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Hcfa 1500 Blank Claim Form - Excel by zga19725

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Hcfa 1500 Blank Claim Form document sample

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									EyeMed Companion Guide to the 837P Implementation Guide
D:\Docstoc\Working\pdf\[13882193-976a-4e79-ba92-7cda142db178.xls]Legend

General Information
 X12 Syntax will be followed
 Implementation Guide syntax will be followed
 Required elements must be included
 Elements with a usage of 'Not Used' may not be included on file


Companion Guide Legend
 Name                               This is the Loop, Segment, or Data Element Name from the Implementation Guide
 Segment ID + Element #             This is the Segment and Element number
 Usage                              Define if Required, Situational, or Not Used -- This usage is the Implementation Guide usage not EyeMed defined
 Element Value                      Value shown in element
                                    -- If value is shown in normal text, the value will be sent as shown
                                    -- If no value, but cell shows green filled. The value must be specified by the receiver of the data
                                    -- If value is show in italic, the value is variable but will contain data shown.




                                                                   EyeMed 837P Submitter
                                                                      Companion Guide
                                                                        Rev 04/03/06                                                            1 of 14
                                            Name                  Segment ID+    Usage                Element Value                                     Element or Content Description
                                                                   Element #

ISA Interchange Control Header
Authorization Information Qualifier                                  ISA01      Required                   00            No Authorization Information Present Qualifier
Authorization Information                                            ISA02      Required                  Blank
Security Information Qualifier                                       ISA03      Required                   00            No Security Information Present Qualifier
Security Information                                                 ISA04      Required                  Blank
Interchange ID Qualifier (Sender)                                    ISA05      Required                    30           U.S. Federal Tax Identification Number - Value may be specified by Receiver
Interchange Sender ID                                                ISA06      Required                311656473        Fed Tax Id of the Sender - Value may be specified by Receiver
Interchange ID Qualifier (Receiver)                                  ISA07      Required                                 Receiver ID qualifier assigned by Receiver
Interchange Receiver ID                                              ISA08      Required                                 Receiver ID assigned by Receiver
Interchange Date                                                     ISA09      Required                YYMMDD           Date the Interchange is created
Interchange Time                                                     ISA10      Required                  HHMM           Time the Interchange is created
Interchange Control Standards Identifier                             ISA11      Required                    U            U.S. EDI ASC X12, TDCC, UCS
Interchange Control Version Number                                   ISA12      Required                  00401          Standards Approved by ACS X12 Review Board
Interchange Control Number                                           ISA13      Required              Unique Number      Unique Sequential Number Assigned by Internal Processes for each Interchange
Acknowledgment Requested                                             ISA14      Required                     0           Interchange Acknowledgment Requested
Usage Identifier                                                     ISA15      Required                  P or T         Production or Test
Component Element Separator                                          ISA16      Required                     :           Colon
Terminator                                                                                                   ~           Default will be Tilde, but Carrier may specify preference
GS Functional Group
Functional Identifier Code                                           GS01       Required                   HC            Health Care Claim (837)
Application Sender's Code                                            GS02       Required                311656473        Value may be specified by Receiver
Application Receiver's Code                                          GS03       Required                                 Assigned by Receiver
Date                                                                 GS04       Required               CCYYMMDD          Date the Functional Group is created
Time                                                                 GS05       Required                  HHMM           Time the Functional Group is created
Group Control Number                                                 GS06       Required              Unique Number      Will match GE02
Responsible Agency Code                                              GS07       Required                    X            Accredited Standard Committee X12
Version/Release/Industry Identifier Code                             GS08       Required              004010X098A1       Addenda version 4010
Header       Segment: ST Transaction Set Header
Transaction Set Identifier Code                                      ST01       Required                   837           Health Care Claim
Transaction Set Control Number                                       ST02       Required              Unique Number      Will match SE02
Header       Segment: BHT Beginning of Hierarchical Transaction
Hierarchical Structure Code                                          BHT01      Required                   0019          Information Source, Subscriber, Dependent
Transaction Set Purpose Code                                         BHT02      Required                    00           Original
Originator Application Transaction Identifier                        BHT03      Required              Unique Number
Transaction Set Creation Date                                        BHT04      Required               CCYYMMDD          File Creation Date
Transaction Set Creation Time                                        BHT05      Required                HHMMSS           File Creation Time
Transaction Type Code/Claim or Encounter Identifier                  BHT06      Required                CH or RP         Value is trading partner specific for chargeable vs encounter/reporting. Some trading partners
                                                                                                                         may trade in both types resulting in two files.
Header       Segment: REF Transmission Type Identification
Reference Identification Qualifier                                   REF01      Required                   87            Functional Category
Transmission Type Code                                               REF02      Required              004010X098A1
Loop: 1000A Submitter Name
 Segment: NM1 Submitter Name
Entity Identifier Code                                              NM101       Required                   41            Submitter
Entity Type Qualifier                                               NM102       Required                   2             Non-Person Entity
Submitter Last or Organization Name                                 NM103       Required            EyeMed Vision Care   Value may be specified by Receiver
Submitter First Name                                                NM104       Situational                              Not sent by EyeMed
Submitter Middle Name                                               NM105       Situational                              Not sent by EyeMed
Name Prefix                                                         NM106       Not Used
Name Suffix                                                         NM107       Not Used
Identification Code Qualifier                                       NM108       Required                   46            Electronic Transmitter Identification Number (ETIN)
Submitter Identifier                                                NM109       Required                311656473        Value may be specified by Receiver
 Segment: PER Submitter EDI Contact Information
Contact Function Code                                               PER01       Required                    IC           Information Contact
Submitter Contact Name                                              PER02       Required                EDI Admin
Communication Number Qualifier                                      PER03       Required                   EM            Electronic Mail



                                                                                      EyeMed 837P Submitter
                                                                                        Companion Guide
                                                                                          Rev 04/03/06                                                                                                  2 of 14
                                             Name                      Segment ID+    Usage                 Element Value                                              Element or Content Description
                                                                        Element #

