XML Requirements.xlsx - Public Sector Partners

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XML Requirements.xlsx - Public Sector Partners Powered By Docstoc
					Level    Field Name            XML Output Slot Name       Claim Form Mapping /                                                                  Slot
                                                          Box        Translation                                                                Length
                                                          Location


        1 XML Root             claimList                               Required Element
        2 Claim                claim                                   Required Element
         Version               version                    Captiva      plug "1.0"                                                                        3
                                                          Assigned
        3 Header               sPhys                                   Required Element
         ICN                   num_icn                    Captiva                                                                                    13
                                                          Assigned
         Detail Count          num_dtl_total              Captiva                                                                                        3
                                                          Calculated
         Amount Paid           tpl_amt                    29           Include decimal (12345678.11)                                                 11


         Date Billed           dte_billed                 Captiva      Needs to be translated into valid date format of CCYY-MM-DD using             10
                                                          Assigned     Julian date from ICN.

         Total Charge          amt_billed                 28           Include decimal (100.00)                                                      11
         Patient's Account NO. num_pat_acct               26           Default to "0"                                                                38

         Provider Signature     ind_prov_sign             31           Default to "N"                                                                    1
         Indicator
         Other Insured's Name                             9            blank, D, Y, P. Other coverage indicator                                          1
                                ind_carrier_denied
         Insured's Policy Group                           11           7, 8. Medicare disclaimer                                                         1
         or FECA Number
                                cde_medicare_disclaimer
         Claim Type             cde_clm_type              Captiva      plug "M" Professional Claims or plug "B" for Professional                         1
                                                          Assigned

         Provider Last Name    clm_lst_nam_prov           33           First two characters of Billing Provider Name                                     2

        4 Diagnosis            diag_xref
         Sequence              cde_diag_seq               Captiva      Take from spot occupied by diags in box 21 e.g. if diag in spot 2 and             1
                                                          Assigned     spot 4, send sequence as 2 and 4. Not 1 and 2. If only diag is in spot
                                                                       3, send sequence as 3. Not 1.
         Qualifier Code        qlf_code_list              Captiva      BK' when the code_diag_seq is 1                                                   2
                                                          Assigned     'BF' when the code_diag_seq is NOT 1

         Diagnosis Code        cde_diag                   21                                                                                             5
4 Header Key             physHdrKey                      Required Element
  Beneficiary ID         id_medicaid          1a         10 digit ID#. Verify against stub file.                                             10


  Billing Provider       id_provider          33                                                                                       8 or 10
  Number

  Referring Provider     id_prov_refer        17a                                                                                            10
  Number
  Bene Last Name         clm_lst_nam_recip    2          Entire first name                                                                   25
  Bene First Name        clm_recip_fst_nam    2          Entire last name                                                                    35
  Program Code                                Captiva    Use WISC_TXIX for Medicaid.                                                         15
                                              Assigned   WISC_WWWP for Wisconsin Well Women's.
                                                         WISC_WCDP for Wisconsin Chronic Disease Program.
                         id_payer_txn_sub                Left justify, space fill.
4 Detail                 detail               3          Required Element
  From Date of Service   dte_first_svc        24a        Format CCYY-MM-DD.                                                                  10

  To Date of Service     dte_last_svc         24a        Format CCYY-MM-DD. If blank copy from dte_first_svc.                                10


  Units                  qty_billed           24g        Include decimal (25.00)                                                             11
  Emergency Indicator    ind_emergency        24i        Default to blank. Assign Y if box 24i has an E. Assign N if box 24i has                 1
                                                         an N. Assign blank if any other value.
  Procedure Modifier 1   cde_proc_mod         24d        data exists in up to 4, two digit codes from right side of field (follows               2
                                                         Procedure Code)
  Procedure Modifier 2   cde_modifier_2       24d        data exists in up to 4, two digit codes from right side of field (follows               2
                                                         Procedure Code)

  Procedure Modifier 3   cde_modifier_3       24d        data exists in up to 4, two digit codes from right side of field (follows               2
                                                         Procedure Code)

  Procedure Modifier 4   cde_modifier_4       24d        data exists in up to 4, two digit codes from right side of field (follows               2
                                                         Procedure Code)

  Detail Charge          amt_billed           24f        Include decimal (100.00)                                                            11
  Family Planning        cde_epsdt_fp         24h        If box 24h is an F, export value Y. Export blank if any other value.                    1
  Indicator

  Diagnosis Indicator    cde_diag_treat_ind   24e         the only valid values are 1,2,3,4, 5,6,7,8. Strip leading zero if present.             4
                                                         · If anything else entered, change to 1


  Place of Service       cde_pos              24b                                                                                                2
5 Detail Key           physDtlKey                     Required Element
 Procedure Code        cde_proc            24d        5 digit code captured from left side of field                          5


 Procedure Qualifier   qlf_procedure_qlf   Captiva    Always HC                                                              2
                                           Assigned

