ID      01 - Actual Pounds
HIERARCHICALLEVEL                 PAT08                      PAT08       Weight                                                         S            10       AN
HIERARCHICALLEVEL                 PAT09                      PAT09       Yes/No Condition or Response Code                              S             1       ID      Y - Yes
                                                  2010BA     NM1         Subscriber Name                                                M
PROFILE                           NM101                      NM101       Entity ID Code                                                 M                 3    ID     IL - Insured or Subscriber
PROFILE                           NM102                      NM102       Entity Type Qualifier                                          M                 1    ID     1 - Person
                                                                                                                                                                      2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM104                      NM104       Name First                                                     S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                    S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                    S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                  M             2       ID      MI - Member Identification Number
                                                                                                                                                                      ZZ - Mutually Defined
PROFILE                           NM109                      NM109       Identification Code                                            M            80       AN
                                                  2010BA     N3          Subscriber Address                                             S
PROFILE                           N301                       N301        Address Information                                            M            55       AN
PROFILE                           N302                       N302        Address Information                                            S            55       AN
                                                  2010BA     N4          Subscriber City/State/Zip Code                                 S
PROFILE                           N401                       N401        City Name                                                      M            30       AN
PROFILE                           N402                       N402        State or Province Code                                         M             2       ID
PROFILE                           N403                       N403        Postal Code                                                    M            15       AN
PROFILE                           N404                       N404        Country Code                                                   S             3       AN
                                                  2010BA     DMG         Subscriber Demographic Information                             S
PROFILE                           DMG01                      DMG01       Date Time Period Format Qualifier                              M             3       ID      D8 - Date expressed in format CCYYMMDD
PROFILE                           DMG02                      DMG02       Date Time Period                                               M            35       AN




    11/12/2010                                                                                                                                                                                                                                        Page: 4
    837P - 4010 - Inbound - 000                                                                             State of Nebraska MMIS
                                                                                                       Mapping Specifications Spreadsheet



                                                              Segment/                                                              Mandatory/    Field       Field
             Record                       Field    Loop ID                                     Element Description                                                                                         Valid Values
                                                              Element                                                               Situational   Size        Type
PROFILE                           DMG03                      DMG03       Gender Code                                                    M                 1    ID     F - Female
                                                                                                                                                                      M - Male
                                                                                                                                                                      U - Unknown
                                                  2010BA     REF         Subscriber Secondarey Identification                           S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                             M                 3    ID     1W - Member Identification Number
                                                                                                                                                                      23 - Client Number
                                                                                                                                                                      IG - Insurance Policy Number
                                                                                                                                                                      SY - Social Security Number
REFERENCE                         REF02                      REF02       Reference Identification                                       M            30       AN
                                                  2010BA     REF         Property and Casualty Claim Number                             S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                             M             3       ID      Y4 - Agency Claim Number
REFERENCE                         REF02                      REF02       Reference Identification                                       M            30       AN
                                                  2010BB     NM1         Payer Name                                                     M
PROFILE                           NM101                      NM101       Entity ID Code                                                 M             3       ID      PR - Payer
PROFILE                           NM102                      NM102       Entity Type Qualifier                                          M             1       ID      2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                  M             2       ID      PI - Payor Identification
                                                                                                                                                                      XV - Health Care Financing Adminstration National PlanID
PROFILE                           NM109                      NM109       Identification Code                                            M            80       AN
                                                  2010BB     N3          Payer Address                                                  S
PROFILE                           N301                       N301        Address Information                                            M            55       AN
PROFILE                           N302                       N302        Address Information                                            S            55       AN
                                                  2010BB     N4          Payer City/State/Zip Code                                      S
PROFILE                           N401                       N401        City Name                                                      M            30       AN
PROFILE                           N402                       N402        State or Province Code                                         M             2       ID
PROFILE                           N403                       N403        Postal Code                                                    M            15       AN
PROFILE                           N404                       N404        Country Code                                                   S             3       AN
                                                  2010BB     REF         Payer Secondary Identification                                 S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                             M                 3    ID     2U - Payer Identification Number
                                                                                                                                                                      FY - Claim Office Number
                                                                                                                                                                      NF - National Association of Insurance Commissioners (NAIC) Code
                                                                                                                                                                      TJ - Federal Taxpayer's Identification Number
REFERENCE                         REF02                      REF02       Reference Identification                                       M            30       AN
                                                  2010BC     NM1         Responsible Party Name                                         S
PROFILE                           NM101                      NM101       Entity ID Code                                                 M                 3    ID     QD - Responsible Party
PROFILE                           NM102                      NM102       Entity Type Qualifier                                          M                 1    ID     1 - Person
                                                                                                                                                                      2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM104                      NM104       Name First                                                     S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                    S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                    S            10       AN
                                                  2010BC     N3          Responsible Party Address                                      M
PROFILE                           N301                       N301        Address Information                                            M            55       AN
PROFILE                           N302                       N302        Address Information                                            S            55       AN
                                                  2010BC     N4          Payor City/State/Zip Code                                      M
PROFILE                           N401                       N401        City Name                                                      M            30       AN
PROFILE                           N402                       N402        State or Province Code                                         M             2       ID
PROFILE                           N403                       N403        Postal Code                                                    M            15       AN
PROFILE                           N404                       N404        Country Code                                                   S             3       AN
                                                  2010BD     NM1         Credit/Debit Card Holder Name                                  S
PROFILE                           NM101                      NM101       Entity ID Code                                                 M                 3    ID     AO - Account Of
PROFILE                           NM102                      NM102       Entity Type Qualifier                                          M                 1    ID     1 - Person
                                                                                                                                                                      2 - Non-person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM104                      NM104       Name First                                                     S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                    S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                    S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                  M             2       ID      MI - Member Identification Number
PROFILE                           NM109                      NM109       Identification Code                                            M            80       AN
                                                  2010BD     REF         Credit/Debit Card Information                                  S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                             M                 3    ID     AB - Acceptable Source Purchase ID
                                                                                                                                                                      BB - Authorization Number
REFERENCE                         REF02                      REF02       Reference Identification                                       M            30       AN
                                                  2000C      HL          Patient Hierarchical Level                                     S




    11/12/2010                                                                                                                                                                                                                           Page: 5
    837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                              Segment/                                                               Mandatory/    Field       Field
             Record                       Field    Loop ID                                    Element Description                                                                                            Valid Values
                                                              Element                                                                Situational   Size        Type
HIERARCHICALLEVEL                 HL01                       HL01        Hierarchical ID Number                                          M            12       AN      HL01 must begin with "1" and be incremented by one each time and HL is used in the
                                                                                                                                                                       transaction. Only numeric values are allowed in HL01.
HIERARCHICALLEVEL                 HL02                       HL02        Hierarchical Parent ID Number                                   M            12       AN      HL02 identifies the hierarchical ID number of the HL Segment to which the current HL
                                                                                                                                                                       is subordinate
HIERARCHICALLEVEL                 HL03                       HL03        Hierarchical Level Code                                         M                 2    ID     23 - Dependent
HIERARCHICALLEVEL                 HL04                       HL04        Hierarchical Child Code                                         M                 1    ID     0 - No Subordinate
                                                  2000C      PAT         Patient Information                                             M
HIERARCHICALLEVEL                 PAT01                      PAT01       Individual Relationship Code                                    M                 2    ID     01 - Spouse
                                                                                                                                                                       04 - Grandfather or Grandmother
                                                                                                                                                                       05 - Grandson or Granddaughter
                                                                                                                                                                       07 - Nephew or Niece
                                                                                                                                                                       09 - Adopted Child
                                                                                                                                                                       10 - Foster Child
                                                                                                                                                                       15 - Ward
                                                                                                                                                                       17 - Stepson or Stepdaughter
                                                                                                                                                                       19 - Child
                                                                                                                                                                       20 - Employee
                                                                                                                                                                       21 - Unknown
                                                                                                                                                                       22 - Handicapped Dependent
                                                                                                                                                                       23 - Sponsored Dependent
                                                                                                                                                                       24 - Dependent of a Minor Dependent
                                                                                                                                                                       29 - Significant Other
                                                                                                                                                                       32 - Mother
                                                                                                                                                                       33 - Father
                                                                                                                                                                       36 - Emancipated Minor
                                                                                                                                                                       39 - Organ Donor
                                                                                                                                                                       40 - Cadavar Donor
                                                                                                                                                                       41 - Injured Plantiff
                                                                                                                                                                       43 - Child where Insured has no financial responsibility
                                                                                                                                                                       53 - Life Partner
                                                                                                                                                                       G8 - Other Relationship

HIERARCHICALLEVEL                 PAT05                      PAT05       Date Time Period Qualifier                                      S             3       ID      D8 - Date expressed in format CCYYMMDD
HIERARCHICALLEVEL                 PAT06                      PAT06       Date Time Period                                                S            35       AN
HIERARCHICALLEVEL                 PAT07                      PAT07       Unit or Basis for Measurement Code                              S             2       ID      01 - Actual Pounds
HIERARCHICALLEVEL                 PAT08                      PAT08       Weight                                                          S            10       AN
HIERARCHICALLEVEL                 PAT09                      PAT09       Yes/No Condition or Response Code                               S             1       ID      Y - Yes
                                                  2010CA     NM1         Patient Name                                                    M
PROFILE                           NM101                      NM101       Entity ID Code                                                  M             3       ID      QC -Patient
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M             1       ID      1 - Person
PROFILE                           NM103                      NM103       Name Last or Organization Name                                  M            35       AN
PROFILE                           NM104                      NM104       Name First                                                      S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                     S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                     S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                   S             2       ID      MI - Member Identification Number
                                                                                                                                                                       ZZ - Mutually Defined
PROFILE                           NM109                      NM109       Identification Code                                             S            80       AN
                                                  2010CA     N3          Patient Address                                                 M
PROFILE                           N301                       N301        Address Information                                             M            55       AN
PROFILE                           N302                       N302        Address Information                                             S            55       AN
                                                  2010CA     N4          Patient City/State/Zip Code                                     M
PROFILE                           N401                       N401        City Name                                                       M            30       AN
PROFILE                           N402                       N402        State or Province Code                                          M             2       ID
PROFILE                           N403                       N403        Postal Code                                                     M            15       AN
PROFILE                           N404                       N404        Country Code                                                    S             3       AN
                                                  2010CA     DMG         Patient Demographic Information                                 M
PROFILE                           DMG01                      DMG01       Date Time Period Format Qualifier                               M             3        ID     D8 - Date expressed in format CCYYMMDD
PROFILE                           DMG02                      DMG02       Date Time Period                                                M            35        An
PROFILE                           DMG03                      DMG03       Gender Code                                                     M             1        ID     F - Female
                                                                                                                                                                       M - Male
                                                                                                                                                                       U - Unknown
                                                  2010CA     REF         Patient Secondary Identification Number                         S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                              M                 3    ID     1W - Member Identification Number
                                                                                                                                                                       23 - Client Number
                                                                                                                                                                       IG - Insurance Policy Number
                                                                                                                                                                       SY - Social Security Number




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    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                                Segment/                                                              Mandatory/    Field       Field
             Record                         Field    Loop ID                                   Element Description                                                                                            Valid Values
                                                                Element                                                               Situational   Size        Type
REFERENCE                         REF02                        REF02       Reference Identification                                       M            30       AN
                                                    2010CA     REF         Property and Casualty Claim Number                             S
REFERENCE                         REF01                        REF01       Reference Identification Qualifier                             M             3       ID      Y4 - Agency Claim Number
REFERENCE                         REF02                        REF02       Reference Identification                                       M            30       AN
                                                    2300       CLM         Claim Information                                              M
CLAIM                             CLM01                        CLM01       Claim Submitter's Identifier                                   M            38       AN
CLAIM                             CLM02                        CLM02       Monetary Amount                                                M            18       R
CLAIM                             CLM05-1                      CLM05-1     Facility Code Value                                            M             2       AN
CLAIM                             CLM05-3                      CLM05-3     Claim Frequency Type Code                                      M             1       ID
CLAIM                             CLM06                        CLM06       Yes/No Condition or Response Code                              M             1       ID      Y -Yes
                                                                                                                                                                        N - No
CLAIM                             CLM07                        CLM07       Provide Accept Assignment Code                                 M                 1    ID     A - Assigned
                                                                                                                                                                        B - Assignement Accepted on Clinical Lab Servcises Only
                                                                                                                                                                        C - Not Assigned
                                                                                                                                                                        P - Patient Refuses to Assign Benefits
CLAIM                             CLM08                        CLM08       Yes/No Condition or Response Code                              M                 1    ID     Y - Yes
                                                                                                                                                                        N - No
CLAIM                             CLM09                        CLM09       Release of Information Code                                    M                 1    ID     A - Appropriate Release of information on file at Health Care Service Provider or to a
                                                                                                                                                                        Utilization Review Organization.
                                                                                                                                                                        I - Informed Consent to release medical information for conditions or diagnoses
                                                                                                                                                                        regulated by Federal Statues
                                                                                                                                                                        M - The provider has limited or restricted ability to release data related to a claim.
                                                                                                                                                                        N - No, Provider is not allowed to release data
                                                                                                                                                                        O - On file at payor or at plan sponsor
                                                                                                                                                                        Y - Yes, provider has a signed statement permitting relase of medical billing data
                                                                                                                                                                        related to a claim.

CLAIM                             CLM10                        CLM10       Patient Signature Source Code                                  S                 1    ID     B - Signed signature authorization form or forms for both HCFA-1500 claim form block
                                                                                                                                                                        12 and block 13 are on file.
                                                                                                                                                                        C - Signed HCFA-1500 Claim form on file
                                                                                                                                                                        M - Signed signature authorization form for HCFA-1500 Claim form block 13 on file
                                                                                                                                                                        P - Signature generated by provider because the patient was not physically present for
                                                                                                                                                                        services
                                                                                                                                                                        S - Signed signature authorization form for HCFA-1500 claim form block 12 on file.