Communication Number                                                         PER04   Required      EDI_Mailbox@eyemedvisioncare.com
Loop: 1000B Receiver Name
 Segment: NM1 Receiver Name
Entity Identifier Code                                                       NM101   Required                      40                 Receiver
Entity Type Qualifier                                                        NM102   Required                       2                 Non-Person Entity
Receiver Name                                                                NM103   Required                                         Assigned by Receiver
Name First                                                                   NM104   Not Used
Name Middle                                                                  NM105   Not Used
Name Prefix                                                                  NM106   Not Used
Name Suffix                                                                  NM107   Not Used
Identification Code Qualifier                                                NM108   Required                      46                 Electronic Transmitter Identification Number (ETIN)
Receiver Identifier                                                          NM109   Required                                         Assigned by Receiver
Loop: 2000A Billing/Pay to Provider
 Segment: HL Billing/Pay to Provider Hierarchical Level
Hierarchical ID Number                                                       HL01    Required                      1
Hierarchical Parent ID Number                                                HL02    Not Used
Hierarchical Level Code                                                      HL03    Required                      20                 Information source
Hierarchical Child Code                                                      HL04    Required                       1                 Additional Subordinate HL Data Segment in this Hierarchical structure
 Segment: PRV Billing/Pay-To Provider Specialty Information (Segment Not Included)
 Segment: CUR Foreign Currency Information (Segment Not Included)
Loop: 2100AA Billing Provider Name
 Segment: NM1 Billing Provider Name
Entity Identifier Code                                                       NM101   Required                    85                   Billing Provider
Entity Type Qualifier                                                        NM102   Required                     2                   Non-Person Entity
Billing Provider Last or Organization Name                                   NM103   Required             EyeMed Vision Care          Value may be specified by Receiver
Billing Provider First Name                                                  NM104   Situational                                      Not sent by EyeMed
Billing Provider Middle Name                                                 NM105   Situational                                      Not sent by EyeMed
Name Prefix                                                                  NM106   Not Used
Billing Provider Name Suffix                                                 NM107   Situational                                      Not sent by EyeMed
Identification Code Qualifier                                                NM108   Required                    24                   Employer's Identification Number
Billing Provider Identifier                                                  NM109   Required                 311656473               Value may be specified by Receiver
 Segment: N3 Billing Provider Address
Billing Provider Address Line 1                                              N301    Required                  Address                Value varies on set up of individual client
Billing Provider Address Line 2                                              N302    Situational            Address Line 2            Value varies on set up of individual client
 Segment: N4 Billing Provider City/State/Zip Code
Billing Provider's City                                                      N401    Required                     City                Value varies on set up of individual client
Billing Provider's State                                                     N402    Required                    State                Value varies on set up of individual client
Billing Provider's Zip Code                                                  N403    Required                  Zip Code               Value varies on set up of individual client
Billing Provider Country Code                                                N404    Situational                                      Not sent by EyeMed
 Segment: REF Billing Provider Secondary Identification (Included Upon Receiver Request Only)
Reference Identification Qualifier                                           REF01   Situational                                      Value must be specified by Receiver, if required
Billing Provider Secondary Identification Number                             REF02   Situational                                      Value must be specified by Receiver, if required
 Segment: REF Credit/Debit Card Billing Information (Segment Not Included)
 Segment: PER Billing Provider Contact Information (Segment Not Included)
Loop: 2100AB Pay-To Provider Name (Loop Not Included)
Loop: 2000B Subscriber Hierarchical Level
 Segment: HL Subscriber Hierarchical Level
Hierarchical ID Number                                                       HL01    Required                  Number                 Sequential value assigned
Hierarchical Parent ID Number                                                HL02    Required                  Number                 Sequential value assigned
Hierarchical Level Code                                                      HL03    Required                     22                  Subscriber
Hierarchical Child Code                                                      HL04    Required                   0 or 1                Value as situation requires
 Segment: SBR Subscriber Information
Payer Responsibility Sequence Number Code                                    SBR01   Required                      P                  Primary
Relationship Code                                                            SBR02   Situational                   18                 Self
Group or Policy Number                                                       SBR03   Situational                                      Not sent by EyeMed
Group or Plan Name                                                           SBR04   Situational                                      Not sent by EyeMed


                                                                                           EyeMed 837P Submitter
                                                                                             Companion Guide
                                                                                               Rev 04/03/06                                                                                                   3 of 14
                                     Name                             Segment ID+     Usage                Element Value                                    Element or Content Description
                                                                       Element #