 Rendering Provider    id_perf_prov        24k        iC will populate renderer with biller if renderer is blank   8 or 10
 Number
Level     Field Name                  XML Output Slot Name      Claim Form Box       Mapping /                                                      Slot
                                                                Location             Translation                                                    Length

        1 XML Root                    claimList                                      Required Element
        2 Claim                       claim                                          Required Element
          Version                     version                   Captiva Assigned     plug "1.0"                                                              3
        3 Header                      sPhys                                          Required Element
          ICN                         num_icn                   Captiva Assigned                                                                             13
          Detail Count                num_dtl_total             Captiva Calculated                                                                            3
          Amount Paid                 tpl_amt                   29                   Include decimal (12345678.11)                                           11
          Date Billed                 dte_billed                Captiva Assigned     Needs to be translated into valid date format of CCYY-                  10
                                                                                     MM-DD using Julian date from ICN.
          Total Charge                amt_billed                28                   Include decimal (100.00)                                                11
          Patient's Account NO.       num_pat_acct              26                   Default to "0"                                                          38
          Provider Signature          ind_prov_sign             31                   Default to "N"                                                           1
          Indicator
          Other Insured's Name        ind_carrier_denied        9                    blank, D, Y, P. Other coverage indicator                                 1
          Zip CODE+4 (NPI)            adr_zip_code              33                   T_clm_adr_n3_n4                                                         15

          Insured's Policy Group or                             11                   7, 8. Medicare disclaimer                                               1
          FECA Number                 cde_medicare_disclaimer
          Claim Type                  cde_clm_type              Captiva Assigned     plug "M" Professional Claims or plug "B" for                            1
                                                                                     Professional
          Provider Last Name          clm_lst_nam_prov          33                   First two characters of Billing Provider Name                           2
        4 Diagnosis                   diag_xref
          Sequence                    cde_diag_seq              Captiva Assigned     Order diags appear in box 21                                            1
          Qualifier Code              qlf_code_list             Captiva Assigned     BK' when the code_diag_seq is 1                                         2
                                                                                     'BF' when the code_diag_seq is NOT 1

          Diagnosis Code              cde_diag                  21                                                                                           5
        4 Header Key                  physHdrKey                                     Required Element
          Beneficiary ID              id_medicaid               1a                   10 digit ID#. Verify against stub file.                                 10
          Billing Provider Number     id_provider               33a or 33b           8 or 10 characters. If data in 33a, put that in id_provider.            10
                                                                                     If 33a blank but 33b is all numeric, put leftmost 8 digits
                                                                                     in id_provider. If 33a blank but 33b is not all numeric,
                                                                                     skip first two characters of 33b and put the rest, up to 8,
                                                                                     in id_provider.


          Referring Provider          id_prov_refer             17b                                                                                          10
          Number
          Bene Last Name              clm_lst_nam_recip         2                    Entire first name                                                       25
          Bene First Name             clm_recip_fst_nam         2                    Entire last name                                                        35
  Program Code                                     Captiva Assigned   Use WISC_TXIX for Medicaid.                                  15
                                                                      WISC_WWWP for Wisconsin Well Women's.
                                                                      WISC_WCDP for Wisconsin Chronic Disease Program.
                              id_payer_txn_sub                        Left justify, space fill.
5 Taxonomy                    clmEntity
  Sequence                    num_dtl              Captiva Assigned   Always 0                                                     1
  Qualifier Entity                                 Captiva Assigned   Assign DN when data comes from box 17b                       3
                              qlf_entity_type                         Assign 85 when data comes from box 33b
  Qualifier Code              qlf_id_taxonomy      17a ,33b                                                                         3
  Taxonomy                    cde_prov_taxonomy    17a ,33b                                                                        10
6 NPI                         clmEntNmAdr
  Qualifier Entity                                 Captiva Assigned   Assign DN when data comes from box 17b                       2
                              qlf_entity_type                         Assign 85 when data comes from box 33a
7 Header NPI                  partyIdentifier
  Provider Number             cde_party_id         17b, 33a, 33b      NPI # from 17b, 33a, 33b                                     10
  Identification Code         qlf_id_type          Captiva Assigned   XX if NPI # in 17b, 33a, 33b is exactly 10 digits. 24         2
  Qualifier                                                           otherwise.
7 Header NPI                  clmAdrN3N4
  Zip CODE+4                  adr_zip_code                            Only create this if both qlf_entity_type is 85 and zip       9
                                                                      code present in box 33
4 Detail                      detail               3                  Required Element
  From Date of Service        dte_first_svc        24a                Format CCYY-MM-DD.                                           10
  To Date of Service          dte_last_svc         24a                Format CCYY-MM-DD. If blank plug FDOS.                       10
  Units                       qty_billed           24g                Include decimal (25.00)                                      11
  Emergency Indicator         ind_emergency        24c                Y or N. Default to N. Assign Y if box 24c has an E.           1
  Procedure Modifier 1        cde_proc_mod         24d                data exists in up to 4, two digit codes from right side of    2
                                                                      field (follows Procedure Code)
  Procedure Modifier 2        cde_modifier_2       24d                data exists in up to 4, two digit codes from right side of   2
                                                                      field (follows Procedure Code)
  Procedure Modifier 3        cde_modifier_3       24d                data exists in up to 4, two digit codes from right side of   2
                                                                      field (follows Procedure Code)
  Procedure Modifier 4        cde_modifier_4       24d                data exists in up to 4, two digit codes from right side of   2
                                                                      field (follows Procedure Code)
  Detail Charge               amt_billed           24f                Include decimal (100.00)                                     11
  Family Planning Indicator   cde_epsdt_fp         24h                If box 24h is an F, export value Y. Export blank if any       1
                                                                      other value.
  Diagnosis Indicator         cde_diag_treat_ind   24e                 the only valid values are 1,2,3,4, 5,6,7,8. Strip leading   4
                                                                      zero if present.
                                                                      · If anything else entered, change to 1
  Place of Service            cde_pos              24b                                                                             2
5 Detail Key                  physDtlKey                              Required Element
  Procedure Code              cde_proc             24d                5 digit code captured from left side of field                5
  Procedure Qualifier   qlf_procedure_qlf   Captiva Assigned   Always HC                                                              2