                                                               CLM11       Composite Field                                                S
CLAIM                             CLM11-1                      CLM11-1     Related-Causes Code                                            M                 3    ID     AA - Auto Accident
                                                                                                                                                                        AP - Another Party Responsible
                                                                                                                                                                        EM - Employment
                                                                                                                                                                        OA - Other Accident
CLAIM                             CLM11-2                      CLM11-2     Related-Causes Code                                            S                 3    ID     AA - Auto Accident
                                                                                                                                                                        AP - Another Party Responsible
                                                                                                                                                                        EM - Employment
                                                                                                                                                                        OA - Other Accident
CLAIM                             CLM11-3                      CLM11-3     Related-Causes Code                                            S                 3    ID     AA - Auto Accident
                                                                                                                                                                        AP - Another Party Responsible
                                                                                                                                                                        EM - Employment
                                                                                                                                                                        OA - Other Accident
CLAIM                             CLM11-4                      CLM11-4     State or Province Code                                         S                 2    ID
CLAIM                             CLM11-5                      CLM11-5     Country Code                                                   S                 3    ID
CLAIM                             CLM12                        CLM12       Special Program Code                                           S                 3    ID     01 - Early & Periodic Screening, Diagnosis and Treatment (EPSDT) or Child Health
                                                                                                                                                                        Assessment Program (CHAP)
                                                                                                                                                                        02 - Physically Handicapped Children's Program
                                                                                                                                                                        03 - Special Federal Funding
                                                                                                                                                                        05 - Disability
                                                                                                                                                                        07 - Induced Abortion - Danger to life
                                                                                                                                                                        08 - Induced Abortion - Rape or Incest
                                                                                                                                                                        09 - Second Opinion or Surgery
CLAIM                             CLM16                        CLM16       Provider Agreement Code                                        S                 1    ID     P - Participation Agreement




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    837P - 4010 - Inbound - 000                                                                          State of Nebraska MMIS
                                                                                                    Mapping Specifications Spreadsheet



                                                              Segment/                                                           Mandatory/    Field       Field
             Record                       Field    Loop ID                                   Element Description                                                                                         Valid Values
                                                              Element                                                            Situational   Size        Type
CLAIM                             CLM20                      CLM20       Delay Reason Code                                           S                 2    ID     1 - Proof of Eligibility Unknown or Unavailable
                                                                                                                                                                   2 - Litigation
                                                                                                                                                                   3 - Authorization Delays
                                                                                                                                                                   4 - Delay in Certifying Provider
                                                                                                                                                                   5 - Delay in supply Billing Forms
                                                                                                                                                                   6 - Delay in delivery of Custom-made Appliances
                                                                                                                                                                   7 - Third Party Processing Delay
                                                                                                                                                                   8 - Delay in Eligibilty Determination
                                                                                                                                                                   9 - Original Claim Rejected or Denied Due to a reason unrelated to billing limitation
                                                                                                                                                                   rules.
                                                                                                                                                                   10 - Administration delay in the prior approval process
                                                                                                                                                                   11 - Other
                                                  2300       DTP         Date - Initial Treatment                                    S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      454 - Initial Treatment
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Date Last Seen                                       S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      304 - Latest Visit or Consultation
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Onset of Current Illness/Sympton                     S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      431 - Onset of Current Symptons or Illness
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Acute Manifestation                                  S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      453 - Acute Manifestation of a Chronic Condition
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Similar Illness/Sympton Onset                        S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      438 - Onset of Similar Symptons or Illness
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Accident                                             S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      439 - Accident
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Last Mensrual Period                                 S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      484 - Last Menstrual Period
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Last X-Ray                                           S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      455 - Last X-Ray
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Hearing and Vision Prescription Date                 S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      471 - Prescription
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Disablilty Begin                                     S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      360 - Disabilty Begins
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Disablilty End                                       S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      361 - Disabilty End
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Last Worked                                          S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      297 - Date Last Worked
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Authorized Return to Work                            S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      296 - Return to Work
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2300       DTP         Date - Admission                                            S




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    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                              Segment/                                                                Mandatory/    Field       Field
             Record                       Field    Loop ID                                      Element Description                                                                                          Valid Values
                                                              Element                                                                 Situational   Size        Type
DATES                             DTP01                      DTP01       Date/Time Qualifier                                              M             3       ID      435 - Admission
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                                M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                                 M            35       AN
                                                  2300       DTP         Date - Discharge                                                 S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                              M             3       ID      096 - Discharge Date
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                                M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                                 M            35       AN
                                                  2300       DTP         Date - Assumed and Relinquished Care Dates                       S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                              M                 3    ID     090 - Report Start
                                                                                                                                                                        091 - Report End
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                                M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                                 M            35       AN
                                                  2300       PWK         Claim Supplemental Information                                   S
PAPERWORK                         PWK01                      PWK01       Report Type Code                                                 M                 2    ID     77 - Support Data for Verification
                                                                                                                                                                        AS - Admission Summary
                                                                                                                                                                        B2 - Prescription
                                                                                                                                                                        B3 - Physician Order
                                                                                                                                                                        B4 - Referral Form
                                                                                                                                                                        CT - Certification
                                                                                                                                                                        DA - Dental Models
                                                                                                                                                                        DG - Diagnostic Report
                                                                                                                                                                        DS - Discharge Summary
                                                                                                                                                                        EB - Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
                                                                                                                                                                        MT - Models
                                                                                                                                                                        NN - Nursing Notes
                                                                                                                                                                        OB - Operative Note
                                                                                                                                                                        OZ - Support Data for Claim
                                                                                                                                                                        PN - Physical Therapy Notes
                                                                                                                                                                        PO - Prosthetics or Orthotic Certification
                                                                                                                                                                        PZ - Physical Therapy Certification
                                                                                                                                                                        RB - Radiololgy Films
                                                                                                                                                                        RR - Ratiololgy Reports
                                                                                                                                                                        RT - Report of Tests and Analysis Report


PAPERWORK                         PWK02                      PWK02       Report Transmission Type                                         M                 2    ID     AA - Available on Request at Provider Site
                                                                                                                                                                        BM - By Mail
                                                                                                                                                                        EL - Electronically Only
                                                                                                                                                                        EM - E-Mail
                                                                                                                                                                        FX - By Fax
PAPERWORK                         PWK05                      PWK05       Identification Code Qualifier                                    S             2       OD      AC - Attachment Control Number
PAPERWORK                         PWK06                      PWK06       Identification Code                                              S            80       AN
                                                  2300       CN1         Contract Information                                             S
CLAIM                             CN101                      CN101       Contract Type Code                                               M                 2    ID     02 - Per Diem
                                                                                                                                                                        03 - Variable Per Diem
                                                                                                                                                                        04 - Flat
                                                                                                                                                                        05 - Capitiated
                                                                                                                                                                        06 - Percent
                                                                                                                                                                        09 - Other
CLAIM                             CN102                      CN102       Monetary Amount                                                  S            18       R
CLAIM                             CN103                      CN103       Percent                                                          S             6       R
CLAIM                             CN104                      CN104       Reference Information                                            S            30       AN
CLAIM                             CN105                      CN105       Terms Discount Percent                                           S             6       R
CLAIM                             CN106                      CN106       Version Identifier                                               S            30       AN
                                                  2300       AMT         Credit/Debit Card Maximum Amount                                 S
AMOUNTS                           AMT01                      AMT01       Amount Qualifier Code                                            M             3        ID     MA - Maximum Amount
AMOUNTS                           AMT02                      AMT02       Monetary Amount                                                  M            18        R
                                                  2300       AMT         Patient Amount Paid                                              S
AMOUNTS                           AMT01                      AMT01       Amount Qualifier Code                                            M             3        ID     F5 - Patient Amount Paid
AMOUNTS                           AMT02                      AMT02       Monetary Amount                                                  M            18        R
                                                  2300       AMT         Total Purchased Service Amount                                   S
AMOUNTS                           AMT01                      AMT01       Amount Qualifier Code                                            M             3        ID     NE - Net Billed
AMOUNTS                           AMT02                      AMT02       Monetary Amount                                                  M            18        R
                                                  2300       REF         Service Authorization Exception Code                             S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                               M                 3    ID     4N - Special Payment Reference Number




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       837P - 4010 - Inbound - 000                                                                             State of Nebraska MMIS
                                                                                                          Mapping Specifications Spreadsheet



                                                                 Segment/                                                              Mandatory/    Field       Field
                Record                       Field    Loop ID                                     Element Description                                                                                          Valid Values
                                                                 Element                                                               Situational   Size        Type
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN      1 - Immediate/Urgent Care
                                                                                                                                                                         2 - Services Rendered in a Retroactive Period
                                                                                                                                                                         3 - Emergency Care
                                                                                                                                                                         4 - Client as Temporary Medicaid
                                                                                                                                                                         5 - Request from County for Second Opinion to Recipient can Work
                                                                                                                                                                         6 - Request for Override Pending
                                                                                                                                                                         7 - Special Handling
                                                     2300       REF         Mandatory Medicare (Section 4081) Crossover Indicator          S

REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      F5 - Medicare Version Code
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN      Y - 4081 (NSF Value 1)
                                                                                                                                                                         N - Regular Crossover (NSF Value 2)
                                                     2300       REF         Mammography Certification Number                               S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      EW - Mammography Certification Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Prior Authorization or Referral Number                         S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M                 3    ID     9F - Referral Number
                                                                                                                                                                         G1 - Prior Authorization Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Original Reference Number (ICN/DCN)                            S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      F8 - Original Reference Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Clinical Laboratory Improvement Amendment (CLIA)               S
                                                                            Number
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      X4 - Clinical Laboratory Improvement Amendment Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Reprice Claim Number                                           S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      9A - Repriced Claim Reference Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Adjusted Reprice Claim Number                                  S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      9C - Adjusted Repriced Claim Reference Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Investigational Device Exemption Number                        S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      LX - Qualified Products List
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Claim Identification Number for Clearinghouses and other       S
                                                                            Transmission Intermediaries.
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      D9 - Claim Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Ambulatory Patient Group (APG)                                 S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      1S - Abulatory Patient Group (APG) Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Medical Record Number                                          S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      EA - Medical Record Identification Number
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       REF         Demostration Project Identifier                                S
REFERENCE                            REF01                      REF01       Reference Identification Qualifier                             M             3       ID      P4 - Project Code
REFERENCE                            REF02                      REF02       Reference Identification                                       M            30       AN
                                                     2300       K3          File Information                                               S
INFO                                 K301                       K301        Fixed Format Information                                       M            80       AN
                                                     2300       NTE         Claim Note                                                     S
INFO                                 NTE01                      NTE01       Note Reference Code                                            M                 3    ID     ADD - Additional Information
                                                                                                                                                                         CER - Certification Narrative
                                                                                                                                                                         DCP - Goals, Rehabilitation Potential or Discharge Plans
                                                                                                                                                                         DGN - Diagnosis Description
                                                                                                                                                                         PMT - Payment
                                                                                                                                                                         TPO - Third Party
INFO                                 NTE02                      NTE02       Description                                                    M            80       AN
                                                     2300       CR1         Ambulance Transport Information                                S
CLAIM                                CR101                      CR101       Unit or Basis for Measurement Code                             S             2        ID     LB - pound
CLAIM                                CR102                      CR102       Weight                                                         S            10        R
CLAIM                                CR103                      CR103       Ambulance Transport Code                                       M             1        ID     I - Initial Trip
                                                                                                                                                                         R - Return Trip
                                                                                                                                                                         T - Transfer Trip
                                                                                                                                                                         X - Rount Trip




       11/12/2010                                                                                                                                                                                                                           Page: 10
      837P - 4010 - Inbound - 000                                                                            State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                                Segment/                                                             Mandatory/    Field       Field
               Record                       Field    Loop ID                                     Element Description                                                                                          Valid Values
                                                                Element                                                              Situational   Size        Type
CLAIM                               CR104                      CR104       Ambulance Transport Reason Code                               M                 1    ID     A - Patient was transported to nearest facility for care of symptons, complaints or both.
                                                                                                                                                                       B - Patient was transported for the benefit of a preferred physician.
                                                                                                                                                                       C - Patient was transported for the nearness of family members.
                                                                                                                                                                       D - Patient was transported for the care of a specialist or for availability of speacialized
                                                                                                                                                                       equipment.
                                                                                                                                                                       E - Patient transferred to rehabilitation facility.

CLAIM                               CR105                      CR105       Unit or Basis for Measurement Code                            M             2       ID      DH - Miles
CLAIM                               CR106                      CR106       Quantity                                                      M            15       R
CLAIM                               CR109                      CR109       Description                                                   S            80       AN
CLAIM                               CR110                      CR110       Description                                                   S            80       AN
                                                    2300       CR2         Spinal Manipulation Service Information                       S
CLAIM                               CR208                      CR208       Nature of Condition Code                                      M                 1    ID     A - Acute Condition
                                                                                                                                                                       C - Chronic Condition
                                                                                                                                                                       D - Non-acute
                                                                                                                                                                       E - Non-life Threatending
                                                                                                                                                                       F - Routine
                                                                                                                                                                       G - Symptomatic
                                                                                                                                                                       M - Acute Manifestation of a Chronic Condition
CLAIM                               CR210                      CR210       Description                                                   S            80       AN
CLAIM                               CR211                      CR211       Description                                                   S            80       AN
CLAIM                               CR212                      CR212       Yes/No Condition or Response Code                             S             1       ID      N - No
                                                                                                                                                                       Y - Yes
                                                    2300       CRC         Ambulance Certification                                       S
CRC                                 CRC01                      CRC01       Code Category                                                 M                 2    ID     07 - Ambulance Certification
CRC                                 CRC02                      CRC02       Yes/No Condition or Response Code                             M                 1    ID     N - No
                                                                                                                                                                       Y - Yes
CRC                                 CRC03                      CRC03       Condition Indicator                                           M                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
CRC                                 CRC04                      CRC04       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
CRC                                 CRC05                      CRC05       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility




      11/12/2010                                                                                                                                                                                                                                                Page: 11
      837P - 4010 - Inbound - 000                                                                            State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                                Segment/                                                             Mandatory/    Field       Field
               Record                       Field    Loop ID                                     Element Description                                                                                        Valid Values
                                                                Element                                                              Situational   Size        Type
CRC                                 CRC06                      CRC06       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
CRC                                 CRC07                      CRC07       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
                                                    2300       CRC         Patient Condition Information - Vision                        S
CRC                                 CRC01                      CRC01       Code Category                                                 M                 2    ID     E1 - Spectable Lenses
                                                                                                                                                                       E2 - Contact Lenses
                                                                                                                                                                       E3 - Spectable Frames
CRC                                 CRC02                      CRC02       Yes/No Condition or Response Code                             M                 1    ID     N - No
                                                                                                                                                                       Y - Yes
CRC                                 CRC03                      CRC03       Condition Indicator                                           M                 2    ID     L1 - General Standard of 20 degree or .5 dipter sphere of cylinder change met
                                                                                                                                                                       L2 - Replacement due to loss or theft
                                                                                                                                                                       L3 - Replacement due to breakage or damage
                                                                                                                                                                       L4 - Replacement due to patient preference
                                                                                                                                                                       L5 - Replacement due to medical reason
CRC                                 CRC04                      CRC04       Condition Indicator                                           S                 2    ID     L1 - General Standard of 20 degree or .5 dipter sphere of cylinder change met
                                                                                                                                                                       L2 - Replacement due to loss or theft
                                                                                                                                                                       L3 - Replacement due to breakage or damage
                                                                                                                                                                       L4 - Replacement due to patient preference
                                                                                                                                                                       L5 - Replacement due to medical reason
CRC                                 CRC05                      CRC05       Condition Indicator                                           S                 2    ID     L1 - General Standard of 20 degree or .5 dipter sphere of cylinder change met
                                                                                                                                                                       L2 - Replacement due to loss or theft
                                                                                                                                                                       L3 - Replacement due to breakage or damage
                                                                                                                                                                       L4 - Replacement due to patient preference
                                                                                                                                                                       L5 - Replacement due to medical reason
CRC                                 CRC06                      CRC06       Condition Indicator                                           S                 2    ID     L1 - General Standard of 20 degree or .5 dipter sphere of cylinder change met
                                                                                                                                                                       L2 - Replacement due to loss or theft
                                                                                                                                                                       L3 - Replacement due to breakage or damage
                                                                                                                                                                       L4 - Replacement due to patient preference
                                                                                                                                                                       L5 - Replacement due to medical reason
CRC                                 CRC07                      CRC07       Condition Indicator                                           S                 2    ID     L1 - General Standard of 20 degree or .5 dipter sphere of cylinder change met
                                                                                                                                                                       L2 - Replacement due to loss or theft
                                                                                                                                                                       L3 - Replacement due to breakage or damage
                                                                                                                                                                       L4 - Replacement due to patient preference
                                                                                                                                                                       L5 - Replacement due to medical reason
                                                    2300       CRC         Homebound Indicator                                           S
CRC                                 CRC01                      CRC01       Code Category                                                 M                 2    ID     75 - Functional limitations
CRC                                 CRC02                      CRC02       Yes/No Condition or Response Code                             M                 1    ID     Y - Yes
CRC                                 CRC03                      CRC03       Condition Indicator                                           M                 2    ID     IH - Independent at Home
                                                    2300       CRC         EPSDT Referral                                                S
CRC                                 CRC01                      CRC01       Code Category                                                 M                 2    ID     ZZ - Mutually Defined
CRC                                 CRC02                      CRC02       Yes/No Condition or Response Code                             M                 1    ID     N - No
                                                                                                                                                                       Y - Yes
CRC                                 CRC03                      CRC03       Condition Indicator                                           M                 2    ID     AV - Available - Not Used
                                                                                                                                                                       NU - Not Used
                                                                                                                                                                       S2 - Under Treatment
                                                                                                                                                                       ST - New Services Requested