Insurance Type Code                                                      SBR05       Situational                             Not sent by EyeMed
COB Code                                                                 SBR06       Not Used
Yes/No Condition or Response Code                                        SBR07       Not Used
Employment Status Code                                                   SBR08       Not Used
Claim Filing Indicator Code                                              SBR09       Situational                   12        Value may be specified by Receiver
 Segment: PAT Patient Information (Segment Not Included)
Loop: 2010BA Subscriber Name
 Segment: NM1 Subscriber Name
Entity Identifier Code                                                   NM101       Required                     IL         Insured or Subscriber
Entity Type Qualifier                                                    NM102       Required                      1         Person
Subscriber Last Name                                                     NM103       Required               Last Name        Value is claim specific
Subscriber First Name                                                    NM104       Situational            First Name       Value is claim specific
Subscriber Middle Name                                                   NM105       Situational            Middle Initial   Value is claim specific
Name Prefix                                                              NM106       Not Used
Subscriber Name Suffix                                                   NM107       Situational               Suffix        Value is claim specific
Identification Code Qualifier                                            NM108       Situational                MI           Member Identification Number
Subscriber Primary Identifier                                            NM109       Situational             Member ID       Value is claim specific
 Segment: N3 Subscriber Address
Subscriber Address 1                                                       N301      Required                 Address        Value is claim specific
Subscriber Address 2                                                       N302      Situational           Address Line 2    Value is claim specific
 Segment: N4 Subscriber City/State/Zip Code
Subscriber City                                                            N401      Required                    City        Value is claim specific
Subscriber State                                                           N402      Required                   State        Value is claim specific
Subscriber Zip Code                                                        N403      Required                 Zip Code       Value is claim specific
Subscriber Country Code                                                    N404      Situational                             Not sent by EyeMed
Location Qualifier                                                         N405      Not Used
Location Identifier                                                        N406      Not Used
 Segment: DMG Subscriber Demographic Information
Date Time Period Format Qualifier                                       DMG01        Required                   D8           Date in CCYYMMDD format
Date of Birth Subscriber                                                DMG02        Required                  DOB           Value is claim specific
Subscriber Gender Code                                                  DMG03        Required                 Gender         Value is claim specific
Marital Status Code                                                     DMG04        Not Used
Race or Ethnicity Code                                                  DMG05        Not Used
Citizenship Status Code                                                 DMG06        Not Used
Country Code                                                            DMG07        Not Used
Basis of Verification Code                                              DMG08        Not Used
Quantity                                                                DMG09        Not Used
 Segment: REF Subscriber Secondary Identification (Segment Not Included)
 Segment: REF Property and Casualty Claim Number (Segment Not Included)
Loop: 2010BB Payer Name
 Segment: NM1 Payer Name
Entity Identifier Code                                                   NM101       Required                      PR        Payer
Entity Type Qualifier                                                    NM102       Required                       2        Non-Person Entity
Payer Name                                                               NM103       Required                                Value specified by Receiver
Name First                                                               NM104       Not Used
Name Middle                                                              NM105       Not Used
Name Prefix                                                              NM106       Not Used
Name Suffix                                                              NM107       Not Used
Identification Code Qualifier                                            NM108       Required                      PI        Payer Identifier
Payer Identifier                                                         NM109       Required                                Value specified by Receiver
Entity Relationship Code                                                 NM110       Not Used
Entity Identifier Code                                                   NM111       Not Used
 Segment: N3 Payer Address (Segment Not Included)
 Segment: N4 Payer City/State/Zip Code (Segment Not Included)
 Segment: REF Payer Secondary Identification (Included Upon Receiver Request Only)
Reference Identification Qualifier                                       REF01       Required                                Value must be specified by Receiver, if required
Payer Additional Identifier                                              REF02       Required                                Value must be specified by Receiver, if required


                                                                                           EyeMed 837P Submitter
                                                                                             Companion Guide
                                                                                               Rev 04/03/06                                                                                  4 of 14
                                    Name                           Segment ID+    Usage                Element Value                                    Element or Content Description
                                                                    Element #

Description                                                           REF03      Not Used
Reference Identifier                                                  REF04      Not Used
Loop: 2010BC Responsible Party Name (Loop Not Included)
Loop: 2010BD Credit/Debit Card Holder Name (Loop Not Included)
Loop: 2000C Patient Hierarchical Level
 Segment: HL Patient Hierarchical Level
Hierarchical ID Number                                                    HL01   Required                 Number         Sequential value assigned
Hierarchical Parent ID Number                                             HL02   Required                 Number         Sequential value assigned
Hierarchical Level Code                                                   HL03   Required                   23           Dependent
Hierarchical Child Code                                                   HL04   Required                    0           No Subordinate HL Segment in this Hierarchical structure
 Segment: PAT Patient Information
Patient Relationship to Insured                                       PAT01      Required               Relationship     Value is claim specific
Patient Location Code                                                 PAT02      Not Used
Employment Status Code                                                PAT03      Not Used
Student Status Code                                                   PAT04      Not Used
Date Time Period Format Qualifier                                     PAT05      Situational                             Not sent by EyeMed
Patient Date of Death                                                 PAT06      Situational                             Not sent by EyeMed
Unit or Basis for Measurement                                         PAT07      Situational                             Not sent by EyeMed
Weight                                                                PAT08      Situational                             Not sent by EyeMed
Pregnancy Indicator                                                   PAT09      Situational                             Not sent by EyeMed
Loop: 2010CA Patient Name
 Segment: NM1 Patient Name
Entity Identifier Code                                                NM101      Required                   QC           Patient
Entity Type Qualifier                                                 NM102      Required                     1          Person
Patient Last Name                                                     NM103      Required               Last Name        Value is claim specific
Patient First Name                                                    NM104      Required               First Name       Value is claim specific
Patient Middle Name                                                   NM105      Situational            Middle Initial   Value is claim specific
Name Prefix                                                           NM106      Not Used
Patient Name Suffix                                                   NM107      Situational               Suffix
Identification Code Qualifier                                         NM108      Situational                MI           Member Identification Number
Patient Primary Identifier                                            NM109      Situational             Member ID       Value is claim specific
Entity Relationship Code                                              NM110      Not Used
Entity Identifier Code                                                NM111      Not Used
 Segment: N3 Patient Address
Patient Address 1                                                         N301   Required                 Address        Value is claim specific
Patient Address 2                                                         N302   Situational           Address Line 2    Value is claim specific
 Segment: N4 Patient City/State/Zip Code
Patient City                                                              N401   Required                    City        Value is claim specific
Patient State                                                             N402   Required                   State        Value is claim specific
Patient Zip Code                                                          N403   Required                 Zip Code       Value is claim specific
Patient Country Code                                                      N404   Situational                             Not sent by EyeMed
Location Qualifier                                                        N405   Not Used
Location Identifier                                                       N406   Not Used
 Segment: DMG Patient Demographic Information
Date Time Period Format Qualifier                                     DMG01      Required                   D8           Date in CCYYMMDD format
Patient Birth Date                                                    DMG02      Required                  DOB           Value is claim specific
Patient Gender Code                                                   DMG03      Required                 Gender         Value is claim specific
Marital Status Code                                                   DMG04      Not Used
Race or Ethnicity Code                                                DMG05      Not Used
Citizenship Status Code                                               DMG06      Not Used
Country Code                                                          DMG07      Not Used
Basis of Verification Code                                            DMG08      Not Used
Quantity                                                              DMG09      Not Used
 Segment: REF Patient Secondary Identification (Segment Not Included)
 Segment: REF Property and Casualty Claim Number (Segment Not Included)
Loop: 2300 Claim Information
 Segment: CLM Claim Information