  Rendering Provider    id_perf_prov        24j                iC will populate renderer with biller if renderer is blank   8 or 10
  Number
6 Taxonomy              clmEntity
  Qualifier Entity                          Captiva Assigned   If any data in box 24i or 24j for the current detail, plug             3
                        qlf_entity_type                        82. (From p 291 of 837p.pdf)
  Rendering Provider    qlf_id_taxonomy     24i                                                                                       3
  Number Qualifier
  Rendering Provider    cde_prov_taxonomy   24j                                                                                       10
  Number Taxonomy
6 Detail NPI            clmEntNmAdr
  Qualifier Entity                          Captiva Assigned   If any data in box 24i or 24j for the current detail, plug             3
                        qlf_entity_type                        82. (From p 291 of 837p.pdf)
7 Detail NPI            partyIdentifier
  NPI Number            cde_party_id        24j                NPI # from 24j                                                         10
  Identification Code   qlf_id_type         Captiva Assigned   XX if NPI # in 24j is exactly 10 digits. 24 otherwise.                  2
  Qualifier                                                    P 292 of 837p.pdf
                                    Field       Starting Ending
Table/File Name                     length
                    Field name in table/file    position position
Beneficiary Extract
rcptstub.dat        rid                      10          1      10
                    filler                    2         11      12
                    last name                 2         13      14
                    first name                3         15      17
                    LF                        1         18      18

Diagnosis Code Extract
diagstub.dat       diag code                7         1         7
                   LF                       1         8         8

Procedure Code (non-Dental) Extract
procstub.dat       procedure code           6         1         6
                   LF                       1         7         7

Provider Extract
provstub.dat        provider id           10          1        10
                    last name              2         11        12
                    LF                     1         13        13

NDC Extract
drugstub.dat        drug code             11          1        11
                    LF                     1         12        12

Revenue Code Extract
revstub.dat       revenue code              4         1         4
                  LF                        1         5         5

Dental Procedure Code Extract
dentstub.dat       code                     6         1         6
                   LF                       1         7         7

ICD-9-CM Code Extract
hospstub.dat       code                     4         1         4
                   LF                       1         5         5
Field Name                   XML Output Slot Name      Claim Form             Mapping /                                                         Slot
                                                       Box Location           Translation                                                       Length

XML Root                     claimList                                        Required Element
Claim                        claim                                            Required Element
Version                      version                   Captiva Assigned       plug "1.0"
Header                       sUb92                                            Required Element
Pat Cntl Number              num_pat_acct              3a                     Default to "0"                                                             38
Type Of Bill                 cde_type_of_bill          4                                                                                                  3
Charge                       amt_billed_ub92           47 From last page if   If 0001 detail present, use billed amt from 0001 detail. If no             11
                                                       multipage document.    0001 detail, sum up charges in all box 47's and use that.

Zip CODE+4 (NPI)             adr_zip_code              1                      T_clm_adr_n3_n4                                                            15

Admit Date                   dte_admission             12                     Format CCYY-MM-DD                                                          10
Attending                    id_prov_attend            76                                                                                                10
Operating                    ????                                                                                                                        10
Through                      dte_last_svc              6                      Format CCYY-MM-DD                                                          10
Covered Days                 num_days_covd             38                                                                                                 3
Remarks                      ind_carrier_denied        80                     If a letter appears in box 80, put value in ind_carrier_denied.             1

Remarks                      cde_medicare_disclaimer   80                     If a number appears in box 80, place value in                              1
                                                                              cde_medicare_disclaimer.
Detail Count                 num_dtl_total             Captiva Assigned       Calculated. Total detail lines on all pages of claim (box 41)              11