      11/12/2010                                                                                                                                                                                                                                       Page: 12
      837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                          Mapping Specifications Spreadsheet



                                                                  Segment/                                                             Mandatory/    Field       Field
               Record                        Field    Loop ID                                      Element Description                                                                                        Valid Values
                                                                  Element                                                              Situational   Size        Type
CRC                                 CRC04                       CRC04        Condition Indicator                                           S                 2    ID     AV - Available - Not Used
                                                                                                                                                                         NU - Not Used
                                                                                                                                                                         S2 - Under Treatment
                                                                                                                                                                         ST - New Services Requested
CRC                                 CRC05                       CRC05        Condition Indicator                                           S                 2    ID     AV - Available - Not Used
                                                                                                                                                                         NU - Not Used
                                                                                                                                                                         S2 - Under Treatment
                                                                                                                                                                         ST - New Services Requested
                                                     2300       HI           Health Care Diagnosis Code                                    S
                                                                HI01         Health Care Code Information                                  M
PROCEDURES                          HI01-1                      HI01-1       Code List Qualifier Code                                      M             3       ID      BK - Principal Diagnosis
PROCEDURES                          HI01-2                      HI01-2       Industry Code                                                 M            30       AN
                                                                HI02         Health Care Code Information                                  S
PROCEDURES                          HI02-1                      HI02-1       Code List Qualifier Code                                      M             3       ID      BF - Diagnosic
PROCEDURES                          HI02-2                      HI02-2       Industry Code                                                 M            30       AN
                                                                HI03         Health Care Code Information                                  S
PROCEDURES                          HI03-1                      HI03-1       Code List Qualifier Code                                      M             3       ID      BF - Diagnosic
PROCEDURES                          HI03-2                      HI03-2       Industry Code                                                 M            30       AN
                                                                HI04         Health Care Code Information                                  S
PROCEDURES                          HI04-1                      HI04-1       Code List Qualifier Code                                      M             3       ID      BF - Diagnosic
PROCEDURES                          HI04-2                      HI04-2       Industry Code                                                 M            30       AN
                                                                HI05         Health Care Code Information                                  S
PROCEDURES                          HI05-1                      HI05-1       Code List Qualifier Code                                      M             3       ID      BF - Diagnosic
PROCEDURES                          HI05-2                      HI05-2       Industry Code                                                 M            30       AN
                                                                HI06         Health Care Code Information                                  S
PROCEDURES                          HI06-1                      HI06-1       Code List Qualifier Code                                      M             3       ID      BF - Diagnosic
PROCEDURES                          HI06-2                      HI06-2       Industry Code                                                 M            30       AN
                                                                HI07         Health Care Code Information                                  S
PROCEDURES                          HI07-1                      HI07-1       Code List Qualifier Code                                      M             3       ID      BF - Diagnosic
PROCEDURES                          HI07-2                      HI07-2       Industry Code                                                 M            30       AN
                                                                HI08         Health Care Code Information                                  S
PROCEDURES                          HI08-1                      HI08-1       Code List Qualifier Code                                      M             3       ID      BF - Diagnosic
PROCEDURES                          HI08-2                      HI08-2       Industry Code                                                 M            30       AN
                                                     2300       HCP          Claim Pricing/Repricing Information                           S
CLAIM                               HCP01                       HCP01        Pricing Methodology                                           M                 2    ID     00 - Zero Pricing
                                                                                                                                                                         01 - Priced as Billed at 100%
                                                                                                                                                                         02 - Priced at the standard fee schedule
                                                                                                                                                                         03 - Priced at a Contractural Percentage
                                                                                                                                                                         04 - Bundled Pricing
                                                                                                                                                                         05 - Peer Review Pricing
                                                                                                                                                                         07 - Flat Rate Pricing
                                                                                                                                                                         08 - Combination Pricing
                                                                                                                                                                         09 - Maternity Pricing
                                                                                                                                                                         10 - Other Pricing
                                                                                                                                                                         11 - Lower of Cost
                                                                                                                                                                         12 - Ratio of Cost
                                                                                                                                                                         13 - Cost Reimbursed
                                                                                                                                                                         14 - Adjustment Pricing
CLAIM                               HCP02                       HCP02        Monetary Amount                                               M            18       R
CLAIM                               HCP03                       HCP03        Monetary Amount                                               S            18       R
CLAIM                               HCP04                       HCP04        Reference Identification                                      S            30       AN
CLAIM                               HCP05                       HCP05        Rate                                                          S             9       R
CLAIM                               HCP06                       HCP06        Reference Identification                                      S            30       AN
CLAIM                               HCP07                       HCP07        Monetary Amount                                               S            18       R
CLAIM                               HCP13                       HCP13        Rejected Reason Code                                          S             2       ID      T1 - Cannot identify provider as TPO participant
                                                                                                                                                                         T2 - Cannot identify payer as TPO participant
                                                                                                                                                                         T3 - Cannot identify insured as TPO particpant
                                                                                                                                                                         T4 - Payer Name or Identifier Missing
                                                                                                                                                                         T5 - Certification Information Missing
                                                                                                                                                                         T6 - Claim doesn't contain enough information for repricing
CLAIM                               HCP14                       HCP14        Policy Compliance Code                                        S                 2    ID     1 - Procedure Followed (Compliance)
                                                                                                                                                                         2 - Not Followed - Call Not Made (Non-compliance call not made)
                                                                                                                                                                         3 - Not Medically Necessary (Non-compliance Non-medically necessary)
                                                                                                                                                                         4 - Not Followed Other (Non-compliance Other)
                                                                                                                                                                         5 - Emergency Admit to Non-Network Hospital




      11/12/2010                                                                                                                                                                                                                                Page: 13
    837P - 4010 - Inbound - 000                                                                           State of Nebraska MMIS
                                                                                                     Mapping Specifications Spreadsheet



                                                              Segment/                                                            Mandatory/    Field       Field
             Record                       Field    Loop ID                                    Element Description                                                                                        Valid Values
                                                              Element                                                             Situational   Size        Type
CLAIM                             HCP15                      HCP15       Exception Code                                               S                 2    ID     1 - Non-network professional provider in network hospital
                                                                                                                                                                    2 - Emergency Care
                                                                                                                                                                    3 - Services or Specialist not in Network
                                                                                                                                                                    4 - Out-of-service Area
                                                                                                                                                                    5 - State Mandates
                                                                                                                                                                    6 - Other
                                                  2305       CR7         Home Health Care Plan Information                            S
HOMEHEALTH                        CR701                      CR701       Code List Qualifier Code                                     M                 2    ID     AI - Home Health Aide
                                                                                                                                                                    MS - Medical Social Worker
                                                                                                                                                                    OT - Occupational Therapy
                                                                                                                                                                    PT - Physical Therapy
                                                                                                                                                                    SN - Skilled Nursing
                                                                                                                                                                    ST - Speech Therapy
HOMEHEALTH                        CR702                      CR702       Number                                                       M                 9    N0
HOMEHEALTH                        CR703                      CR703       Number                                                       M                 9    N0
                                                  2305       HSD         Health Care Services Delivery                                S
HEALTHCARE                        HSD01                      HSD01       Quantity Qualifier                                           S             2        ID     VS - Visits
HEALTHCARE                        HSD02                      HSD02       Quantity                                                     S            15        R
HEALTHCARE                        HSD03                      HSD03       Unit or Basis for Measurement Code                           S             2        ID     DA - Days
                                                                                                                                                                    MO - Months
                                                                                                                                                                    Q1 - Quarter (Time)
                                                                                                                                                                    WK - Week
HEALTHCARE                        HSD04                      HSD04       Sample Selection Modulus                                     S                 6    R
HEALTHCARE                        HSD05                      HSD05       Time Period Qualifier                                        S                 2    ID     7 - Day
                                                                                                                                                                    35 - Week
HEALTHCARE                        HSD06                      HSD06       Number of Periods                                            S                 3    N0
HEALTHCARE                        HSD07                      HSD07       Ship/Delivery or Calendar Pattern Code                       S                 2    ID     1 - 1st week of the month
                                                                                                                                                                    2 - 2nd week of the month
                                                                                                                                                                    3 - 3rd week of the month
                                                                                                                                                                    4 - 4th week of the month
                                                                                                                                                                    5 - 5th week of the month
                                                                                                                                                                    6 - 1st and 3rd weeks of the month
                                                                                                                                                                    7 - 2nd and 4th weeks of the month
                                                                                                                                                                    A - Monday through Friday
                                                                                                                                                                    B - Monday through Saturday
                                                                                                                                                                    C - Monday through Sunday
                                                                                                                                                                    D - Monday
                                                                                                                                                                    E - Tuesday
                                                                                                                                                                    F - Wednesday
                                                                                                                                                                    G - Thursday
                                                                                                                                                                    H - Friday
                                                                                                                                                                    J - Saturday
                                                                                                                                                                    K - Sunday
                                                                                                                                                                    L - Monday through Thursday
                                                                                                                                                                    N - As directed
                                                                                                                                                                    O - Daily Monday through Friday
                                                                                                                                                                    S - Once anytime Monday through Friday
                                                                                                                                                                    SA - Sunday, Monday, Thursday, Friday, Saturday
                                                                                                                                                                    SB - Tuesday through Saturday
                                                                                                                                                                    SC - Sunday, Wednesday, Thursday, Friday, Saturday
                                                                                                                                                                    SD - Monday, Wednesday, Thursday, Friday, Saturday
                                                                                                                                                                    SG - Tuesday through Friday
                                                                                                                                                                    SL - Monday, Tuesday and Thursday
                                                                                                                                                                    SP - Monday, Tuesday and Friday
                                                                                                                                                                    SX - Wednesday and Thursday
                                                                                                                                                                    SY - Monday, Wednesday and Thursday
                                                                                                                                                                    SZ - Tuesday, Thursday and Friday
                                                                                                                                                                    W - Whenever Necessary

HEALTHCARE                        HSD08                      HSD08       Ship/Delivery Pattern Time Code                              S                 1    ID     D - A.M.
                                                                                                                                                                    E - P.M.
                                                                                                                                                                    F - As Directed.
                                                  2310A      NM1         Referring Provider Name                                      S
PROFILE                           NM101                      NM101       Entity ID Code                                               M                 3    ID     DN - Referring Provider
                                                                                                                                                                    P3 - Primary Care Provider




    11/12/2010                                                                                                                                                                                                                  Page: 14
    837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                              Segment/                                                               Mandatory/    Field       Field
             Record                       Field    Loop ID                                       Element Description                                                                                        Valid Values
                                                              Element                                                                Situational   Size        Type
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-Person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                  M            35       AN
PROFILE                           NM104                      NM104       Name First                                                      S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                     S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                     S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                   S             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                       34 - Social Security Number
                                                                                                                                                                       XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                             S            80       AN
                                                  2310A      PRV         Referring Provider Specialty Information                        S
PROFILE                           PRV01                      PRV01       Provider Code                                                   M             3       ID      RF - Referring
PROFILE                           PRV02                      PRV02       Reference Identification Qualifier                              M             3       ID      ZZ - Mutually defined
PROFILE                           PRV03                      PRV03       Reference Identification                                        M            30       AN
                                                  2310A      REF         Referring Provider Secondary Identification                     S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                              M                 3    ID     0B - State License Number
                                                                                                                                                                       1B - Blue Shield Provider Number
                                                                                                                                                                       1C - Medicare Provider Number
                                                                                                                                                                       1D - Medicaid Provider Number
                                                                                                                                                                       1G - Provider UPIN Number
                                                                                                                                                                       1H - CHAMPUS Identification Number
                                                                                                                                                                       EI - Employer's Identification Number
                                                                                                                                                                       G2 - Provider Commercial Number
                                                                                                                                                                       LU - Location Number
                                                                                                                                                                       N5 - Provider Plan Network Identification Number
                                                                                                                                                                       SY - Social Security Number - Can't be used for Medicare
                                                                                                                                                                       X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                        M            30       AN
                                                  2310B      NM1         Rendering Provider Name                                         S
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     82 - Rendering Provider
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-Person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                  M            35       AN
PROFILE                           NM104                      NM104       Name First                                                      S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                     S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                     S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                   S             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                       34 - Social Security Number
                                                                                                                                                                       XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                             S            80       AN
                                                  2310B      PRV         Rendering Provider Specialty Information                        S
PROFILE                           PRV01                      PRV01       Provider Code                                                   M             3       ID      PE - Performing
PROFILE                           PRV02                      PRV02       Reference Identification Qualifier                              M             3       ID      ZZ - Mutually defined
PROFILE                           PRV03                      PRV03       Reference Identification                                        M            30       AN
                                                  2310B      REF         Referring Provider Secondary Identification                     S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                              M                 3    ID     0B - State License Number
                                                                                                                                                                       1B - Blue Shield Provider Number
                                                                                                                                                                       1C - Medicare Provider Number
                                                                                                                                                                       1D - Medicaid Provider Number
                                                                                                                                                                       1G - Provider UPIN Number
                                                                                                                                                                       1H - CHAMPUS Identification Number
                                                                                                                                                                       EI - Employer's Identification Number
                                                                                                                                                                       G2 - Provider Commercial Number
                                                                                                                                                                       LU - Location Number
                                                                                                                                                                       N5 - Provider Plan Network Identification Number
                                                                                                                                                                       SY - Social Security Number
                                                                                                                                                                       X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                        M            30       AN
                                                  2310C      NM1         Purchased Service Provider Name                                 S
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     QB - Purchase Service Provider
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-Person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                  R            35       AN
PROFILE                           NM104                      NM104       Name First                                                      S            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                     S            25       AN




    11/12/2010                                                                                                                                                                                                                                       Page: 15
    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                              Segment/                                                                Mandatory/    Field       Field
             Record                       Field    Loop ID                                      Element Description                                                                                          Valid Values
                                                              Element                                                                 Situational   Size        Type
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S                 2    ID     24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN
                                                  2310C      REF         Purchased Service Provider Secondary Identification              S