                                                                                       EyeMed 837P Submitter
                                                                                         Companion Guide
                                                                                           Rev 04/03/06                                                                                  5 of 14
                                          Name                            Segment ID+    Usage                Element Value                                            Element or Content Description
                                                                           Element #

Patient Account Number                                                       CLM01      Required      EyeMed Claim or Invoice Number   Value is claim specific
Total Claim Charge Amount                                                    CLM02      Required              Total Charge             Value is claim specific
Claim Filing Indicator Code                                                  CLM03      Not Used
Non-Institutional Claim Type Code                                            CLM04      Not Used
Place of Service Code                                                       CLM05-1     Required                      11               Value may be specified by Receiver
Facility Code Qualifier                                                     CLM05-2     Not Used
Claim Frequency Code                                                        CLM05-3     Required                      1
Provider Signature on File                                                   CLM06      Required                      Y                Yes
Provider Accept Assignment Code                                              CLM07      Required                      C                Not assigned
Assignment of Benefit Indicator                                              CLM08      Required                      Y                Yes
Release of Information Code                                                  CLM09      Required                      Y                Yes, provider has a Signed Statement Permitting Release of Data related to Claim
Patient Signature Source Code                                                CLM10      Required                      B                Signed signature authorization forms or forms for both HCFA 1500 Claim Form on file
Accident/Employment/Related Causes Code                                     CLM11-1     Situational                                    Not sent by EyeMed
Related Causes Code                                                         CLM11-2     Situational                                    Not sent by EyeMed
Related Causes Code                                                         CLM11-3     Situational                                    Not sent by EyeMed
Auto Accident State or Province Code                                        CLM11-4     Situational                                    Not sent by EyeMed
Country Code                                                                CLM11-5     Situational                                    Not sent by EyeMed
Special Program Indicator                                                    CLM12      Situational                                    Not sent by EyeMed
Yes/No Condition or Response Code                                            CLM13      Not Used
Level of Service Code                                                        CLM14      Not Used
Yes/No Condition or Response Code                                            CLM15      Not Used
Participation Agreement                                                      CLM16      Situational                                    Not sent by Eyemed
Claim Status Code                                                            CLM17      Not Used
Yes/No Condition or Response Code                                            CLM18      Not Used
Claim Submission Reason Code                                                 CLM19      Not Used
Delay Reason Code                                                            CLM20      Situational                                    Not sent by EyeMed
 Segment:      DTP Date-Initial Treatment (Segment Not Included)
 Segment:      DTP Date-Date Last Seen (Segment Not Included)
 Segment:      DTP Date-Onset of Current Illness/Symptom (Segment Not Included)
 Segment:      DTP Date-Acute Manifestation (Segment Not Included)
 Segment:      DTP Date-Similar Illness/Symptom Onset (Segment Not Included)
 Segment:      DTP Date-Accident (Segment Not Included)
 Segment:      DTP Date-Last Menstrual Period (Segment Not Included)
 Segment:      DTP Date-Last X-Ray (Segment Not Included)
 Segment:      DTP Date-Hearing and Vision Prescription Date
Date/Time Qualifier                                                          DTP01      Required                   471                 Prescription
Date Time Period Format Qualifier                                            DTP02      Required                    D8                 Date in CCYYMMDD format
Prescription Date                                                            DTP03      Required               Service Date            Value is claim specific
 Segment:      DTP Date-Disability Begin (Segment Not Included)
 Segment:      DTP Date-Disability End (Segment Not Included)
 Segment:      DTP Date-Last Worked (Segment Not Included)
 Segment:      DTP Date-Authorized Return to Work (Segment Not Included)
 Segment:      DTP Date-Admission (Segment Not Included)
 Segment:      DTP Date-Discharge (Segment Not Included)
 Segment:      DTP Date-Assumed and Relinquished Care Dates (Segment Not Included)
 Segment:      PWK Claim Supplemental Information (Segment Not Included)
 Segment:      CN1 Contract Information (Segment Not Included)
 Segment:      AMT Credit/Debit Maximum Amount (Segment Not Included)
 Segment:      AMT Patient Amount Paid
Amount Qualifier Code                                                       AMT01       Required                    F5                 Patient Amount Paid
Patient Amount Paid                                                         AMT02       Required               Patient POS             Value is claim specific - if zero, segment is not sent
Credit/Debit Flag Code                                                      AMT03       Not Used
 Segment: AMT Total Purchased Service Amount (Segment Not Included)
 Segment: REF Service Authorization Exception Code (Segment Not Included)
 Segment: REF Mandatory Medicare (Section 4081) Crossover Indicator (Segment Not Included)

                                                                                              EyeMed 837P Submitter
                                                                                                Companion Guide
                                                                                                  Rev 04/03/06                                                                                                     6 of 14
                                         Name                                 Segment ID+    Usage              Element Value                                      Element or Content Description
                                                                               Element #