Date Billed                  dte_billed                Captiva Assigned       Julian date from ICN. Needs to be translated into valid date               11
                                                                              format of CCYY-MM-DD.
Admit Type                   cde_admit_type            14                                                                                                 1
Internal Control Number      num_icn                   Captiva Assigned                                                                                  13
Med Rec Number               cde_med_rec_num           3b                                                                                                30
Admit Source                 cde_admit_source          15                                                                                                 1
From                         dte_first_svc             6                      Format CCYY-MM-DD                                                          10
Claim Type                   cde_clm_type              Captiva Assigned       If not A, C, H, I, L, O flag claim.                                         1
Patient Status               cde_patient_status        17                                                                                                 2
Billing Provider Last Name   clm_lst_nam_prov          1                      First two characters of Billing Provider's Name                             2

Taxonomy                     clmEntity
Sequence                     num_dtl                   Captiva Assigned       Always 0                                                                   1
Qualifier Entity                                       Captiva Assigned       Assign 85 when data comes from box 57                                      3
                                                                              Assign 71 when data comes from box 76
                             qlf_entity_type                                  Assign 72 when data comes from box 77
Qualifier Code               qlf_id_taxonomy           57,76,77                                                                                           3
Taxonomy                     cde_prov_taxonomy         57,76,77                                                                                          10
PARS number                  clmRef
Sequence                     num_dtl                   Captiva Assigned       Always 0                                                                   1
Qualifier Code                                         Captiva Assigned       Always plug G4                                                             2


                             qlf_reference_id
PARS number                cde_ref_id          2                        If spots 11 or 12 present, iC will fail edit A70.                  12
Diagnosis                  ubDiagX
Sequence                   cde_diag_seq        Captiva Assigned - See   A for diag in box 68.                                              2
                                               Translation comments     E= Emergency,
                                                                        1= Primary and up numerically for other diags
                                                                        Example: If diags only in box 66B, 66E, 66K sequences should
                                                                        be 1,2,3. Not 3, 6, 12. If diags in box 66, 66B sequences should
                                                                        be 1,2. Not 1,3.
Qualifier Code             qlf_code_list       Captiva Assigned         BK' (primary) for diagnosis in box 67                              2
                                                                        'BJ' (admitting) for diagnosis in box 69
                                                                        'BN' (external) for diagnosis in box 72a,72b,72c
                                                                        'BF' for all other diagnoses
Diagnosis Code             cde_diag            69, 67A-67Q, 67,                                                                            5
                                               72a,72b,72c
Condition                  condition
Sequence                   cde_cond_seq        Captiva Assigned         Begin with 1 and increment by 1 for each condition. Eleven is      2
                                                                        maximum number of occurrences. Do not zero fill e.g., if
                                                                        cde_cond_seq is two, pass 2, not 02.
Condition Code             cde_cond            18-28                                                                                       2
Value                      value
Sequence                   num_seq             Captiva Assigned         Begin with 1 and increment by 1 for each value. Do not zero fill   2
                                                                        e.g., if num_seq is two, pass 2, not 02.
Value Code                 cde_value           39-41                                                                                        2
Amount                     amt_value           39-41                    Include decimal (100.00)                                           11
Procedure                  proc
Sequence                   num_seq             Captiva Assigned         Begin with 1 and increment by 1 for each ICD9 Procedure            1
Qualifier Code             qlf_code_list       Captiva Assigned         BR when code in Box 74                                             2
                                                                        BQ when codes in Box 74a-74e
Principal Procedure ICD9   cde_proc_icd9       74a - 74e                Only on Claim Type I and A                                          4
Principal Procedure Date   dte_icd_9_cm_proc   74a - 74e                Format CCYY-MM-DD                                                  10
Occurance                  occur
Sequence                   num_seq             Captiva Assigned         Begin with 1 and increment by 1 for each Occurrence and/or         2
                                                                        Occurrence Span. Twelve is maximum number of occurrences.
                                                                        Do not zero fill e.g., if num_seq is two, pass 2, not 02.

Qualifier Code             qlf_code_list       Captiva Assigned         BH when data is from box 31 - 34. Up to eight possible.            2
                                                                        BI when data is from box 35 - 36. Up to four possible.
Occurrence Code            cde_occurrence      31-36                                                                                       2

Date From                  dte_occurrence      31-36                    Format CCYY-MM-DD                                                  10
Date To                    dte_occ_to          35-36                    Format CCYY-MM-DD.                                                 10

Payer                      payer
Sequence                   num_seq             Captiva Assigned         Begin with 1 and increment by 1 for each payer                     1
Payer Code                 cde                 50                                                                                          1


Prior Payment Amount       amt_prior_payment   53                                                                                          11
Estimated Amount Due       amt_due_est         54                                                                                          11
Header Key                 ubHdrKey                                     Required Element
Billing Provider Number   id_provider          56                 Eight or ten characters                                             10
(NPI)
Beneficiary ID            id_medicaid          60                                                                                     10
Beneficary First Name     clm_recip_fst_nam    8b                 Entire first name                                                   25
Beneficiary Last Name     clm_lst_nam_recip    8b                 Entire last name                                                    35