REFERENCE                         REF01                      REF01       Reference Identification Qualifier                               M                 3    ID     0B - State License Number
                                                                                                                                                                        1B - Blue Shield Provider Number
                                                                                                                                                                        1C - Medicare Provider Number
                                                                                                                                                                        1D - Medicaid Provider Number
                                                                                                                                                                        1G - Provider UPIN Number
                                                                                                                                                                        1H - CHAMPUS Identification Number
                                                                                                                                                                        EI - Employer's Identification Number
                                                                                                                                                                        G2 - Provider Commercial Number
                                                                                                                                                                        LU - Location Number
                                                                                                                                                                        N5 - Provider Plan Network Identification Number
                                                                                                                                                                        SY - Social Security Number
                                                                                                                                                                        X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2310D      NM1         Service Facility Location                                        S
PROFILE                           NM101                      NM101       Entity ID Code                                                   M                 3    ID     77 - Service Location
                                                                                                                                                                        FA - Facility
                                                                                                                                                                        LI - Independent Lab
                                                                                                                                                                        TL - Testing laboratory
PROFILE                           NM102                      NM102       Entity Type Qualifier                                            M             1       ID      2 - Non-Person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                   S            35       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN
                                                  2310D      N3          Service Facility Location Address                                M
PROFILE                           N301                       N301        Address Information                                              M            55       AN
PROFILE                           N302                       N302        Address Information                                              S            55       AN
                                                  2310D      N4          Service Facility City/State/Zip Code                             M
PROFILE                           N401                       N401        City Name                                                        M            30       AN
PROFILE                           N402                       N402        State or Province Code                                           M             2       ID
PROFILE                           N403                       N403        Postal Code                                                      M            15       AN
PROFILE                           N404                       N404        Country Code                                                     S             3       AN
                                                  2310D      REF         Service Facility Location Secondary Identification               S

REFERENCE                         REF01                      REF01       Reference Identification Qualifier                               M                 3    ID     0B - State License Number
                                                                                                                                                                        1A - Blue Cross Provider Number
                                                                                                                                                                        1B - Blue Shield Provider Number
                                                                                                                                                                        1C - Medicare Provider Number
                                                                                                                                                                        1D - Medicaid Provider Number
                                                                                                                                                                        1G - Provider UPIN Number
                                                                                                                                                                        1H - CHAMPUS Identification Number
                                                                                                                                                                        EI - Employer's Identification Number
                                                                                                                                                                        G2 - Provider Commercial Number
                                                                                                                                                                        LU - Location Number
                                                                                                                                                                        N5 - Provider Plan Network Identification Number
                                                                                                                                                                        SY - Social Security Number
                                                                                                                                                                        X4 - Clinical laboratory Improvement Amendment Number
                                                                                                                                                                        X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2310E      NM1         Supervising Provider Name                                        S
PROFILE                           NM101                      NM101       Entity ID Code                                                   M             3       ID      DQ - Supervising Physician
PROFILE                           NM102                      NM102       Entity Type Qualifier                                            M             1       ID      1 - Person
PROFILE                           NM103                      NM103       Name Last or Organization Name                                   M            35       AN
PROFILE                           NM104                      NM104       Name First                                                       M            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                      S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                      S            10       AN




    11/12/2010                                                                                                                                                                                                                                        Page: 16
    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                              Segment/                                                                Mandatory/    Field       Field
             Record                       Field    Loop ID                                      Element Description                                                                                           Valid Values
                                                              Element                                                                 Situational   Size        Type
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S                 2    ID     24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN
                                                  2310E      REF         Supervising Provider Secondary Identification                    S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                               M                 3    ID     0B - State License Number
                                                                                                                                                                        1B - Blue Shield Provider Number
                                                                                                                                                                        1C - Medicare Provider Number
                                                                                                                                                                        1D - Medicaid Provider Number
                                                                                                                                                                        1G - Provider UPIN Number
                                                                                                                                                                        1H - CHAMPUS Identification Number
                                                                                                                                                                        EI - Employer's Identification Number
                                                                                                                                                                        G2 - Provider Commercial Number
                                                                                                                                                                        LU - Location Number
                                                                                                                                                                        N5 - Provider Plan Network Identification Number
                                                                                                                                                                        SY - Social Security Number
                                                                                                                                                                        X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2320       SBR         Other Subscriber Information                                     S
OTHERSUBSCRIBER                   SBR01                      SBR01       Payer Responsibility Sequence Number Code                        M                 1    ID     P - Primary
                                                                                                                                                                        S - Secondary
                                                                                                                                                                        T - Tertiary
OTHERSUBSCRIBER                   SBR02                      SBR02       Individual Relationship Code                                     M                 2    ID     01 - Spouse
                                                                                                                                                                        04 - Grandfather or Grandmother
                                                                                                                                                                        05 - Grandson or Granddaughter
                                                                                                                                                                        07 - Nephew or Niece
                                                                                                                                                                        10 - Foster Child
                                                                                                                                                                        15 - Ward
                                                                                                                                                                        17 - Stepson or Stepdaughter
                                                                                                                                                                        18 - Self
                                                                                                                                                                        19 - Child
                                                                                                                                                                        20 - Employee
                                                                                                                                                                        21 - Unknown
                                                                                                                                                                        22 - Handicapped Dependent
                                                                                                                                                                        23 - Sponsored Dependent
                                                                                                                                                                        24 - Dependent of a Minor Dependent
                                                                                                                                                                        29 - Significant Other
                                                                                                                                                                        32 - Mother
                                                                                                                                                                        33 - Father
                                                                                                                                                                        36 - Emancipated Minor
                                                                                                                                                                        39 - Organ Donor
                                                                                                                                                                        40 - Cadavar Donor
                                                                                                                                                                        41 - Injured Plantiff
                                                                                                                                                                        43 - Child where Insured has no financial responsibility
                                                                                                                                                                        53 - Life Partner
                                                                                                                                                                        G8 - Other Relationship

OTHERSUBSCRIBER                   SBR03                      SBR03       Reference Identification                                         S            30       AN
OTHERSUBSCRIBER                   SBR04                      SBR04       Name                                                             S            60       AN
OTHERSUBSCRIBER                   SBR05                      SBR05       Insurance Type Code                                              M             3       ID      AP - Auto Insurance Policy
                                                                                                                                                                        C1 - Commercial
                                                                                                                                                                        CP - Medicare Conditionally Primary
                                                                                                                                                                        GP - Group Policty
                                                                                                                                                                        HM - Health maintenance Organization
                                                                                                                                                                        IP - Individual Policy
                                                                                                                                                                        LD - Long Term Policy
                                                                                                                                                                        LT - Litigation
                                                                                                                                                                        MB - Medicare Part B
                                                                                                                                                                        MC - Medicaid
                                                                                                                                                                        MI - Medigap Part B
                                                                                                                                                                        MP - Medicare Primary
                                                                                                                                                                        OT - Other
                                                                                                                                                                        PP - Personal Payment (Cash - No Insurance)
                                                                                                                                                                        SP - Supplemental Policy




    11/12/2010                                                                                                                                                                                                                                        Page: 17
   837P - 4010 - Inbound - 000                                                                             State of Nebraska MMIS
                                                                                                      Mapping Specifications Spreadsheet



                                                             Segment/                                                              Mandatory/    Field       Field
             Record                      Field    Loop ID                                    Element Description                                                                                           Valid Values
                                                             Element                                                               Situational   Size        Type
OTHERSUBSCRIBER                  SBR09                      SBR09       Claim Filing Indicator Code                                    S                 2    ID     09 - Self-pay
                                                                                                                                                                     10 - Central Certification (K)
                                                                                                                                                                     11 - Other Non-federal Programs
                                                                                                                                                                     12 - Preferred Provider Organization (PPO)
                                                                                                                                                                     13 - Point of Service (POS)
                                                                                                                                                                     14 - Exclusive Provider Organization (EPO)
                                                                                                                                                                     15 - Indemnity Insurance
                                                                                                                                                                     16 - Health Maintenance Organization (HMO) Medicare Risk
                                                                                                                                                                     AM - Automobile Medical
                                                                                                                                                                     BL - Blue Cross/Blue Shield
                                                                                                                                                                     CH - Champus
                                                                                                                                                                     CI - Commercial Insurance Co.
                                                                                                                                                                     DS - Disability
                                                                                                                                                                     HM - Health Maintenance Organization
                                                                                                                                                                     LI - Liability
                                                                                                                                                                     LM - Liability Medical
                                                                                                                                                                     MB - Medicare Part B
                                                                                                                                                                     MC - Medicaid
                                                                                                                                                                     OF - Other Frederal Program
                                                                                                                                                                     TV - Titile V
                                                                                                                                                                     VA - Veterans Administration Plan
                                                                                                                                                                     WC - Worker's Compensation Health Claim
                                                                                                                                                                     ZZ - Mutually Defined

                                                 2320       CAS         Claim Level Adjustment                                         S
ADJUSTMENT                       CAS01                      CAS01       Claim Adjustment Group Code                                    M                 2    ID     CO - Contractual Obligations
                                                                                                                                                                     CR - Correction and Reversals
                                                                                                                                                                     OA - Other Adjustments
                                                                                                                                                                     PI - Payor Initiated Reductions
                                                                                                                                                                     PR - Patient Responsibility
ADJUSTMENT                       CAS02                      CAS02       Claim Adjustment Reason Code                                   M             5        ID
ADJUSTMENT                       CAS03                      CAS03       Monetary Amount                                                M            18        R
ADJUSTMENT                       CAS04                      CAS04       Quantity                                                       S            15        R
ADJUSTMENT                       CAS05                      CAS05       Claim Adjustment Reason Code                                   S             5        ID
ADJUSTMENT                       CAS06                      CAS06       Monetary Amount                                                S            18        R
ADJUSTMENT                       CAS07                      CAS07       Quantity                                                       S            15        R
ADJUSTMENT                       CAS08                      CAS08       Claim Adjustment Reason Code                                   S             5        ID
ADJUSTMENT                       CAS09                      CAS09       Monetary Amount                                                S            18        R
ADJUSTMENT                       CAS10                      CAS10       Quantity                                                       S            15        R
ADJUSTMENT                       CAS11                      CAS11       Claim Adjustment Reason Code                                   S             5        ID
ADJUSTMENT                       CAS12                      CAS12       Monetary Amount                                                S            18        R
ADJUSTMENT                       CAS13                      CAS13       Quantity                                                       S            15        R
ADJUSTMENT                       CAS14                      CAS14       Claim Adjustment Reason Code                                   S             5        ID
ADJUSTMENT                       CAS15                      CAS15       Monetary Amount                                                S            18        R
ADJUSTMENT                       CAS16                      CAS16       Quantity                                                       S            15        R
ADJUSTMENT                       CAS17                      CAS17       Claim Adjustment Reason Code                                   S             5        ID
ADJUSTMENT                       CAS18                      CAS18       Monetary Amount                                                S            18        R
ADJUSTMENT                       CAS19                      CAS19       Quantity                                                       S            15        R
                                                 2320       AMT         Coordination of Benefits (COB) Payer Paid Amount               S

AMOUNTS                          AMT01                      AMT01       Amount Qualifier Code                                          M             3        ID     D - Payer Amount Paid
AMOUNTS                          AMT02                      AMT02       Monetary Amount                                                M            18        R
                                                 2320       AMT         Coordination of Benefits (COB) Approved Amount                 S

AMOUNTS                          AMT01                      AMT01       Amount Qualifier Code                                          M             3        ID     AAE - Approved Amount
AMOUNTS                          AMT02                      AMT02       Monetary Amount                                                M            18        R
                                                 2320       AMT         Coordination of Benefits (COB) Allowed Amount                  S

AMOUNTS                          AMT01                      AMT01       Amount Qualifier Code                                          M             3        ID     B6 - Allowed - Actual
AMOUNTS                          AMT02                      AMT02       Monetary Amount                                                M            18        R
                                                 2320       AMT         Coordination of Benefits (COB) Patient Responsibility          S
                                                                        Amount
AMOUNTS                          AMT01                      AMT01       Amount Qualifier Code                                          M             3        ID     F2 - Patient Responsibilty - Actual
AMOUNTS                          AMT02                      AMT02       Monetary Amount                                                M            18        R
                                                 2320       AMT         Coordination of Benefirs (COB) Covered Amount                  S




    11/12/2010                                                                                                                                                                                                                  Page: 18
    837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                               Segment/                                                              Mandatory/    Field       Field
             Record                       Field    Loop ID                                    Element Description                                                                                             Valid Values
                                                               Element                                                               Situational   Size        Type
AMOUNTS                           AMT01                      AMT01        Amount Qualifier Code                                          M             3        ID     AU - Coverage Amoun
AMOUNTS                           AMT02                      AMT02        Monetary Amount                                                M            18        R
                                                  2320       AMT          Coordination of Benefirs (COB) Discount Amount                 S

AMOUNTS                           AMT01                      AMT01        Amount Qualifier Code                                          M             3        ID     D8 - Discount Amoun
AMOUNTS                           AMT02                      AMT02        Monetary Amount                                                M            18        R
                                                  2320       AMT          Coordination of Benefirs (COB) Per Day Limit Amount            S

AMOUNTS                           AMT01                      AMT01        Amount Qualifier Code                                          M             3        ID     DY - Per Day Limit
AMOUNTS                           AMT02                      AMT02        Monetary Amount                                                M            18        R
                                                  2320       AMT          Coordination of Benefirs (COB) Patient Paid Amount             S

AMOUNTS                           AMT01                      AMT01        Amount Qualifier Code                                          M             3        ID     F5 - Patient Amount Paid
AMOUNTS                           AMT02                      AMT02        Monetary Amount                                                M            18        R
                                                  2320       AMT          Coordination of Benefirs (COB) Tax Amount                      S
AMOUNTS                           AMT01                      AMT01        Amount Qualifier Code                                          M             3        ID     T - Tax
AMOUNTS                           AMT02                      AMT02        Monetary Amount                                                M            18        R
                                                  2320       AMT          Coordination of Benefirs (COB) Total Claim Before Taxes        S
                                                                          Amount
AMOUNTS                           AMT01                      AMT01        Amount Qualifier Code                                          M             3        ID     T2 - Total Claim Before Taxes
AMOUNTS                           AMT02                      AMT02        Monetary Amount                                                M            18        R
                                                  2320       DMG          Subscriber Demographic Information                             S
OTHERSUBSCRIBER                   DMG01                      DMG01        Date Time Period Format Qualifier                              M             3       ID      D8 - Date expressed in format CCYYMMDD
OTHERSUBSCRIBER                   DMG02                      DMG02        Date Time Period                                               M            35       AN
OTHERSUBSCRIBER                   DMG03                      DMG03        Gender Code                                                    M             1       ID      F - Female
                                                                                                                                                                       M - Male
                                                                                                                                                                       U - Unknown
                                                  2320       OI           Other Insurance Coverage Information                           M
OTHERSUBSCRIBER                   OI03                       OI03         Yes/No Condition or Response Code                              M                 1    ID     N - No
                                                                                                                                                                       Y - Yes
OTHERSUBSCRIBER                   OI04                       OI04         Patient Signature Source Code                                  S                 1    ID     B - Signed signature authorization form or forms for both HCFA-1500 claim form block
                                                                                                                                                                       12 and block 13 are on file.
                                                                                                                                                                       C - Signed HCFA-1500 Claim form on file
                                                                                                                                                                       M - Signed signature authorization form for HCFA-1500 Claim form block 13 on file
                                                                                                                                                                       P - Signature generated by provider because the patient was not physically present for
                                                                                                                                                                       services
                                                                                                                                                                       S - Signed signature authorization form for HCFA-1500 claim form block 12 on file.