 Segment: REF Mammography Certification Number (Segment Not Included)
 Segment: REF Prior Authorization or Referral Number (Included Upon Receiver Request Only)
Reference Identification Qualifier                                               REF01      Required                                Value must be specified by Receiver, if required
Prior Authorization or Referral Number                                           REF02      Required                                Value must be specified by Receiver, if required
Description                                                                      REF03      Not Used
Reference Identifier                                                             REF04      Not Used
 Segment:      REF Original Reference Number (ICN/DCN) (Segment Not Included)                                                   May be available Q3, 2006
 Segment:      REF Clinical Laboratory Improvement Amendment (CLIA) Number (Segment Not Included)
 Segment:      REF Repriced Claim Number (Segment Not Included)
 Segment:      REF Adjusted Repriced Claim Number (Segment Not Included)
 Segment:      REF Investigational Device Exemption Number (Segment Not Included)
 Segment:      REF Claim Identification number for Clearing Houses and other Transmission Intermediaries (Segment Not Included)
 Segment:      REF Ambulatory Patient Group (APG) (Segment Not Included)
 Segment:      REF Medical Record Number (Segment Not Included)
 Segment:      REF Demonstration Project Identifier (Segment Not Included)
 Segment:      K3 File Information (Segment Not Included)
 Segment:      NTE Claim Note (Segment Not Included)
 Segment:      CR1 Ambulance Transport Information (Segment Not Included)
 Segment:      CR2 Spinal Manipulation Service Information (Segment Not Included)
 Segment:      CRC Ambulance Certification (Segment Not Included)
 Segment:      CRC Patient Condition Information: Vision (Segment Not Included)
 Segment:      CRC Homebound Indicator (Segment Not Included)
 Segment:      CRC EPSDT Referral (Segment Not Included)
 Segment:      HI Health Care Diagnosis Code
Diagnosis Type Code                                                              HI01-1     Required                  BK            Principal Diagnosis ICD-9 Codes
Diagnosis Code                                                                   HI01-2     Required            Diagnosis Code      Value is claim specific
Date Time Period Format Qualifier                                                HI01-3     Not Used
Date Time Period                                                                 HI01-4     Not Used
Monetary Amount                                                                  HI01-5     Not Used
Quantity                                                                         HI01-6     Not Used
Version Identifier                                                               HI01-7     Not Used
Diagnosis Type Code                                                              HI02-1     Required                  BF            Diagnosis ICD-9 Codes
Diagnosis Code                                                                   HI02-2     Required            Diagnosis Code      Value is claim specific
Date Time Period Format Qualifier                                                HI02-3     Not Used
Date Time Period                                                                 HI02-4     Not Used
Monetary Amount                                                                  HI02-5     Not Used
Quantity                                                                         HI02-6     Not Used
Version Identifier                                                               HI02-7     Not Used
Diagnosis Type Code                                                              HI03-1     Required                  BF            Diagnosis ICD-9 Codes
Diagnosis Code                                                                   HI03-2     Required            Diagnosis Code      Value is claim specific
Date Time Period Format Qualifier                                                HI03-3     Not Used
Date Time Period                                                                 HI03-4     Not Used
Monetary Amount                                                                  HI03-5     Not Used
Quantity                                                                         HI03-6     Not Used
Version Identifier                                                               HI03-7     Not Used
Diagnosis Type Code                                                              HI04-1     Required                  BF            Diagnosis ICD-9 Codes
Diagnosis Code                                                                   HI04-2     Required            Diagnosis Code      Value is claim specific
Date Time Period Format Qualifier                                                HI04-3     Not Used
Date Time Period                                                                 HI04-4     Not Used
Monetary Amount                                                                  HI04-5     Not Used
Quantity                                                                         HI04-6     Not Used
Version Identifier                                                               HI04-7     Not Used
Diagnosis Type Code                                                              HI05-1     Required                  BF            Diagnosis ICD-9 Codes
Diagnosis Code                                                                   HI05-2     Required            Diagnosis Code      Value is claim specific
Date Time Period Format Qualifier                                                HI05-3     Not Used



                                                                                                EyeMed 837P Submitter
                                                                                                  Companion Guide
                                                                                                    Rev 04/03/06                                                                                    7 of 14
                                          Name                        Segment ID+    Usage                Element Value                                    Element or Content Description
                                                                       Element #

Date Time Period                                                           HI05-4   Not Used
Monetary Amount                                                            HI05-5   Not Used
Quantity                                                                   HI05-6   Not Used
Version Identifier                                                         HI05-7   Not Used
Diagnosis Type Code                                                        HI06-1   Required                    BF          Diagnosis ICD-9 Codes
Diagnosis Code                                                             HI06-2   Required              Diagnosis Code    Value is claim specific
Date Time Period Format Qualifier                                          HI06-3   Not Used
Date Time Period                                                           HI06-4   Not Used
Monetary Amount                                                            HI06-5   Not Used
Quantity                                                                   HI06-6   Not Used
Version Identifier                                                         HI06-7   Not Used
Diagnosis Type Code                                                        HI07-1   Required                    BF          Diagnosis ICD-9 Codes
Diagnosis Code                                                             HI07-2   Required              Diagnosis Code    Value is claim specific
Date Time Period Format Qualifier                                          HI07-3   Not Used
Date Time Period                                                           HI07-4   Not Used
Monetary Amount                                                            HI07-5   Not Used
Quantity                                                                   HI07-6   Not Used
Version Identifier                                                         HI07-7   Not Used
Diagnosis Type Code                                                        HI08-1   Required                    BF          Diagnosis ICD-9 Codes
Diagnosis Code                                                             HI08-2   Required              Diagnosis Code    Value is claim specific
Date Time Period Format Qualifier                                          HI08-3   Not Used
Date Time Period                                                           HI08-4   Not Used
Monetary Amount                                                            HI08-5   Not Used
Quantity                                                                   HI08-6   Not Used
Version Identifier                                                         HI08-7   Not Used
Health Care Code Information                                                HI09    Not Used
Health Care Code Information                                                HI10    Not Used
Health Care Code Information                                                HI11    Not Used
Health Care Code Information                                                HI12    Not Used
 Segment: HCP Claim Pricing/Repricing Information (Segment Not Included)
Loop: 2305 Home Health Care Plan Information (Loop Not Included)
Loop: 2310A Referring Provider Name (Loop Not Included)
Loop: 2310B Rendering Provider Name
 Segment: NM1 Rendering Provider Name
Entity Identifier Code                                                     NM101    Required                    82          Rendering Provider
Entity Type Qualifier                                                      NM102    Required                  1 or 2        Value is claim specific
Rendering Provider Last Name                                               NM103    Required               Last Name        Value is claim specific
Rendering Provider First Name                                              NM104    Situational            First name       Value is claim specific
Rendering Provider Middle Name                                             NM105    Situational            Middle Initial   Value is claim specific
Name Prefix                                                                NM106    Not Used
Rendering Provider Name Suffix                                             NM107    Situational               Suffix        Value is claim specific
Identification Code Qualifier                                              NM108    Required                    24          Employer's Identification Number
Rendering Provider Primary Identifier                                      NM109    Required                   TIN          Value is claim specific
Entity Relationship Code                                                   NM110    Not Used
Entity Identifier Code                                                     NM111    Not Used
 Segment: PRV Rendering Provider Specialty Information
Provider Code                                                              PRV01    Required                    PE          Performing
Reference Identification Qualifier                                         PRV02    Required                    ZZ          Health Care Provider Taxonomy Code list
Provider Taxonomy Code                                                     PRV03    Required              Taxonomy Code     Value is claim specific
State or Province Code                                                     PRV04    Not Used
Provider Specialty Code                                                    PRV05    Not Used
Provider Organization Code                                                 PRV06    Not Used
 Segment: REF Rendering Provider Secondary Identification (Included Upon Receiver Request Only)
Reference Identification Qualifier                                         REF01    Required                                Value must be specified by Receiver, if required
Rendering Provider Secondary Identifier                                    REF02    Required                                Value must be specified by Receiver, if required
Description                                                                REF03    Not Used
Reference Identifier                                                       REF04    Not Used
Loop: 2310C Purchased Service Provider Name (Loop Not Included)