Beneficiary DOB           dte_subscriber_dob   10                 Format CCYY-MM-DD                                                   10



Program Code              id_payer_txn_sub     Captiva Assigned   Use WISC_TXIX for Medicaid.                                         15
                                                                  WISC_WWWP for Wisconsin Well Women's.
                                                                  WISC_WCDP for Wisconsin Chronic Disease Program.
                                                                  Left justify, space fill.
Detail                    detail                                  Required Element
Revenue Code              cde_revenue          42                                                                                      4
Charge                    amt_billed_ub92      47                 Include decimal (100.00)                                            11
Serv. Date                dte_first_svc        45                 For Claim Type I and Claim Type A, plug FROM value of box 6         10
                                                                  into dte_first_svc. For all other claim types, use value from box
                                                                  45.
To Date of Service        dte_last_svc         Captiva Assigned   For Claim Type I and Claim Type A, plug THROUGH value of            10
                                                                  box 6 into dte_last_svc. For all other claim types, use value
                                                                  from box 49. If box 49 is blank, use value from box 45. If TOB
                                                                  in box 4 is 72X, do not use box 49 but instead plug dte_last_svc
                                                                  using box 45.
Units                     qty_units_billed     46                 Include decimal (25.00)                                             11
Modifier                  modifier
Sequence                  seq                  Captiva Assigned   When <claim_type> = "I", do not create iteration of the modifier    1
                                                                  element.
Modifier Code             cde_modifier         44                 When <claim_type> = "I", do not create iteration of the modifier    2
                                                                  element.

                                                                  Data exists in up to 4, two digit codes from right side of field
                                                                  (follows Procedure Code)
Detail Key                ubDtlKey                                Required Element
Qualifier Code            qlf_procedure_id     Captiva Assigned   Value = "HC"                                                        2
                                                                  The qlf_procedure_id should not be populated unless the
                                                                  corresponding procedure code is present.

Procedure Code            cde_proc             44                                                                                     5
Field Name                   XML Output Slot Name      Claim Form               Mapping /                                                                     Slot
                                                       Box Location             Translation                                                                   Length

XML Root                     claimList                                          Required Element
Claim                        claim                                              Required Element
Version                      version                   Captiva Assigned         plug "1.0"
Header                       sUb92                                              Required Element
Patient Account Number       num_pat_acct              3                        Default to "0"                                                                     38
Type Of Bill                 cde_type_of_bill          4                                                                                                            3
Charge                       amt_billed_ub92           47 w/ 0001 rev code.     If 0001 detail present, use billed amt from 0001 detail. If no 0001 detail,        11
                                                       From last page if        sum up charges in all box 47's and use that.
                                                       multipage document.
Admit Date                   dte_admission             17                       Format CCYY-MM-DD                                                                  10
Remarks                      ind_carrier_denied        84                       If a letter appears in box 84, put value in ind_carrier_denied.                     1


Remarks                      cde_medicare_disclaimer   84                       If a number appears in box 84, place value in cde_medicare_disclaimer.                 1


Provider Signature Indicator ind_prov_sign             85                       default to "N"                                                                         1

Attending Phys. ID           id_prov_attend            82                                                                                                          10
To Date of Service           dte_last_svc              6                        Format CCYY-MM-DD                                                                  10
Covered Days                 num_days_covd             7                                                                                                            3
Other Phys. ID               id_prov_other_1           83a                                                                                                         10
Other Phys. ID               id_prov_other_2           83a                                                                                                         10
Detail Count                 num_dtl_total             Captiva Assigned         Calculated. Total detail lines on claim (box 42)                                   11
Date Billed                  dte_billed                Captiva Assigned         Julian date from ICN. Needs to be translated into valid date format of             11
                                                                                CCYY-MM-DD.
Admit Type                   cde_admit_type            19                                                                                                           1
Internal Control Number      num_icn                   Captiva Assigned                                                                                            13
Medical Record Number        cde_med_rec_num           23                                                                                                          30
Admit Source                 cde_admit_source          20                                                                                                           1
From Date Of Service         dte_first_svc             6                        Format CCYY-MM-DD                                                                  10
Claim Type                   cde_clm_type              Captiva Assigned         If not A, C, H, I, L, O flag claim.                                                 1
Patient Status               cde_patient_status        22                                                                                                           2
Billing Provider Last Name   clm_lst_nam_prov          1                        First two characters of Billing Provider's Name                                     2