OTHERSUBSCRIBER                   OI06                       OI06         Release of Information Code                                    M                 1    ID     A - Appropriate release of information on file at health care service provider or at
                                                                                                                                                                       utilization review organization
                                                                                                                                                                       I -Informed consent to release medical information for conditions or diagnosis
                                                                                                                                                                       regulated by federal statutes
                                                                                                                                                                       M - The provider has limited or restricted ability to release data related to a claim
                                                                                                                                                                       N - No, provider is not allowed to release data
                                                                                                                                                                       O - On file at payor or at plan sponsor
                                                                                                                                                                       Y - Yes, provider has a signed statement permitting release of medical billing data
                                                                                                                                                                       related to a claim

                                                  2320       MOA          Medicare Outpatient Adjudication Information                   S
OTHERSUBSCRIBER                   MOA01                      MOA01        Percent                                                        S            10       R
OTHERSUBSCRIBER                   MOA02                      MOA02        Monetary Amount                                                S            18       R
OTHERSUBSCRIBER                   MOA03                      MOA03        Reference Identification                                       S            30       AN
OTHERSUBSCRIBER                   MOA04                      MOA04        Reference Identification                                       S            30       AN
OTHERSUBSCRIBER                   MOA05                      MOA05        Reference Identification                                       S            30       AN
OTHERSUBSCRIBER                   MOA06                      MOA06        Reference Identification                                       S            30       AN
OTHERSUBSCRIBER                   MOA07                      MOA07        Reference Identification                                       S            30       AN
OTHERSUBSCRIBER                   MOA08                      MOA08        Monetary Amount                                                S            18       R
OTHERSUBSCRIBER                   MOA09                      MOA09        Monetary Amount                                                S            18       R
                                                  2330A      NM1          Other Subscriber Name                                          M
PROFILE                           NM101                      NM101        Entity ID Code                                                 M                 3    ID     IL - Isured or Subscriber
PROFILE                           NM102                      NM102        Entity Type Qualifier                                          M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-Person Entity
PROFILE                           NM103                      NM103        Name Last or Organization Name                                 M            35       AN
PROFILE                           NM104                      NM104        Name First                                                     S            25       AN




    11/12/2010                                                                                                                                                                                                                                                 Page: 19
    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                              Segment/                                                                Mandatory/    Field       Field
             Record                       Field    Loop ID                                      Element Description                                                                                           Valid Values
                                                              Element                                                                 Situational   Size        Type
PROFILE                           NM105                      NM105       Name Middle                                                      S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                      S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S             2       ID      MI - Member Identification Number
                                                                                                                                                                        ZZ - Mutually Defined
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN
                                                  2330A      N3          Other Subscriber Address                                         S
PROFILE                           N301                       N301        Address Information                                              M            55       AN
PROFILE                           N302                       N302        Address Information                                              S            55       AN
                                                  2330A      N4          Other Subscriber City/State/Zip Code                             S
PROFILE                           N401                       N401        City Name                                                        M            30       AN
PROFILE                           N402                       N402        State or Province Code                                           M             2       ID
PROFILE                           N403                       N403        Postal Code                                                      M            15       AN
PROFILE                           N404                       N404        Country Code                                                     S             3       AN
                                                  2330A      REF         Other Subscriber Secondary Information                           S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                                M                 3    ID     1W - Member Identification Number
                                                                                                                                                                        23 - Client Number
                                                                                                                                                                        SY - Social Security Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2330B      NM1         Other Payer Name                                                 M
PROFILE                           NM101                      NM101       Entity ID Code                                                   M             3       ID      PR - Payer
PROFILE                           NM102                      NM102       Entity Type Qualifier                                            M             1       ID      2 - Non-Person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                   M            35       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S             2       ID      PI - Payor Identification
                                                                                                                                                                        XV - Health Care Financing Adminstration National PlanID
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN
                                                  2330B      PER         Other Payer Contact Information                                  S
CONTACT                           PER01                      PER01       Contact Function Code                                            M             2       ID      IC - Information Contact
CONTACT                           PER02                      PER02       Name                                                             M            60       AN
CONTACT                           PER03                      PER03       Communication Number Qualifier                                   M             2       ID      ED - Electronic Data Interchange Access Number
                                                                                                                                                                        EM - Electronic Mail
                                                                                                                                                                        FX - Facsimile
                                                                                                                                                                        TE - Telephone
CONTACT                           PER04                      PER04       Communication Number                                             M            80       AN
CONTACT                           PER05                      PER05       Communication Number Qualifier                                   S             2       ID      ED - Electronic Data Interchange Access Number
                                                                                                                                                                        EM - Electronic Mail
                                                                                                                                                                        EX - Telephone Extension
                                                                                                                                                                        FX - Facsimile
                                                                                                                                                                        TE - Telephone
CONTACT                           PER06                      PER06       Communication Number                                             S            80       AN
CONTACT                           PER07                      PER07       Communication Number Qualifier                                   S             2       ID      ED - Electronic Data Interchange Access Number
                                                                                                                                                                        EM - Electronic Mail
                                                                                                                                                                        EX - Telephone Extension
                                                                                                                                                                        FX - Facsimile
                                                                                                                                                                        TE - Telephone
CONTACT                           PER08                      PER08       Communication Number                                             S            80       AN
                                                  2330B      DTP         Claim Adjudication Date                                          S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                              M             3       ID      573 - Date Claim Paid
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                                M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                                 M            35       AN
                                                  2330B      REF         Other Payer Secondary Identification                             S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                                M                 3    ID     2U - Payer Identification Number
                                                                                                                                                                        F8 - Original Reference Number
                                                                                                                                                                        FY - Claim Office Number
                                                                                                                                                                        NF - National Association of Insurance Commissioners (NAIC) code.
                                                                                                                                                                        TJ - Federal Taxpayer's Identification Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2330B      REF         Other Payer Prior Authorization and Referral Number              S

REFERENCE                         REF01                      REF01       Reference Identification Qualifer                                M                 3    ID     9F - Referral Number
                                                                                                                                                                        G1 - Prior Authorization Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2330B      REF         Other Payer Claim Adjustment Indicator                           S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                                M             3       ID      T4 - Signal Code
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN      Y - Indicates this claim has previously been adjudicated.
                                                  2330C      NM1         Other Payer Patient Information                                  S




    11/12/2010                                                                                                                                                                                                                              Page: 20
    837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                              Segment/                                                               Mandatory/    Field       Field
             Record                       Field    Loop ID                                       Element Description                                                                                         Valid Values
                                                              Element                                                                Situational   Size        Type
PROFILE                           NM101                      NM101       Entity ID Code                                                  M             3       ID      QC - Patient
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M             1       ID      1 - Person
PROFILE                           NM108                      NM108       Identification Code Qualifier                                   M             2       ID      MI - Member Identification Number
PROFILE                           NM109                      NM109       Identification Code                                             M            80       AN
                                                  2330C      REF         Other Payer Patient Identification Number                       S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                               M                 3    ID     1W - Member Identification Number
                                                                                                                                                                       23 - Client Number
                                                                                                                                                                       IG - Insurance Policy Number
                                                                                                                                                                       SY - Social Security Number
REFERENCE                         REF02                      REF02       Reference Identification                                        M            30       AN
                                                  2330D      NM1         Other Payer Referring Provider                                  S
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     DN - Referring Provider - 1st iteration of loop
                                                                                                                                                                       P3 - Primary Care Provider - 2nd iteration of loop
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-Person Entity
                                                  2330D      REF         Other Payer Referring Provider Identification                   M
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                               M                 3    ID     1B - Blue Shield Provider Number
                                                                                                                                                                       1C - Medicare Provider Number
                                                                                                                                                                       1D - Medicaid Provider Number
                                                                                                                                                                       EI - Employer's Identification Number
                                                                                                                                                                       G2 - Provider Commercial Number
                                                                                                                                                                       LU - Location Number
                                                                                                                                                                       N5 - Provider Plan Network Identification Number
REFERENCE                         REF02                      REF02       Reference Identification                                        M            30       AN
                                                  2330E      NM1         Other Payer Rendering Provider                                  S
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     82 - Rendering Provider
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-Person Entity
                                                  2330E      REF         Other Payer Rendering Provider Secondary Identification         M

REFERENCE                         REF01                      REF01       Reference Identification Qualifer                               M                 3    ID     1B - Blue Shield Provider Number
                                                                                                                                                                       1C - Medicare Provider Number
                                                                                                                                                                       1D - Medicaid Provider Number
                                                                                                                                                                       EI - Employer's Identification Number
                                                                                                                                                                       G2 - Provider Commercial Number
                                                                                                                                                                       LU - Location Number
                                                                                                                                                                       N5 - Provider Plan Network Identification Number
REFERENCE                         REF02                      REF02       Reference Identification                                        M            30       AN
                                                  2330F      NM1         Other Payer Purchased Service Provider                          S
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     QB - Purchase Service Provider
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                                                                                                                                       2 - Non-Person Entity
                                                  2330F      REF         Other Payer Purchased Service Provider Identification           M
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                               M                 3    ID     1A - Blue Cross Provider Number
                                                                                                                                                                       1B - Blue Shield Provider Number
                                                                                                                                                                       1C - Medicare Provider Number
                                                                                                                                                                       1D - Medicaid Provider Number
                                                                                                                                                                       EI - Employer's Identification Number
                                                                                                                                                                       G2 - Provider Commercial Number
                                                                                                                                                                       LU - Location Number
                                                                                                                                                                       N5 - Provider Plan Network Identification Number
REFERENCE                         REF02                      REF02       Reference Identification                                        M            30       AN
                                                  2330G      NM1         Other Payer Service Facility Location                           S
PROFILE                           NM101                      NM101       Entity ID Code                                                  M                 3    ID     77 - Service Location
                                                                                                                                                                       FA - Faicility
                                                                                                                                                                       LI - Independent Lab
                                                                                                                                                                       TL - Testing Laboratory
PROFILE                           NM102                      NM102       Entity Type Qualifier                                           M                 1    ID     2 - Non-Person Entity
                                                  2330G      REF         Other Payer Service Facility Location Identification            M




    11/12/2010                                                                                                                                                                                                              Page: 21
    837P - 4010 - Inbound - 000                                                                                State of Nebraska MMIS
                                                                                                          Mapping Specifications Spreadsheet



                                                                Segment/                                                               Mandatory/    Field       Field
              Record                        Field    Loop ID                                     Element Description                                                                                          Valid Values
                                                                Element                                                                Situational   Size        Type
REFERENCE                         REF01                        REF01       Reference Identification Qualifer                               M                 3    ID     1A - Blue Cross Provider Number
                                                                                                                                                                         1B - Blue Shield Provider Number
                                                                                                                                                                         1C - Medicare Provider Number
                                                                                                                                                                         1D - Medicaid Provider Number
                                                                                                                                                                         G2 - Provider Commercial Number
                                                                                                                                                                         LU - Location Number
                                                                                                                                                                         N5 - Provider Plan Network Identification Number
REFERENCE                         REF02                        REF02       Reference Identification                                        M            30       AN
                                                    2330H      NM1         Other Payer Supervising Provider                                S
PROFILE                           NM101                        NM101       Entity ID Code                                                  M                 3    ID     DQ - Supervising Physician
PROFILE                           NM102                        NM102       Entity Type Qualifier                                           M                 1    ID     1 - Person
                                                    2330H      REF         Other Payer Referring Provider Identification                   M
REFERENCE                         REF01                        REF01       Reference Identification Qualifer                               M                 3    ID     1B - Blue Shield Provider Number
                                                                                                                                                                         1C - Medicare Provider Number
                                                                                                                                                                         1D - Medicaid Provider Number
                                                                                                                                                                         EI - Employer's Identification Number
                                                                                                                                                                         G2 - Provider Commercial Number
                                                                                                                                                                         N5 - Provider Plan Network Identification Number
REFERENCE                         REF02                        REF02       Reference Identification                                        M            30       AN
                                                    2400       LX          Service Line Number                                             M
SERVICELINE                       LX01                         LX01        Assigned Number                                                 M                 6    N0     Incremented one for each new LX segment within a claim
                                                    2400       SV1         Professsional Service                                           M
SERVICELINE                       SV101-1                      SV101-1     Product/Service ID Qualifier                                    M                 2    ID     HC - Health Care Financing Admistration Common Procedural Coding System
                                                                                                                                                                         (HCPCS) Codes
                                                                                                                                                                         IV - Home Infusion EDI Coalition (HIEC) Product/Service Code
                                                                                                                                                                         N4 - National Drug Code in 5-4-2 format - Only used if J codes are not allowed for use
                                                                                                                                                                         under HIPAA.
                                                                                                                                                                         ZZ - Mutually Defined - Use code to convey the Health Insurance Prospective Payment
                                                                                                                                                                         System (HIPPS) Skilled Nursing Facility Rate Code.
SERVICELINE                       SV101-2                      SV101-2     Product/Service ID                                              M            48       AN
SERVICELINE                       SV101-3                      SV101-3     Procedure Modifier                                              S             2       AN
SERVICELINE                       SV101-4                      SV101-4     Procedure Modifier                                              S             2       AN
SERVICELINE                       SV101-5                      SV101-5     Procedure Modifier                                              S             2       AN
SERVICELINE                       SV101-6                      SV101-6     Procedure Modifier                                              S             2       AN
SERVICELINE                       SV102                        SV102       Monetary Amount                                                 M            18       R
SERVICELINE                       SV103                        SV103       Unit or Basis for Measurement Code                              M             2       ID      F2 - International Unit
                                                                                                                                                                         MJ - Minutes
                                                                                                                                                                         UN - Unit
SERVICELINE                       SV104                        SV104       Quantity                                                        M            15       R
SERVICELINE                       SV105                        SV105       Facility Code Value                                             S             2       AN
                                                               SV107       Composite Field                                                 S
SERVICELINE                       SV107-1                      SV107-1     Diagnosis Code Pointer                                          M                 2    N0
SERVICELINE                       SV107-2                      SV107-2     Diagnosis Code Pointer                                          S                 2    N0
SERVICELINE                       SV107-3                      SV107-3     Diagnosis Code Pointer                                          S                 2    N0
SERVICELINE                       SV107-4                      SV107-4     Diagnosis Code Pointer                                          S                 2    N0
SERVICELINE                       SV109                        SV109       Yes/No Condition or Response Code                               S                 1    ID     Y - Yes
SERVICELINE                       SV111                        SV111       Yes/No Condition or Response Code                               S                 1    ID     Y - Yes
SERVICELINE                       SV112                        SV112       Yes/No Condition or Response Code                               S                 1    ID     Y - Yes
SERVICELINE                       SV115                        SV115       Copay Status Code                                               S                 1    ID     0 - Copay Exempt
                                                    2400       SV5         Durable Medical Equipment Service                               S
SERVICELINE                       SV501-1                      SV501-1     Product/Service ID Qualifier                                    M             2       ID      HC - Health Care Financing Admistration Common Procedural Coding System
SERVICELINE                       SV501-2                      SV501-2     Product/Service ID                                              M            48       AN      (HCPCS) Codes
SERVICELINE                       SV502                        SV502       Unit or Basis for Measurement Code                              M             2       ID      DA - Days
SERVICELINE                       SV503                        SV503       Quantity                                                        M            15       R
SERVICELINE                       SV504                        SV504       Monetary Amount                                                 S            18       R
SERVICELINE                       SV505                        SV505       Monetary Amount                                                 S            18       R
SERVICELINE                       SV506                        SV506       Frequency Code                                                  S             1       ID      1 - Weekly
                                                                                                                                                                         4 - Monthly
                                                                                                                                                                         6 - Daily
                                                    2400       PWK         DMERC CMN Indicator                                             S
PAPERWORK                         PWK01                        PWK01       Report Type Code                                                M                 2    ID     CT - Certification




    11/12/2010                                                                                                                                                                                                                                              Page: 22
      837P - 4010 - Inbound - 000                                                                            State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                                Segment/                                                             Mandatory/    Field       Field
               Record                       Field    Loop ID                                   Element Description                                                                                            Valid Values
                                                                Element                                                              Situational   Size        Type
PAPERWORK                           PWK02                      PWK02       Report Transmission Code                                      M                 2    ID     AB - Previously submitted to payer
                                                                                                                                                                       AD - Certification included in this claim
                                                                                                                                                                       AF - Narrative segment included in this claim
                                                                                                                                                                       AG - No documentation is required
                                                                                                                                                                       NS - Not Specified
                                                    2400       CR1         Ambulance Transport Information                               S
SERVICELINE                         CR101                      CR101       Unit or Basis for Measurement Code                            S             2        ID     LB - Pound
SERVICELINE                         CR102                      CR102       Weight                                                        S            10        R
SERVICELINE                         CR103                      CR103       Ambulance Transport Code                                      M             1        ID     I - Initial Trip
                                                                                                                                                                       R - Return Trip
                                                                                                                                                                       T - Transfer Trip
                                                                                                                                                                       X - Round Trip
SERVICELINE                         CR104                      CR104       Ambulance Transport Reason Code                               M                 1    ID     A - Patient was transported to nearest facility for care of symptons, complaints or both.
                                                                                                                                                                       B - Patient was transported for the benefit of a preferred physician.
                                                                                                                                                                       C - Patient was transported for the nearness of family members.
                                                                                                                                                                       D - Patient was transported for the care of a specialist or for availability of speacialized
                                                                                                                                                                       equipment.
                                                                                                                                                                       E - Patient transferred to rehabilitation facility.