                                                                                          EyeMed 837P Submitter
                                                                                            Companion Guide
                                                                                              Rev 04/03/06                                                                                  8 of 14
                                             Name                        Segment ID+    Usage                Element Value                                   Element or Content Description
                                                                          Element #

Loop: 2310D Service Facility Location
 Segment: NM1 Service Facility Location
Entity Identifier Code                                                     NM101       Required                    77         Service Location
Entity Type Qualifier                                                      NM102       Required                     2         Non-Person Entity
Laboratory or Facility Name                                                NM103       Situational           Location Name    Value is claim specific
Name First                                                                 NM104       Not Used
Name Middle                                                                NM105       Not Used
Name Prefix                                                                NM106       Not Used
Name Suffix                                                                NM107       Not Used
Identification Code Qualifier                                              NM108       Situational                    24      Employer's Identification Number
Laboratory or Facility Primary Identifier                                  NM109       Situational                   TIN      Value is claim specific
Entity Relationship Code                                                   NM110       Not Used
Entity Identifier Code                                                     NM111       Not Used
 Segment: N3 Service Facility Location Address
Laboratory/Facility Address 1                                               N301       Required                 Address       Value is claim specific
Laboratory/Facility Address 2                                               N302       Situational           Address Line 2   Value is claim specific
 Segment: N4 Service Facility Location City/State/Zip
Laboratory or Facility City Name                                            N401       Required                    City       Value is claim specific
Laboratory or Facility State or Province Code                               N402       Required                   State       Value is claim specific
Laboratory or Facility Postal Zone or Zip Code                              N403       Required                 Zip Code      Value is claim specific
Laboratory or Facility Country Code                                         N404       Situational                            Not sent by EyeMed
Location Qualifier                                                          N405       Not Used
Location Identifier                                                         N406       Not Used
 Segment: REF Service Facility Location Secondary Identification (Included Upon Receiver Request Only)
Reference Identification Qualifier                                          REF01      Situational                            Value must be specified by Receiver, if required
Laboratory/Facility Secondary Identification Number                         REF02      Situational                            Value must be specified by Receiver, if required
Loop: 2310E Supervising Provider Name (Loop Not Included)
Loop: 2320 Other Subscriber Information (Loop Not Included)
Loop: 2330A Other Subscriber Name (Loop Not Included)
Loop: 2330B Other Payer Name (Loop Not Included)
Loop: 2330C Other Payer Patient Information (Loop Not Included)
Loop: 2330D Other Payer Referring Provider (Loop Not Included)
Loop: 2330E Other Payer Rendering Provider (Loop Not Included)
Loop: 2330F Other Payer Purchased Service Provider (Loop Not Included)
Loop: 2330G Other Payer Service Facility Location (Loop Not Included)
Loop: 2330H Other Payer Supervising Provider (Loop Not Included)
Loop: 2400 Service Line
 Segment: LX Service Line - May repeat up to 50
Line Counter                                                                LX01       Required                 Number        Increments by 1 for each service line
 Segment: SV1 Professional Service
Product or Service ID Qualifier                                            SV101-1     Required                   HC          HCPCS Code
Procedure Code                                                             SV101-2     Required               HCPCS Code      Value is claim specific
Procedure Modifier 1                                                       SV101-3     Situational              Modifier      Value is claim specific
Procedure Modifier 2                                                       SV101-4     Situational              Modifier      Value is claim specific
Procedure Modifier 3                                                       SV101-5     Situational              Modifier      Value is claim specific
Procedure Modifier 4                                                       SV101-6     Situational              Modifier      Value is claim specific
Description                                                                SV101-7     Not Used
Submitted Charge Amount/Line Item Charge Amount                             SV102      Required              Charge Amount    Value is claim specific - For encounters may be 0
Unit or Basis for Measurement Code                                          SV103      Required                   UN          Unit
Service Unit Count                                                          SV104      Required                 Number        Value is claim specific
Place of Service Code                                                       SV105      Situational                            Not sent by EyeMed
Service Type Code                                                           SV106      Not Used
Diagnosis Code Pointer                                                     SV107-1     Required                 Number        Value is claim specific
Diagnosis Code Pointer                                                     SV107-2     Situational
Diagnosis Code Pointer                                                     SV107-3     Situational
Diagnosis Code Pointer                                                     SV107-4     Situational