PARS number                  clmRef
Sequence                     num_dtl                   Captiva Assigned         Always 0                                                                            1
Qualifier Code               qlf_reference_id          Captiva Assigned         Always plug G4                                                                      2
PARS number                  cde_ref_id                2                        If spots 11 or 12 present, iC will fail edit A70.                                  12
Diagnosis                    ubDiagX
Sequence                     cde_diag_seq              Captiva Assigned - See   A= Admitting,                                                                          1
                                                       Translation comments     E= Emergency,
                                                                                Take from spot occupied by diags in box 67-76 e.g. if diag in spot 2 and
                                                                                spot 4, send sequence as 2 and 4. Not 1 and 2. If only diag is in spot 3,
                                                                                send sequence as 3. Not 1.
Qualifier Code            qlf_code_list       Captiva Assigned   BK' (primary) for diagnosis in box 67                                           2
                                                                 'BJ' (admitting) for diagnosis in box 76
                                                                 'BN' (external) for diagnosis in box 77
                                                                 'BF' for all other diagnoses
Diagnosis Code            cde_diag            67-76                                                                                              5
Condition                 condition
Sequence                  cde_cond_seq        Captiva Assigned   Begin with 1 and increment by 1 for each condition. Do not zero fill e.g., if   2
                                                                 cde_cond_seq is two, pass 2, not 02.
Condition Code            cde_cond            24-30                                                                                              2
Value                     value
Sequence                  num_seq             Captiva Assigned   Begin with 1 and increment by 1 for each value. Do not zero fill e.g., if       2
                                                                 num_seq is two, pass 2, not 02.
Value Code                cde_value           39-41                                                                                               2
Amount                    amt_value           39-41              Include decimal (100.00)                                                        11
Procedure                 proc
Sequence                  num_seq             Captiva Assigned   Begin with 1 and increment by 1 for each ICD9 Procedure                         1
Qualifier Code            qlf_code_list       Captiva Assigned   BR when code in Box 80                                                          2
                                                                 BQ for all other codes
ICD9                      cde_proc_icd9       80 & 81            Only on Claim Type I and A                                                       4
Date of ICD9              dte_icd_9_cm_proc   80 & 81            Format CCYY-MM-DD                                                               10
Occurance                 occur
Sequence                  num_seq             Captiva Assigned   Begin with 1 and increment by 1 for each Occurrence and/or Occurrence           2
                                                                 Span. Do not zero fill e.g., if num_seq is two, pass 2, not 02.

Qualifier Code            qlf_code_list       Captiva Assigned   BH when data is from box 32 - 35                                                2
                                                                 BI when data is from box 36
Occurrence Code           cde_occurrence      32-36                                                                                               2
Date From                 dte_occurrence      32-36              Format CCYY-MM-DD                                                               10
Date To                   dte_occ_to          36                 Format CCYY-MM-DD.                                                              10
Payer                     payer
Sequence                  num_seq             Captiva Assigned   Always 1. Only create if amts in box 54 greater than 0                          1
Payer Code                cde                 50                 Always B. Only create if amts in box 54 greater than 0                           1
Prior Payment Amount      amt_prior_payment   54                                                                                                 11
Header Key                ubHdrKey                               Required Element
Billing Provider Number   id_provider         51                                                                                                 10
Beneficiary ID            id_medicaid         60                                                                                                 10
Beneficary First Name     clm_recip_fst_nam   12                 Entire first name                                                               25
Beneficiary Last Name     clm_lst_nam_recip   12                 Entire last name                                                                35
Program Code              id_payer_txn_sub    Captiva Assigned   Use WISC_TXIX for Medicaid.                                                     15
                                                                 WISC_WWWP for Wisconsin Well Women's.
                                                                 WISC_WCDP for Wisconsin Chronic Disease Program.
                                                                 Left justify, space fill.
Detail                    detail                                 Required Element
Revenue Code              cde_revenue         42                                                                                                 4
Charge            amt_billed_ub92    47                 Include decimal (100.00)                                                       11



Date of Service   dte_first_svc      45                 For Claim Type I and Claim Type A, plug FROM value of box 6 into               10
                                                        dte_first_svc. For all other claim types, use value from box 45.
Date of Service   dte_last_svc       Captiva Assigned   For Claim Type I and Claim Type A, plug THROUGH value of box 6 into            10
                                                        dte_last_svc. For all other claim types, use value from box 49. If box 49 is
                                                        blank, use value from box 45. If TOB in box 4 is 72X, do not use box 49
                                                        but instead plug dte_last_svc using box 45. Box 49 has only 2 digit date.
                                                        Obtain month and year from box 45 and make a date of form CCYY-MM-
                                                        DD
Units             qty_units_billed   46                 Include decimal (25.00)                                                        11
Modifier          modifier
Sequence          seq                Captiva Assigned   When <claim_type> = "I", do not create iteration of the modifier element.      1

Modifier Code     cde_modifier       44                 When <claim_type> = "I", do not create iteration of the modifier element.      2

                                                        Data exists in up to 4, two digit codes from right side of field (follows
                                                        Procedure Code). Four modifiers needed for Home Health/Hospice.



Detail Key        ubDtlKey                              Required Element
Qualifier Code    qlf_procedure_id   Captiva Assigned   Value = "HC"                                                                   2
                                                        The qlf_procedure_id should not be populated unless the corresponding
                                                        procedure code is present.