SERVICELINE                         CR105                      CR105       Unit or Basis for Measurement Code                            M             2       OD      DH - Miles
SERVICELINE                         CR106                      CR106       Quantity                                                      M            15        R
SERVICELINE                         CR109                      CR109       Description                                                   S            80       AN
SERVICELINE                         CR110                      CR110       Description                                                   S            80       AN
                                                    2400       CR2         Spinal Manipulation Service Information                       S
SPINAL                              CR208                      CR208       Nature of Condition Code                                      M                 1    ID     A - Acute Condition
                                                                                                                                                                       C - Chronic Condition
                                                                                                                                                                       D - Non-acute
                                                                                                                                                                       E - Non-life Threatending
                                                                                                                                                                       F - Routine
                                                                                                                                                                       G - Symptomatic
                                                                                                                                                                       M - Acute Manifestation of a Chronic Condition
SPINAL                              CR210                      CR210       Description                                                   S            80       AN
SPINAL                              CR211                      CR211       Description                                                   S            80       AN
SPINAL                              CR212                      CR212       Yes/No Condition or Response Code                             S             1       ID      N - No
                                                                                                                                                                       Y - Yes
                                                    2400       CR3         Durable Medical Equipment Certification                       S
SERVICELINE                         CR301                      CR301       Certification Type Code                                       M                 1    ID     I - Initial
                                                                                                                                                                       R - Renewal
                                                                                                                                                                       S - Revised
SERVICELINE                         CR302                      CR302       Unit or Basis for Measurement Code                            M             2        ID     MO - Months
SERVICELINE                         CR303                      CR303       Quantity                                                      M            15        R
                                                    2400       CR5         Home Oxygen Therapy Information                               S
SERVICELINE                         CR501                      CR501       Certification Type Code                                       M                 1    ID     I - Initial
                                                                                                                                                                       R - Renewal
                                                                                                                                                                       S - Revised
SERVICELINE                         CR502                      CR502       Quantity                                                      M            15        R
SERVICELINE                         CR510                      CR510       Quantity                                                      S            15        R
SERVICELINE                         CR511                      CR511       Quantity                                                      S            15        R
SERVICELINE                         CR512                      CR512       Oxygen Test Condition Code                                    M             1        ID     E - Exercising
                                                                                                                                                                       R - At rest on room air
                                                                                                                                                                       S - Sleeping
SERVICELINE                         CR513                      CR513       Oxygen Test Findings Code                                     S                 1    ID     1 - Dependent edema suggesting congestive heart failure.
SERVICELINE                         CR514                      CR514       Oxygen Test Findings Code                                     S                 1    ID     2 - "P" Pulmonale on Electrocardiogram
SERVICELINE                         CR515                      CR515       Oxygen Test Findings Code                                     S                 1    ID     3 - Erythrocythemia with a hematocrit greater than 56%
                                                    2400       CRC         Ambulance Certification                                       S
CRC                                 CRC01                      CRC01       Code Category                                                 M                 2    ID     07 - Ambulance Certification
CRC                                 CRC02                      CRC02       Yes/No Condition or Response Code                             M                 1    ID     N - No
                                                                                                                                                                       Y - Yes




      11/12/2010                                                                                                                                                                                                                                                Page: 23
      837P - 4010 - Inbound - 000                                                                            State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                                Segment/                                                             Mandatory/    Field       Field
               Record                       Field    Loop ID                                     Element Description                                                                                           Valid Values
                                                                Element                                                              Situational   Size        Type
CRC                                 CRC03                      CRC03       Condition Indicator                                           M                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
CRC                                 CRC04                      CRC04       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
CRC                                 CRC05                      CRC05       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
CRC                                 CRC06                      CRC06       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
CRC                                 CRC07                      CRC07       Condition Indicator                                           S                 2    ID     01 - Patient was admitted to a hospital
                                                                                                                                                                       02 - Patient was bed confined before the ambulance service
                                                                                                                                                                       03 - Patient was bed confined after the ambulance service
                                                                                                                                                                       04 - Patient was moved by stretcher
                                                                                                                                                                       05 - Patient was unconscious or in shock
                                                                                                                                                                       06 - Patient was transported in an emergency situation
                                                                                                                                                                       07 - Patient had to be physically restrained
                                                                                                                                                                       08 - Patient has visable hemorrhaging
                                                                                                                                                                       09 - Ambulance service was medically necessary
                                                                                                                                                                       60 - Transportation was to the nearest facility
                                                    2400       CRC         Hospice Employee Indicator                                    S
CRC                                 CRC01                      CRC01       Code Category                                                 M                 2    ID     70 - Hospice
CRC                                 CRC02                      CRC02       Yes/No Condition or Response Code                             M                 1    ID     N - No
                                                                                                                                                                       Y - Yes
CRC                                 CRC03                      CRC03       Condition Indicator                                           M                 2    ID     65 - Open
                                                    2400       CRC         DMERC Condition Indicator                                     S
CRC                                 CRC01                      CRC01       Code Category                                                 M                 2    ID     09 - Durable Medical Equipment Certification
                                                                                                                                                                       11 - Oxygen Therapy Certification
CRC                                 CRC02                      CRC02       Yes/No Condition or Response Code                             M                 1    ID     N - No
                                                                                                                                                                       Y - Yes
CRC                                 CRC03                      CRC03       Condition Indicator                                           M                 2    ID     37 - Oxygen delivery equipment is stationary
                                                                                                                                                                       38 - Certification signed by the physician is on file at the supplier's office
                                                                                                                                                                       AL - Ambulation Limitations
                                                                                                                                                                       P1 - Patient was discharged for the first facility
                                                                                                                                                                       ZV - Replacement Item




      11/12/2010                                                                                                                                                                                                                                        Page: 24
      837P - 4010 - Inbound - 000                                                                            State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                                Segment/                                                             Mandatory/    Field       Field
               Record                       Field    Loop ID                                     Element Description                                                                                           Valid Values
                                                                Element                                                              Situational   Size        Type
CRC                                 CRC04                      CRC04       Condition Indicator                                           S                 2    ID     37 - Oxygen delivery equipment is stationary
                                                                                                                                                                       38 - Certification signed by the physician is on file at the supplier's office
                                                                                                                                                                       AL - Ambulation Limitations
                                                                                                                                                                       P1 - Patient was discharged for the first facility
                                                                                                                                                                       ZV - Replacement Item
CRC                                 CRC05                      CRC05       Condition Indicator                                           S                 2    ID     37 - Oxygen delivery equipment is stationary
                                                                                                                                                                       38 - Certification signed by the physician is on file at the supplier's office
                                                                                                                                                                       AL - Ambulation Limitations
                                                                                                                                                                       P1 - Patient was discharged for the first facility
                                                                                                                                                                       ZV - Replacement Item
CRC                                 CRC06                      CRC06       Condition Indicator                                           S                 2    ID     37 - Oxygen delivery equipment is stationary
                                                                                                                                                                       38 - Certification signed by the physician is on file at the supplier's office
                                                                                                                                                                       AL - Ambulation Limitations
                                                                                                                                                                       P1 - Patient was discharged for the first facility
                                                                                                                                                                       ZV - Replacement Item
CRC                                 CRC07                      CRC07       Condition Indicator                                           S                 2    ID     37 - Oxygen delivery equipment is stationary
                                                                                                                                                                       38 - Certification signed by the physician is on file at the supplier's office
                                                                                                                                                                       AL - Ambulation Limitations
                                                                                                                                                                       P1 - Patient was discharged for the first facility
                                                                                                                                                                       ZV - Replacement Item
                                                    2400       DTP         Date - Service Date                                           M
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M                 3    ID     472 - Service
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M                 3    ID     D8 - Date expressed in format CCYYMMDD
                                                                                                                                                                       RD8 - Range of dates expressed in format CCYYMMDD-CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Certification Revision Date                            S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M             3       ID      607 - Certification Revision
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Begin Therapy Date                                     S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M             3       ID      463 - Begin Therapy
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Last Certification Date                                S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M             3       ID      461 - Last Certification
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Date Last Seen                                         S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M             3       ID      304 - Latest Visit or Consultation
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Test                                                   S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M                 3    ID     738 - Most Recent Hemoglobin or Hematocrit or both
                                                                                                                                                                       739 - Most Recent Serum Creatine
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Oxygen Saturation/Arterial Blood Gas Test              S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M                 3    ID     119 - Test Performed
                                                                                                                                                                       480 - Arterial Blood Gas Test
                                                                                                                                                                       481 - Oxygen Saturation Test
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Shipped                                                S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M             3       ID      011 - Shipped
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Onset of Current Sympton/Illness                       S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M             3       ID      431 - Onset of Current Sympton or Illness
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Last X-Ray                                             S
DATES                               DTP01                      DTP01       Date/Time Qualifier                                           M             3       ID      455 - Last X-Ray
DATES                               DTP02                      DTP02       Date Time Period Format Qualifier                             M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                               DTP03                      DTP03       Date Time Period                                              M            35       AN
                                                    2400       DTP         Date - Acute Manifestation                                    S




      11/12/2010                                                                                                                                                                                                                                        Page: 25
    837P - 4010 - Inbound - 000                                                                          State of Nebraska MMIS
                                                                                                    Mapping Specifications Spreadsheet



                                                              Segment/                                                           Mandatory/    Field       Field
              Record                      Field    Loop ID                                   Element Description                                                                                        Valid Values
                                                              Element                                                            Situational   Size        Type
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      453 - Acute Manifestation of a Chronic Condition
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2400       DTP         Date - Initial Treatment                                    S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      454 - Initial Treatment
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2400       DTP         Date - Similar Illness/Sympton Onset                        S
DATES                             DTP01                      DTP01       Date/Time Qualifier                                         M             3       ID      438 - Onset of Similar Symptons or Illness
DATES                             DTP02                      DTP02       Date Time Period Format Qualifier                           M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                             DTP03                      DTP03       Date Time Period                                            M            35       AN
                                                  2400       MEA         Test Result                                                 S
TESTRESULTS                       MEA01                      MEA01       Measurement Reference ID Code                               M                 2    ID     OG - Original
                                                                                                                                                                   TR - Test Results
TESTRESULTS                       MEA02                      MEA02       Measurement Qualifier                                       M                 3    ID     GRA - Gas Test Rate
                                                                                                                                                                   HT - Height
                                                                                                                                                                   R1 - Hemoglobin
                                                                                                                                                                   R2 - Hematocrit
                                                                                                                                                                   R3 - Epoetin Starting Dosage
                                                                                                                                                                   R4 - Creatin
                                                                                                                                                                   ZO - Oxygen
TESTRESULTS                       MEA03                      MEA03       Measurement Value                                           M            20        R
                                                  2400       CN1         Contract Information                                        S
SERVICELINE                       CN101                      CN101       Contract Type Code                                          M                 2    ID     01 - Diagnosis Related Group (DRG)
                                                                                                                                                                   02 - Per Diem
                                                                                                                                                                   03 - Variable Per Diem
                                                                                                                                                                   04 - Flat
                                                                                                                                                                   05 - Capitiated
                                                                                                                                                                   06 - Percent
                                                                                                                                                                   09 - Other
SERVICELINE                       CN102                      CN102       Monetary Amount                                             S            18       R
SERVICELINE                       CN103                      CN103       Percent                                                     S             6       R
SERVICELINE                       CN104                      CN104       Reference Information                                       S            30       AN
SERVICELINE                       CN105                      CN105       Terms Discount Percent                                      S             6       R
SERVICELINE                       CN106                      CN106       Version Identifier                                          S            30       AN
                                                  2400       REF         Repriced Line Item Reference Number                         S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      9B - Repriced Line Item Reference Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Adjusted Repriced Line Item Reference Number                S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      9D - Adjusted Repriced Line Item Reference Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Prior Authorization Or Referral Number                      S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M                 3    ID     9F - Referral Number
                                                                                                                                                                   G1 - Prior Authorization Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Line Item Control Number                                    S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      6R - Provider Control Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Mammography Certification Number                            S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      EW - Mammography Certification Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Clinical Laboratory Improvement Amendment (CLIA)            S
                                                                         Indentification
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      X4 - Clinical Laboratory Improvement Amendment Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Referring Clinical Laboratory Improvement Amendment         S
                                                                         (CLIA) Facility Identification
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      F4 - Faciltiy Certification Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Immuzation Batch Number                                     S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      BT - Batch Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2400       REF         Ambulatory Patient Group (APG)                              S
REFERENCE                         REF01                      REF01       Reference Identification Qualifer                           M             3       ID      1S - Ambulatory Patient Group Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN




    11/12/2010                                                                                                                                                                                                             Page: 26
       837P - 4010 - Inbound - 000                                                                          State of Nebraska MMIS
                                                                                                       Mapping Specifications Spreadsheet