                                                                                             EyeMed 837P Submitter
                                                                                               Companion Guide
                                                                                                 Rev 04/03/06                                                                                 9 of 14
                                          Name                              Segment ID+    Usage                Element Value                                        Element or Content Description
                                                                             Element #

Monetary Amount                                                                SV108      Not Used
Emergency Indicator                                                            SV109      Situational                            Not sent by EyeMed
Multiple Procedure Code                                                        SV110      Not Used
EPSDT Indicator                                                                SV111      Situational                            Not sent by EyeMed
Family Planning Indicator                                                      SV112      Situational                            Not sent by EyeMed
Review Code                                                                    SV113      Not Used
National or Local Assigned Review Value                                        SV114      Not Used
Co-Pay Status Code/Copay Waiver                                                SV115      Situational                            Not sent by EyeMed
Health Care Professional Shortage Area Code                                    SV116      Not Used
Reference Identification                                                       SV117      Not Used
Postal Code                                                                    SV118      Not Used
Monetary Amount                                                                SV119      Not Used
Level of Care Code                                                             SV120      Not Used
Provider Agreement Code                                                        SV121      Not Used
 Segment:       SV5 Durable Medical Equipment Service (Segment Not Included)
 Segment:       PWK DMERC CMN Indicator (Segment Not Included)
 Segment:       CR1 Ambulance Transport Information (Segment Not Included)
 Segment:       CR2 Spinal Manipulation Service Information (Segment Not Included)
 Segment:       CR3 Durable Medical Equipment Certification (Segment Not Included)
 Segment:       CR5 Home Oxygen Therapy Information (Segment Not Included)
 Segment:       CRC Ambulance Certification (Segment Not Included)
 Segment:       CRC Hospice Employee Indicator (Segment Not Included)
 Segment:       CRC DMERC Condition Indicator (Segment Not Included)
 Segment:       DTP Date - Service Date
Date/Time Qualifier                                                            DTP01      Required                   472         Service
Date Time Period Format Qualifier                                              DTP02      Required                    D8         Date in CCYYMMDD format
Service Date                                                                   DTP03      Required               Service Date    Value is claim specific
 Segment:       DTP Date - Certification Revision Date (Segment Not Included)
 Segment:       DTP Date - Begin Therapy Date (Segment Not Included)
 Segment:       DTP Date - Last Certification Date (Segment Not Included)
 Segment:       DTP Date - Date Last Seen (Segment Not Included)
 Segment:       DTP Date - Test (Segment Not Included)
 Segment:       DTP Date - Oxygen Saturation/Arterial Blood Gas Test (Segment Not Included)
 Segment:       DTP Date - Shipped (Segment Not Included)
 Segment:       DTP Date - Onset of Current Symptom/Illness (Segment Not Included)
 Segment:       DTP Date - Last X-Ray (Segment Not Included)
 Segment:       DTP Date - Acute Manifestation (Segment Not Included)
 Segment:       DTP Date - Initial Treatment (Segment Not Included)
 Segment:       DTP Date - Similar Illness/Symptom Onset (Segment Not Included)
 Segment:       MEA Test Result (Segment Not Included)
 Segment:       CN1 Contract Information (Segment Not Included)
 Segment:       REF Repriced Line Item Reference Number (Segment Not Included)
 Segment:       REF Adjusted Repriced Line Item Reference Number (Segment Not Included)
 Segment:       REF Prior Authorization or Referral Number (Segment Not Included)
 Segment:       REF Line Item Control Number
Reference Identification Qualifier                                             REF01      Required                    6R         Provider Control Number
Line Item Control Number                                                       REF02      Required               Control Value   Value is claim/line item specific
 Segment:       REF Mammography Certification Number (Segment Not Included)
 Segment:       REF Clinical Laboratory Improvement Amendment (CLIA) (Segment Not Included)
 Segment:       REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identifier (Segment Not Included)
 Segment:       REF Immunization Batch Number (Segment Not Included)
 Segment:       REF Ambulatory Patient Group (APG) (Segment Not Included)


                                                                                                EyeMed 837P Submitter
                                                                                                  Companion Guide
                                                                                                    Rev 04/03/06                                                                                      10 of 14
                                       Name                            Segment ID+    Usage              Element Value                            Element or Content Description
                                                                        Element #

 Segment: REF Oxygen Flow Rate (Segment Not Included)
 Segment: REF Universal Product Number (UPN) (Segment Not Included)
 Segment: AMT Sales Tax Amount (Segment Not Included)
 Segment: AMT Approved Amount (Segment Not Included)
 Segment: AMT Postage Claimed Amount (Segment Not Included)
 Segment: K3 File Information (Segment Not Included)
 Segment: NTE Line Note (Segment Not Included)
 Segment: PS1 Purchased Service Information (Segment Not Included)
 Segment: HSD Health Care Services Delivery (Segment Not Included)
 Segment: HCP Line Pricing/Repricing Information (Segment Not Included)
Loop: 2410 Drug Identification (Loop Not Included)
Loop: 2420A Rendering Provider Name (Loop Not Included)
Loop: 2420B Purchased Service Provider Name (Loop Not Included)
Loop: 2420C Service Facility Location (Loop Not Included)
Loop: 2420D Supervising Provider Name (Loop Not Included)
Loop: 2420E Ordering Provider Name (Loop Not Included)
Loop: 2420F Referring Provider Name (Loop Not Included)
Loop: 2420G Other Payer Prior Authorization or Referral Number (Loop Not Included)
Loop: 2430 Line Adjudication Information (Loop Not Included)
Loop: 2440 Form Identification Code (Loop Not Included)
Trailer Segment: SE Transaction Set Trailer
Transaction Segment Count                                                  SE01      Required               Number       Value specific to file
Transaction Set Control Number                                             SE02      Required            Unique Number   Value matches ST02
Trailer   Segment: GE Functional Group Trailer
Number of Transaction Sets Included                                        GE01      Required               Number       Value specific to file
Group Control Number                                                       GE02      Required            Unique Number   Value matches GS06
Trailer   Segment: IEA Interchange Control Trailer
Number of Included Functional Groups                                       IEA01     Required               Number       Value specific to file
Interchange Control Number                                                 IEA02     Required            Unique Number   Value matches ISA13