Procedure Code    cde_proc           44                                                                                                5
Level     Field Name                 XML Output Slot Name   Claim Form Box Location   Mapping /                         Slot
                                                                                      Translation                       Length

        1 XML Root                   claimList                                        Required Element
        2 Claim                      claim                                            Required Element
          Version                    version                Captiva Assigned          plug "1.0"
        3 Header                     sPhrm                                            Required Element
          Internal Control Number    num_icn                Captiva Assigned                                                      13
          Location Code              cde_patient_loc        19                                                                     2
          Patient paid               amt_patnt_liab         29                        Include decimal (100.00)                    11
          Date Billed                dte_billed             Captiva Assigned          Format of CCYY-MM-DD.                       10
          Prescription Date          dte_prescribe          9                         Format of CCYY-MM-DD.                       10
          Dispense Date              dte_dispense           10                        CCYY-MM-DD                                  10
          Prescriber ID              id_prov_prescrb        8                                                                     10
          Prescription Number        num_prscrip            16                                                                     7
          Refill Code                qty_refill             11                                                                     2
          Days Supply                num_day_supply         13                                                                     3
          Sub Clar Code              cde_clarification      25                                                                     2
          Signature                  ind_prov_sign          31                        Default to 'N'                               1
          Claim Type                 cde_clm_type           Captiva Assigned          "P" for Pharmacy                             1
          Detail Count               num_dtl_total          Captiva Assigned          Always 1                                     1
          Other Coverage Amount      tpl_amt                28                                                                    11
          Charge                     amt_billed             27                                                                    11
          Level of Effort            level_of_effort        21                                                                     2
          Reason for Service         reason_for_svc_cde     22                                                                     2
          Professional Service       professional_svc_cde   23                                                                     2
          Other Coverage Code        ind_carrier_denied     26                                                                     1
          Result of Service          result_of_svc_cde      24                                                                     2
          Dispensed as Written       ind_brand_med_nec      17                                                                     1
        3 Diagnosis Crossreference   diag_xref
          Sequence                   cde_diag_seq           Captiva Assigned          Always 1                                    1

          Qualifier Code             qlf_code_list          Captiva Assigned          BK' since the code_diag_seq                 2
                                                                                      is 1
          Diagnosis Code             cde_diag               20                                                                    7
        3 Header Key                 phrmHdrKey                                       Required Element
          Provider Number            id_provider            2                                                           8 or 10
          Provider Last Name         clm_lst_nam_prov       1                         First two characters of Billing             2
                                                                                      Provider Name
          Recipient ID               id_medicaid            4                                                                     10
          First Name                 clm_recip_fst_nam      5                         Entire first name                           12
          Last Name                  clm_lst_nam_recip      5                         Entire last name                            15
          Program Code               id_payer_txn_sub       Captiva Assigned          Use WISC_TXIX for Medicaid.                 15
                                                                                      WISC_WWWP for Wisconsin
                                                                                      Well Women's.
                                                                                      WISC_WCDP for Wisconsin
        3 Detail                     detail                                           Chronic Disease Program.
                                                                                      Required Element
 Detail Number   num_dtl                   Captiva Assigned   Always 1           1


  Unit Dose      ind_submitted_unit_dose   15                                     1
  Quantity       qty_dispense              14                 Default to 0.000   11
4 Detail Key     phrmDtlKey                                   Required Element
  NDC Code       cde_ndc                   12                                    11
                                                                     Claim Form                        Mapping /
Level     Field Name                      XML Output Slot Name       Box Location                     Translation                    Slot Length

        1 XML Root                        claimList                                  Required Element
        2 Claim                           claim                                      Required Element
          Version                         version                                    plug "1.0"
        3 Header                          sDntl                                      Required Element
          ICN                             num_icn                                                                                        13
          Detail Count                    num_dtl_total              Captiva                                                             4
                                                                     assigned
          Claim Type                      cde_clm_type               Captiva         plug "D" Dental Claims                              1
                                                                     assigned
          Patient Account #               num_pat_acct               31-37                                                               38
          TPL Amount                      tpl_amt                    59 Payment by   Include decimal (100.00)                            11
                                                                     other plan
          Date Billed                     dte_billed                                 Julian date from ICN. Needs to be translated        10
                                                                                     into valid date format of CCYY-MM-DD.

          Total Fee                       amt_billed                 59 Total fee    (include decimal (100.00)                           11
          Provider Signature Indicator    ind_prov_sign              62              Autoplug a "Y"                                      1
          Place of Service                cde_pos                    49              Office = 11                                          2
                                                                                     Hospital = 22
                                                                                     ECF = 32
                                                                                     Other = 11
                                                                                     Valid Values: Y, N. Default to N. Set to Y if
                                                                                     an E or e is present on any line in box 59
          Admin Use Only                  ind_emergency              59              Admin Use Only                                      1
                                                                                     Any alpha value in box 33 goes in
                                                                                     ind_carrier_denied. Other insurance indicator
          Other subscriber's Name         ind_carrier_denied         33                                                                  1
                                                                                     Any numeric value in box 11 goes in
                                                                                     cde_medicare_disclaimer. T18 Disclaimer
          Other subscriber's Name          cde_medicare_disclaimer   33              Codes                                               1
          Provider Last Name              clm_lst_nam_prov           42              First two characters of Billing Provider Name       2