                                                                 Segment/                                                           Mandatory/    Field       Field
                Record                       Field    Loop ID                                   Element Description                                                                                        Valid Values
                                                                 Element                                                            Situational   Size        Type
                                                     2400       REF         Oxygen Flow Rate                                            S
REFERENCE                            REF01                      REF01       Reference Identification Qualifer                           M             3       ID      TP - Test Specification Number
REFERENCE                            REF02                      REF02       Reference Identification                                    M            30       AN
                                                     2400       REF         Universal Product Number (UPN)                              S
REFERENCE                            REF01                      REF01       Reference Identification Qualifer                           M                 3    ID     OZ - Product Number
                                                                                                                                                                      VP - Vender Product Number
REFERENCE                            REF02                      REF02       Reference Identification                                    M            30       AN
                                                     2400       AMT         Sales Tax Amount                                            S
AMOUNTS                              AMT01                      AMT01       Amount Qualifier Code                                       M             3        ID     T - Tax
AMOUNTS                              AMT02                      AMT02       Monetary Amount                                             M            18        R
                                                     2400       AMT         Approved Amount                                             S
AMOUNTS                              AMT01                      AMT01       Amount Qualifier Code                                       M             3        ID     AAE - Approved Amount
AMOUNTS                              AMT02                      AMT02       Monetary Amount                                             M            18        R
                                                     2400       AMT         Postage Claimed Amount                                      S
AMOUNTS                              AMT01                      AMT01       Amount Qualifier Code                                       M             3        ID     F4 - Postage Claimed
AMOUNTS                              AMT02                      AMT02       Monetary Amount                                             M            18        R
                                                     2400       K3          File Information                                            S
INFO                                 K301                       K301        Fixed Format Information                                    M            80       AN
                                                     2400       NTE         Line Note                                                   S
INFO                                 NTE01                      NTE01       Note Reference Code                                         M                 3    ID     ADD - Additional Information
                                                                                                                                                                      DCP - Goals, Rehabilitation Potential or Discharge Plans
                                                                                                                                                                      PMT - Payment
                                                                                                                                                                      TPO - Third Party
INFO                                 NTE02                      NTE02       Description                                                 M            80       AN
                                                     2400       PS1         Purchased Service Information                               S
SERVICELINE                          PS101                      PS101       Reference Identification                                    M            30       AN
SERVICELINE                          PS102                      PS102       Monetary Amount                                             M            18       R
                                                     2400       HSD         Health Care Services Delivery                               S
SERVICELINE                          HSD01                      HSD01       Quantity Qualifier                                          S             2        ID     VS - Visits
SERVICELINE                          HSD02                      HSD02       Quantity                                                    S            15        R
SERVICELINE                          HSD03                      HSD03       Unit or Basis for Measurement Code                          S             2        ID     DA - Days
                                                                                                                                                                      MO - Months
                                                                                                                                                                      Q1 - Quarter Time
                                                                                                                                                                      WK - Week
SERVICELINE                          HSD04                      HSD04       Sample Selection Modulus                                    S                 6    R
SERVICELINE                          HSD05                      HSD05       Time Period Qualifier                                       S                 2    ID     7 - Day
                                                                                                                                                                      34 - Month
                                                                                                                                                                      35 - Week
SERVICELINE                          HSD06                      HSD06       Number of Periods                                           S                 3    N0




       11/12/2010                                                                                                                                                                                                                Page: 27
    837P - 4010 - Inbound - 000                                                                              State of Nebraska MMIS
                                                                                                        Mapping Specifications Spreadsheet



                                                              Segment/                                                               Mandatory/    Field       Field
              Record                      Field    Loop ID                                     Element Description                                                                                          Valid Values
                                                              Element                                                                Situational   Size        Type
SERVICELINE                       HSD07                      HSD07       Ship/Delivery or Calendar Pattern Code                          S                 2    ID     1 - 1st week of the month
                                                                                                                                                                       2 - 2nd week of the month
                                                                                                                                                                       3 - 3rd week of the month
                                                                                                                                                                       4 - 4th week of the month
                                                                                                                                                                       5 - 5th week of the month
                                                                                                                                                                       6 - 1st and 3rd weeks of the month
                                                                                                                                                                       7 - 2nd and 4th weeks of the month
                                                                                                                                                                       A - Monday through Friday
                                                                                                                                                                       B - Monday through Saturday
                                                                                                                                                                       C - Monday through Sunday
                                                                                                                                                                       D - Monday
                                                                                                                                                                       E - Tuesday
                                                                                                                                                                       F - Wednesday
                                                                                                                                                                       G - Thursday
                                                                                                                                                                       H - Friday
                                                                                                                                                                       J - Saturday
                                                                                                                                                                       K - Sunday
                                                                                                                                                                       L - Monday through Thursday
                                                                                                                                                                       N - As directed
                                                                                                                                                                       O - Daily Monday through Friday
                                                                                                                                                                       S - Once anytime Monday through Friday
                                                                                                                                                                       SA - Sunday, Monday, Thursday, Friday, Saturday
                                                                                                                                                                       SB - Tuesday through Saturday
                                                                                                                                                                       SC - Sunday, Wednesday, Thursday, Friday, Saturday
                                                                                                                                                                       SD - Monday, Wednesday, Thursday, Friday, Saturday
                                                                                                                                                                       SG - Tuesday through Friday
                                                                                                                                                                       SL - Monday, Tuesday and Thursday
                                                                                                                                                                       SP - Monday, Tuesday and Friday
                                                                                                                                                                       SX - Wednesday and Thursday
                                                                                                                                                                       SY - Monday, Wednesday and Thursday
                                                                                                                                                                       SZ - Tuesday, Thursday and Friday
                                                                                                                                                                       W - Whenever Necessary

SERVICELINE                       HSD08                      HSD08       Ship/Delivery Pattern Time Code                                 S                 1    ID
                                                  2400       HCP         Line Pricing/Repricing Information                              S
SERVICELINE                       HCP01                      HCP01       Pricing Methodology                                             M                 2    ID     00 - Zero Pricing
                                                                                                                                                                       01 - Priced as Billed at 100%
                                                                                                                                                                       02 - Priced at the standard fee schedule
                                                                                                                                                                       03 - Priced at a Contractural Percentage
                                                                                                                                                                       04 - Bundled Pricing
                                                                                                                                                                       05 - Peer Review Pricing
                                                                                                                                                                       06 - Per Diem Pricing
                                                                                                                                                                       07 - Flat Rate Pricing
                                                                                                                                                                       08 - Combination Pricing
                                                                                                                                                                       09 - Maternity Pricing
                                                                                                                                                                       10 - Other Pricing
                                                                                                                                                                       11 - Lower of Cost
                                                                                                                                                                       12 - Ratio of Cost
                                                                                                                                                                       13 - Cost Reimbursed
                                                                                                                                                                       14 - Adjustment Pricing
SERVICELINE                       HCP02                      HCP02       Monetary Amount                                                 M            18       R
SERVICELINE                       HCP03                      HCP03       Monetary Amount                                                 S            18       R
SERVICELINE                       HCP04                      HCP04       Reference Identification                                        S            30       AN
SERVICELINE                       HCP05                      HCP05       Rate                                                            S             9       R
SERVICELINE                       HCP06                      HCP06       Reference Identification                                        S            30       AN
SERVICELINE                       HCP07                      HCP07       Monetary Amount                                                 S            18       R
SERVICELINE                       HCP09                      HCP09       Product/Service ID Qualifier                                    S             2       ID      HC - Health Care Financing Adminstration Common Procedural Coding System
                                                                                                                                                                       (HCPCS) Codes
                                                                                                                                                                       IV - Home Infusion EDI Coalition (HIEC) Product/Service Code
                                                                                                                                                                       ZZ - Mutually Defined
SERVICELINE                       HCP10                      HCP10       Product/Service ID                                              S            48       AN
SERVICELINE                       HCP11                      HCP11       Unit or Basis for Measurement Code                              S             2       ID      DA - Days
                                                                                                                                                                       UN - Unit
SERVICELINE                       HCP12                      HCP12       Quantity                                                        S            15        R




    11/12/2010                                                                                                                                                                                                                                    Page: 28
    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                                Segment/                                                              Mandatory/    Field       Field
              Record                        Field    Loop ID                                     Element Description                                                                                         Valid Values
                                                                Element                                                               Situational   Size        Type
SERVICELINE                       HCP13                        HCP13       Rejected Reason Code                                           S                 2    ID     T1 - Cannot identify provider as TPO participant
                                                                                                                                                                        T2 - Cannot identify payer as TPO participant
                                                                                                                                                                        T3 - Cannot identify insured as TPO particpant
                                                                                                                                                                        T4 - Payer Name or Identifier Missing
                                                                                                                                                                        T5 - Certification Information Missing
                                                                                                                                                                        T6 - Claim doesn't contain enough information for repricing
SERVICELINE                       HCP14                        HCP14       Policy Compliance Code                                         S                 2    ID     1 - Procedure Followed (Compliance)
                                                                                                                                                                        2 - Not Followed - Call Not Made (Non-compliance call not made)
                                                                                                                                                                        3 - Not Medically Necessary (Non-compliance Non-medically necessary)
                                                                                                                                                                        4 - Not Followed Other (Non-compliance Other)
                                                                                                                                                                        5 - Emergency Admit to Non-Network Hospital
SERVICELINE                       HCP15                        HCP15       Exception Code                                                 S                 2    ID     1 - Non-network professional provider in network hospital
                                                                                                                                                                        2 - Emergency Care
                                                                                                                                                                        3 - Services or Specialist not in Network
                                                                                                                                                                        4 - Out-of-service Area
                                                                                                                                                                        5 - State Mandates
                                                                                                                                                                        6 - Other
                                                    2410       LIN         Drug Identification                                            S
DRUG                              LIN02                        LIN02       Time Period Qualifier                                          M             2       ID      N4 - National Drug Code in 5-4-2 Format
DRUG                              LIN03                        LIN03       Product/Service ID                                             M            48       AN
                                                    2410       CTP         Drug Pricing                                                   S
DRUG                              CTP03                        CTP03       Unit Price                                                     M            17        R
DRUG                              CTP04                        CTP04       Quantity                                                       M            15        R
DRUG                              CTP05-1                      CTP05-1     Unit or Basis for Measurement Code                             M             2        ID     F2 - International Unit
                                                                                                                                                                        GR - Gram
                                                                                                                                                                        ML - Milliliter
                                                                                                                                                                        UN - Unit
                                                    2410       REF         Presciption Number                                             S
REFERENCE                         REF01                        REF01       Reference Identification Qualifer                              M             3       ID      XZ - Pharmacy Prescription Number
REFERENCE                         REF02                        REF02       Reference Identification                                       M            30       AN
                                                    2420A      NM1         Rendering Provider Name                                        S
PROFILE                           NM101                        NM101       Entity ID Code                                                 M                 3    ID     82 - Rendering Provider
PROFILE                           NM102                        NM102       Entity Type Qualifier                                          M                 1    ID     1 - Person
                                                                                                                                                                        2 - Non-Person Entity
PROFILE                           NM103                        NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM104                        NM104       Name First                                                     S            25       AN
PROFILE                           NM105                        NM105       Name Middle                                                    S            25       AN
PROFILE                           NM107                        NM107       Name Suffix                                                    S            10       AN
PROFILE                           NM108                        NM108       Identification Code Qualifier                                  M             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                        NM109       Identification Code                                            M            80       AN
                                                    2420A      PRV         Rendering Provider Specialty Information                       S
PROFILE                           PRV01                        PRV01       Provider Code                                                  M             3       ID      PE - Performing
PROFILE                           PRV02                        PRV02       Reference Identification Qualifier                             M             3       ID      ZZ - Mutually defined
PROFILE                           PRV03                        PRV03       Reference Identification                                       M            30       AN
                                                    2420A      REF         Rendering Provider Secondary Identification                    S
REFERENCE                         REF01                        REF01       Reference Identification Qualifier                             M                 3    ID     0B - State License Number
                                                                                                                                                                        1B - Blue Shield Provider Number
                                                                                                                                                                        1C - Medicare Provider Number
                                                                                                                                                                        1D - Medicaid Provider Number
                                                                                                                                                                        1G - Provider UPIN Number
                                                                                                                                                                        1H - CHAMPUS Identification Number
                                                                                                                                                                        EI - Employer's Identification Number
                                                                                                                                                                        G2 - Provider Commercial Number
                                                                                                                                                                        LU - Location Number
                                                                                                                                                                        N5 - Provider Plan Network Identification Number
                                                                                                                                                                        SY - Social Security Number
                                                                                                                                                                        X5 - State Industrial Accident Payer Number
REFERENCE                         REF02                        REF02       Reference Identification                                       M            30       AN
                                                    2420B      NM1         Purchased Service Provider Name                                S
PROFILE                           NM101                        NM101       Entity ID Code                                                 M                 3    ID     QB - Purchase Service Provider
PROFILE                           NM102                        NM102       Entity Type Qualifier                                          M                 1    ID     1 - Person
                                                                                                                                                                        2 - Non-Person Entity




    11/12/2010                                                                                                                                                                                                                                        Page: 29
    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                              Segment/                                                                Mandatory/    Field       Field
             Record                       Field    Loop ID                                      Element Description                                                                                          Valid Values
                                                              Element                                                                 Situational   Size        Type
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S                 2    ID     24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN
                                                  2420B      REF         Purchased Service Provider Secondary Identification              S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                               M                 3    ID     0B - State License Number
                                                                                                                                                                        1A - Blue Cross Provider Number
                                                                                                                                                                        1B - Blue Shield Provider Number
                                                                                                                                                                        1C - Medicare Provider Number
                                                                                                                                                                        1D - Medicaid Provider Number
                                                                                                                                                                        1G - Provider UPIN Number
                                                                                                                                                                        1H - CHAMPUS Identification Number
                                                                                                                                                                        EI - Employer's Identification Number
                                                                                                                                                                        G2 - Provider Commercial Number
                                                                                                                                                                        LU - Location Number
                                                                                                                                                                        N5 - Provider Plan Network Identification Number
                                                                                                                                                                        SY - Social Security Number
                                                                                                                                                                        U3 - Unique Supplier Identification Number (USIN)
                                                                                                                                                                        X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2420C      NM1         Service Facility Location                                        S
PROFILE                           NM101                      NM101       Entity ID Code                                                   M                 3    ID     77 - Service Location
                                                                                                                                                                        FA - Facility
                                                                                                                                                                        LI - Independent Lab
                                                                                                                                                                        Tl - Testing Laboratory
PROFILE                           NM102                      NM102       Entity Type Qualifier                                            M             1       ID      2 - Non-Person Entity
PROFILE                           NM103                      NM103       Name Last or Organization Name                                   M            35       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN
                                                  2420C      N3          Service Facility Location Address                                M
PROFILE                           N301                       N301        Address Information                                              M            55       AN
PROFILE                           N302                       N302        Address Information                                              S            55       AN
                                                  2420C      N4          Service Facility Location City/State/Zip Code                    M
PROFILE                           N401                       N401        City Name                                                        M            30       AN
PROFILE                           N402                       N402        State or Province Code                                           M             2       ID
PROFILE                           N403                       N403        Postal Code                                                      M            15       AN
PROFILE                           N404                       N404        Country Code                                                     S             3       AN
                                                  2420C      REF         Service Facility Location Secondary Identification               S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                               M                 3    ID     0B - State License Number
                                                                                                                                                                        1A - Blue Cross Provider Number
                                                                                                                                                                        1B - Blue Shield Provider Number
                                                                                                                                                                        1C - Medicare Provider Number
                                                                                                                                                                        1D - Medicaid Provider Number
                                                                                                                                                                        1G - Provider UPIN Number
                                                                                                                                                                        1H - CHAMPUS Identification Number
                                                                                                                                                                        G2 - Provider Commercial Number
                                                                                                                                                                        LU - Location Number
                                                                                                                                                                        N5 - Provider Plan Network Identification Number
                                                                                                                                                                        TJ - Federal Taxpayer's Identification Number
                                                                                                                                                                        X4 - Clinical laboratory Identification Number
                                                                                                                                                                        X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                         M            30       AN
                                                  2420D      NM1         Supervising Provider Name                                        S
PROFILE                           NM101                      NM101       Entity ID Code                                                   M             3       ID      DQ - Supervising Physicain
PROFILE                           NM102                      NM102       Entity Type Qualifier                                            M             1       ID      1 - Person
PROFILE                           NM103                      NM103       Name Last or Organization Name                                   M            35       AN
PROFILE                           NM104                      NM104       Name First                                                       M            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                      S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                      S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                                    S             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                              S            80       AN