                                                                                         EyeMed 837P Submitter
                                                                                           Companion Guide
                                                                                             Rev 04/03/06                                                                          11 of 14
Loops not Included in EyeMed 837 Transmission
2100AB Pay-To Provider Name
2010BC Responsible Party Name
2010BD Credit/Debit Card Holder Name
2305 Home Health Care Plan Information
2310A Referring Provider Name
2310C Purchased Service Provider Name
2310E Supervising Provider Name
2320 Other Subscriber Information
2330A Other Subscriber Name
2330B Other Payer Name
2330C Other Payer Patient Information
2330D Other Payer Referring Provider
2330E Other Payer Rendering Provider
2330F Other Payer Purchased Service Provider
2330G Other Payer Service Facility Location
2330H Other Payer Supervising Provider
2410 Drug Identification
2420A Rendering Provider Name
2420B Purchased Service Provider Name
2420C Service Facility Location
2420D Supervising Provider Name
2420E Ordering Provider Name
2420F Referring Provider Name
2420G Other Payer Prior Authorization or Referral Number
2430 Line Adjudication Information
2440 Form Identification Code


Segments Not Included in EyeMed 837 Transmission
2000A Billing/Pay to Provider
      PRV Billing/Pay-To Provider Specialty Information
      CUR Foreign Currency Information
2100AA Billing Provider Name
      REF Credit/Debit Card Billing Information
      PER Billing Provider Contact Information
2000B Subscriber Hierarchical Level
      PAT Patient Information
2010BA Subscriber Name
      REF Subscriber Secondary Identification
      REF Property and Casualty Claim Number
2010BB Payer Name
      N3 Payer Address
      N4 Payer City/State/Zip Code
2010CA Patient Name
      REF Patient Secondary Identification
      REF Property and Casualty Claim Number
2300 Claim Information
      DTP Date-Initial Treatment
      DTP Date-Date Last Seen
      DTP Date-Onset of Current Illness/Symptom
                                       EyeMed 837P Submitter
                                          Companion Guide
                                            Rev 04/03/06       12 of 14
      DTP Date-Acute Manifestation
      DTP Date-Similar Illness/Symptom Onset
      DTP Date-Accident
      DTP Date-Last Menstrual Period
      DTP Date-Last Xray
      DTP Date-Disability Begin
      DTP Date-Disability End
      DTP Date-Last Worked
      DTP Date-Authorized Return to Work
      DTP Date-Admission
      DTP Date-Discharge
      DTP Date-Assumed and Relinquished Care Dates
      PWK Claim Supplemental Information
      CN1 Contract Information
      AMT Credit/Debit Maximum Amount
      AMT Total Purchased Service Amount
      REF Service Authorization Exception Code
      REF Mandatory Medicare (Section 4081) Crossover Indicator
      REF Mammography Certification Number
      REF Original Reference Number (ICN/DCN)
      REF Clinical Laboratory Improvement Amendment (CLIA) Number
      REF Repriced Claim Number
      REF Adjusted Repriced Claim Number
      REF Invesitgational Device Exemption Number
      REF Claim Identification number for Clearing Houses and other Transmission Intermediaries
      REF Ambulatory Patient Group (APG)
      REF Medical Record Number
      REF Demonstration Project Identifier
      K3 File Information
      NTE Claim Note
      CR1 Ambulance Transport Information
      CR2 Spinal Manipulation Service Information
      CRC Ambulance Certification
      CRC Patient Condition Information: Vision
      CRC Homebound Indicator
      CRC EPSDT Referral
      HCP Claim Pricing/Repricing Information
2400 Service Line
      SV5 Durable Medical Equipment Service
      PWK DMERC CMN Indicator
      CR1 Ambulance Transport Information
      CR2 Spinal Manipulatioin Service Information
      CR3 Durable Medical Equipment Certification
      CR5 Home Oxygen Therapy Information
      CRC Ambulance Certification
      CRC Hospice Employee Indicator
      DTP Date - Certification Revision Date
      DTP Date - Begin Therapy Date
      DTP Date - Last Certification Date
      DTP Date - Date Last Seen
      DTP Date - Test
      DTP Date - Oxygen Saturation/Arterial Blood Gas Test
                                     EyeMed 837P Submitter
                                       Companion Guide
                                         Rev 04/03/06                                             13 of 14
DTP Date - Shipped
DTP Date - Onset of Current Sympton/Illness
DTP Date - Last X-Ray
DTP Date - Acute Manifestation
DTP Date - Initial Treatment
DTP Date - Similar Illness/Sympton Onset
MEA Test Result
CN1 Contract Information
REF Repriced Line Item Reference Number
REF Adjusted Repriced Line Item Reference Number
REF Prior Authorization or Referral Number
REF Mammography Certification Number
REF Clinical Laboratory Improvement Amendment (CLIA)
REF Immunization Batch Number
REF Ambulatory Patient Group (APG)
REF Oxygen Flow Rate
REF Univeral Product Number (UPN)
AMT Sales Tax Amount
AMT Approved Amount
AMT Postage Claimed Amount
K3 File Information
NTE Line Note
PS1 Purchased Services Delivery
HSD Health Care Services Delivery
HCP Line Pricing/Repricing Information




                             EyeMed 837P Submitter
                               Companion Guide
                                 Rev 04/03/06          14 of 14

								
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