    11/12/2010                                                                                                                                                                                                                                        Page: 30
    837P - 4010 - Inbound - 000                                                                          State of Nebraska MMIS
                                                                                                    Mapping Specifications Spreadsheet



                                                              Segment/                                                           Mandatory/    Field       Field
             Record                       Field    Loop ID                                   Element Description                                                                                        Valid Values
                                                              Element                                                            Situational   Size        Type
                                                  2420D      REF         Supervising Provider Secondary Identification               S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                          M                 3    ID     0B - State License Number
                                                                                                                                                                   1B - Blue Shield Provider Number
                                                                                                                                                                   1C - Medicare Provider Number
                                                                                                                                                                   1D - Medicaid Provider Number
                                                                                                                                                                   1G - Provider UPIN Number
                                                                                                                                                                   1H - CHAMPUS Identification Number
                                                                                                                                                                   EI - Employer's Identification Number
                                                                                                                                                                   G2 - Provider Commercial Number
                                                                                                                                                                   LU - Location Number
                                                                                                                                                                   N5 - Provider Plan Network Identification Number
                                                                                                                                                                   SY - Social Security Number
                                                                                                                                                                   X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2420E      NM1         Ordering Provider Name                                      S
PROFILE                           NM101                      NM101       Entity ID Code                                              M             3       ID      DK - Ordering Physician
PROFILE                           NM102                      NM102       Entity Type Qualifier                                       M             1       ID      1 - Person
PROFILE                           NM103                      NM103       Name Last or Organization Name                              M            35       AN
PROFILE                           NM104                      NM104       Name First                                                  M            25       AN
PROFILE                           NM105                      NM105       Name Middle                                                 S            25       AN
PROFILE                           NM107                      NM107       Name Suffix                                                 S            10       AN
PROFILE                           NM108                      NM108       Identification Code Qualifier                               S             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                   34 - Social Security Number
                                                                                                                                                                   XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                      NM109       Identification Code                                         S            80       AN
                                                  2420E      N3          Ordering Provider Address                                   S
PROFILE                           N301                       N301        Address Information                                         M            55       AN
PROFILE                           N302                       N302        Address Information                                         S            55       AN
                                                  2420E      N4          Ordering Provider City/State/Zip Code                       S
PROFILE                           N401                       N401        City Name                                                   M            30       AN
PROFILE                           N402                       N402        State or Province Code                                      M             2       ID
PROFILE                           N403                       N403        Postal Code                                                 M            15       AN
PROFILE                           N404                       N404        Country Code                                                S             3       AN
                                                  2420E      REF         Ordering Provider Secondary Identification                  S
REFERENCE                         REF01                      REF01       Reference Identification Qualifier                          M                 3    ID     0B - State License Number
                                                                                                                                                                   1B - Blue Shield Provider Number
                                                                                                                                                                   1C - Medicare Provider Number
                                                                                                                                                                   1D - Medicaid Provider Number
                                                                                                                                                                   1G - Provider UPIN Number
                                                                                                                                                                   1H - CHAMPUS Identification Number
                                                                                                                                                                   EI - Employer's Identification Number
                                                                                                                                                                   G2 - Provider Commercial Number
                                                                                                                                                                   LU - Location Number
                                                                                                                                                                   N5 - Provider Plan Network Identification Number
                                                                                                                                                                   SY - Social Security Number
                                                                                                                                                                   X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                      REF02       Reference Identification                                    M            30       AN
                                                  2420E      PER         Ordering Provider Contact Information                       S
CONTACT                           PER01                      PER01       Contact Function Code                                       M             2       ID      IC - Information Contact
CONTACT                           PER02                      PER02       Name                                                        M            60       AN
CONTACT                           PER03                      PER03       Communication Number Qualifier                              M             2       ID      EM - Electronic Mail
                                                                                                                                                                   FX - Facsimile
                                                                                                                                                                   TE - Telephone
CONTACT                           PER04                      PER04       Communication Number                                        M            80       AN
CONTACT                           PER05                      PER05       Communication Number Qualifier                              S             2       ID      EM - Electronic Mail
                                                                                                                                                                   EX - Telephone Extentsion
                                                                                                                                                                   FX - Facsimile
                                                                                                                                                                   TE - Telephone
CONTACT                           PER06                      PER06       Communication Number                                        S            80       AN
CONTACT                           PER07                      PER07       Communication Number Qualifier                              S             2       ID      EM - Electronic Mail
                                                                                                                                                                   EX - Telephone Extentsion
                                                                                                                                                                   FX - Facsimile
                                                                                                                                                                   TE - Telephone
CONTACT                           PER08                      PER08       Communication Number                                        S            80       AN
                                                  2420F      NM1         Referring Provider Name                                     S




    11/12/2010                                                                                                                                                                                                                                   Page: 31
    837P - 4010 - Inbound - 000                                                                               State of Nebraska MMIS
                                                                                                         Mapping Specifications Spreadsheet



                                                                Segment/                                                              Mandatory/    Field       Field
               Record                       Field    Loop ID                                     Element Description                                                                                         Valid Values
                                                                Element                                                               Situational   Size        Type
PROFILE                           NM101                        NM101       Entity ID Code                                                 M                 3    ID     DN - Referring Provider
                                                                                                                                                                        P3 - Primary Care Provider
PROFILE                           NM102                        NM102       Entity Type Qualifier                                          M             1       ID      1 - Person
PROFILE                           NM103                        NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM104                        NM104       Name First                                                     M            25       AN
PROFILE                           NM105                        NM105       Name Middle                                                    S            25       AN
PROFILE                           NM107                        NM107       Name Suffix                                                    S            10       AN
PROFILE                           NM108                        NM108       Identification Code Qualifier                                  S             2       ID      24 - Employer's Indentification Number
                                                                                                                                                                        34 - Social Security Number
                                                                                                                                                                        XX - Home Health Care Financing Administration National Provider Identifier
PROFILE                           NM109                        NM109       Identification Code                                            S            80       AN
                                                    2420F      PRV         Referring Provider Specialty Information                       S
PROFILE                           PRV01                        PRV01       Provider Code                                                  M             3       ID      RF - Referring
PROFILE                           PRV02                        PRV02       Reference Identification Qualifier                             M             3       ID      ZZ - Mutually defined
PROFILE                           PRV03                        PRV03       Reference Identification                                       M            30       AN
                                                    2420F      REF         Referring Provider Secondary Identification                    S
REFERENCE                         REF01                        REF01       Reference Identification Qualifier                             M                 3    ID     0B - State License Number
                                                                                                                                                                        1B - Blue Shield Provider Number
                                                                                                                                                                        1C - Medicare Provider Number
                                                                                                                                                                        1D - Medicaid Provider Number
                                                                                                                                                                        1G - Provider UPIN Number
                                                                                                                                                                        1H - CHAMPUS Identification Number
                                                                                                                                                                        EI - Employer's Identification Number
                                                                                                                                                                        G2 - Provider Commercial Number
                                                                                                                                                                        LU - Location Number
                                                                                                                                                                        N5 - Provider Plan Network Identification Number
                                                                                                                                                                        SY - Social Security Number
                                                                                                                                                                        X5 - State Industrial Accident Provider Number
REFERENCE                         REF02                        REF02       Reference Identification                                       M            30       AN
                                                    2420G      NM1         Other Payer Prior Authorization or Referral Number             S

PROFILE                           NM101                        NM101       Entity ID Code                                                 M             3       ID      PR - Payer
PROFILE                           NM102                        NM102       Entity Type Qualifier                                          M             1       ID      2 - Non-Person
PROFILE                           NM103                        NM103       Name Last or Organization Name                                 M            35       AN
PROFILE                           NM108                        NM108       Identification Code Qualifier                                  S             2       ID      PI - Payor Identification
                                                                                                                                                                        XV - Health Care Financing Administration National PlanID
PROFILE                           NM109                        NM109       Identification Code                                            S            80       AN
                                                    2420G      REF         Other Payer Prior Authorization or Referral Number             M

REFERENCE                         REF01                        REF01       Reference Identification Qualifer                              M                 3    ID     9F - Referral Number
                                                                                                                                                                        G1 - Prior Authorization Number
REFERENCE                         REF02                        REF02       Reference Identification                                       M            30       AN
                                                    2430       SVD         Line Adjudication Information                                  S
ADJUDICATION                      SVD01                        SVD01       Identification Code                                            M            80       AN
ADJUDICATION                      SVD02                        SVD02       Monetary Amount                                                M            18       R
                                                               SVD03       Composite Field                                                M
ADJUDICATION                      SVD03-1                      SVD03-1     Product/Service ID Qualifier                                   M                 2    ID     HC - Health Care Financing Admistration Common Procedural Coding System
                                                                                                                                                                        (HCPCS) Codes
                                                                                                                                                                        IV - Home Infusion EDI Coalition (HIEC) Product/Service Code
                                                                                                                                                                        N4 - National Drug Code in 5-4-2 format
                                                                                                                                                                        ZZ - Mutually Defined - Use code to convey the Health Insurance Prospective Payment
                                                                                                                                                                        System (HIPPS) Skilled Nursing Facility Rate Code.
ADJUDICATION                      SVD03-2                      SVD03-2     Product/Service ID                                             M            48       AN
ADJUDICATION                      SVD03-3                      SVD03-3     Procedure Modifier                                             S             2       AN
ADJUDICATION                      SVD03-4                      SVD03-4     Procedure Modifier                                             S             2       AN
ADJUDICATION                      SVD03-5                      SVD03-5     Procedure Modifier                                             S             2       AN
ADJUDICATION                      SVD03-6                      SVD03-6     Procedure Modifier                                             S             2       AN
ADJUDICATION                      SVD03-7                      SVD03-7     Description                                                    S            80       AN
ADJUDICATION                      SVD05                        SVD05       Quantity                                                       M            15       R
ADJUDICATION                      SVD06                        SVD06       Assigned Number                                                S             6       N0
                                                    2430       CAS         Line Adjustment                                                S




    11/12/2010                                                                                                                                                                                                                                          Page: 32
   837P - 4010 - Inbound - 000                                                                           State of Nebraska MMIS
                                                                                                    Mapping Specifications Spreadsheet



                                                             Segment/                                                            Mandatory/    Field       Field
            Record                       Field    Loop ID                                    Element Description                                                                                        Valid Values
                                                             Element                                                             Situational   Size        Type
LINEADJUSTMENT                   CAS01                      CAS01       Claim Adjustment Group Code                                  M                 2    ID     CO - Contractual Obligations
                                                                                                                                                                   CR - Correction and Reversals
                                                                                                                                                                   OA - Other Adjustments
                                                                                                                                                                   PI - Payor Initiated Reductions
                                                                                                                                                                   PR - Patient Responsibility
LINEADJUSTMENT                   CAS02                      CAS02       Claim Adjustment Reason Code                                 M             5        ID     Use the LX from this transaction which points to the bundled/unbundled line.
LINEADJUSTMENT                   CAS03                      CAS03       Monetary Amount                                              M            18        R
LINEADJUSTMENT                   CAS04                      CAS04       Quantity                                                     S            15        R
LINEADJUSTMENT                   CAS05                      CAS05       Claim Adjustment Reason Code                                 S             5        ID
LINEADJUSTMENT                   CAS06                      CAS06       Monetary Amount                                              S            18        R
LINEADJUSTMENT                   CAS06                      CAS06       Monetary Amount                                              S            18        R
LINEADJUSTMENT                   CAS07                      CAS07       Quantity                                                     S            15        R
LINEADJUSTMENT                   CAS08                      CAS08       Claim Adjustment Reason Code                                 S             5        ID
LINEADJUSTMENT                   CAS09                      CAS09       Monetary Amount                                              S            18        R
LINEADJUSTMENT                   CAS10                      CAS10       Quantity                                                     S            15        R
LINEADJUSTMENT                   CAS11                      CAS11       Claim Adjustment Reason Code                                 S             5        ID
LINEADJUSTMENT                   CAS12                      CAS12       Monetary Amount                                              S            18        R
LINEADJUSTMENT                   CAS13                      CAS13       Quantity                                                     S            15        R
LINEADJUSTMENT                   CAS14                      CAS14       Claim Adjustment Reason Code                                 S             5        ID
LINEADJUSTMENT                   CAS15                      CAS15       Monetary Amount                                              S            18        R
LINEADJUSTMENT                   CAS15                      CAS15       Monetary Amount                                              S            18        R
LINEADJUSTMENT                   CAS16                      CAS16       Quantity                                                     S            15        R
LINEADJUSTMENT                   CAS17                      CAS17       Claim Adjustment Reason Code                                 S             5        ID
LINEADJUSTMENT                   CAS18                      CAS18       Monetary Amount                                              S            18        R
LINEADJUSTMENT                   CAS19                      CAS19       Quantity                                                     S            15        R
                                                 2430       DTP         Line Adjudication Date                                       M
DATES                            DTP01                      DTP01       Date/Time Qualifier                                          M             3       ID      573 - Date Claim Paid
DATES                            DTP02                      DTP02       Date Time Period Format Qualifier                            M             3       ID      D8 - Date expressed in format CCYYMMDD
DATES                            DTP03                      DTP03       Date Time Period                                             M            35       AN
                                                 2440       LQ          Form Identification Code                                     S
FORM                             LQ01                       LQ01        Code List Qualifier Code                                     M                 3    ID     AS - Form Type Code
                                                                                                                                                                   UT - Health Care Financing Adminstration (HCFA) Durable Medical Equipment
                                                                                                                                                                   Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms
FORM                             LQ02                       LQ02        Industry Code                                                M
                                                 2440       FRM         Supporting Documentation                                     M
FORM                             FRM01                      FRM01       Assigned Identification                                      M            20       AN
FORM                             FRM02                      FRM02       Yes/No Condition or Response Code                            S             1       ID      N - No
                                                                                                                                                                   W - Not Applicable
                                                                                                                                                                   Y - Yes
FORM                             FRM03                      FRM03       Reference Identification                                     S            30       AN
FORM                             FRM04                      FRM04       Date                                                         S             8       DT
FORM                             FRM05                      FRM05       Percent                                                      S             6       R
                                                            SE          Transaction Set Trailer                                      M
                                                            SE01        Number of Included Segment                                   M             10      N0      Automatically calculated
                                                            SE02        Transaction Set Control Number                               M              9      AN      Automatically generated. Has to match ST02




    11/12/2010                                                                                                                                                                                                                                    Page: 33

				
DOCUMENT INFO
Description: Certificate of Medical Necessity Form document sample