          Zip code                        adr_zip_code               52                                                                  15
        4 Header Key                      dntlHdrKey                                 Required Element
          Beneficiary ID                  id_medicaid                13              Capture 10 digit MA ID#.                            10
          Billing Provider Number         id_provider                44                                                                  10
          Bene Last Name                  clm_lst_nam_recip          8               Entire last name                                    35
          Bene First Name                 clm_recip_fst_nam          8               Entire first name                                   25
          Program Code                    id_payer_txn_sub           Captiva         Use WISC_TXIX for Medicaid.                         15
                                                                     Assigned        WISC_WWWP for Wisconsin Well Women's.
                                                                                     WISC_WCDP for Wisconsin Chronic
        5 Billing Provider Taxonomy       clmEntity                                  Disease Program.
          Sequence                        num_dtl                    Captiva         Always 0                                            1
                                                                     Assigned        Only create if data in box 44 is exactly 10
                                                                                     digits long

          Qualifier Entity                                           Captiva         Only create if data in box 44 is exactly 10         2
                                                                     Assigned        digits long
                                          qlf_entity_type                            Always 85
        6 Billing Provider NPI            clmEntNmAdr                                P 196 of 837d.pdf
          Qualifier Entity                                           Captiva         Only create if data in box 44 is exactly 10         2
                                                                     Assigned        digits long
                                          qlf_entity_type                            Always 85
        7 Billing Provider NPI            partyIdentifier
          Provider Number                 cde_party_id               44              Only create if data in box 44 is exactly 10         10
                                                                                     digits long
          Identification Code Qualifier   qlf_id_type                Captiva         Only create if data in box 44 is exactly 10         2
                                                                     Assigned        digits long
                                                                                     Always XX
                                                                                     P 292 of 837p.pdf
        7 Billing Provider NPI            clmAdrN3N4
  Zip CODE+4                       adr_zip_code        52                Only create this if both                         9
                                                                         1) zip code present in box 52
                                                                         2) data in box 44 is exactly 10 digits long
5 Performing Provider Taxonomy     clmEntity
  Sequence                         num_dtl             Captiva           Always 0                                         1
                                                       Assigned          Only create if data in box 62 is exactly 10
                                                                         digits long

  Qualifier Entity                                     Captiva           Only create if data in box 62 is exactly 10      2
                                                       Assigned          digits long
                                                                         Always 82
                                   qlf_entity_type                       P 196 of 837d.pdf
6 Performing Provider NPI          clmEntNmAdr
  Qualifier Entity                                     Captiva           Only create if data in box 62 is exactly 10      2
                                                       Assigned          digits long
                                   qlf_entity_type                       Always 82
7 Performing Provider Header NPI   partyIdentifier
  Provider Number                  cde_party_id        62                Only create if data in box 62 is exactly 10      10
                                                                         digits long
  Identification Code Qualifier    qlf_id_type         Captiva           Only create if data in box 62 is exactly 10      2
                                                       Assigned          digits long
7 Performing Provider Header NPI   clmAdrN3N4
  Zip CODE+4                       adr_zip_code        66                Only create this if both                         9
                                                                         1) zip code present in box 66
                                                                         2) data in box 62 is exactly 10 digits long

4 Detail                           detail                                Required Element

                                                                         Format CCYY-MM-DD
  Service Date                     dte_first_svc       59                                                                 10


                                                                         If procedure code is D5510, D5520, D5610,
                                                                         D5620, D5630, D5640, D5650, or D5660
                                                                         move contents of tooth box to cde_quadrant.
                                                                         If procedure code is NOT D5510, D5520,
                                                                         D5610, D5620, D5630, D5640, D5650,
                                                                         D5660 contents of tooth box goes in
  Tooth                            cde_tooth_nbr       59                cde_tooth_nbr.                                    2
  Quantity                         qty_billed          59                include decimal (25.00)                          11
  Quadrant Code                    cde_quadrant        59                                                                  2
  Fee                              amt_billed          59                Include decimal (100.00)                         11
5 Detail Key                       dntlDtlKey
  Procedure Code                   cde_proc            59                                                                  5
  Performing Provider              id_prov_perf        62                                                               8 or 10
5 Surface                          surface
                                                                        Begin with 1 and increment by 1 for each
                                                                        surface. Do not zero fill e.g., if num_seq is
  Sequence                         num_seq             Captiva assigned two, pass 2, not 02.                               2
                                                                        Separate each character in Surface field of
                                                                        box 59. If two surfaces, make two entries. If
  Surface                          cde_tooth_surface   59               five, make five entries                            1
                                                                 Claim Form          Mapping /
Level    Field Name                XML Output Slot Name         Box Location         Translation                       Slot Length
  1      XML Root                  claimList              Required Element
  2      Claim                     claim                    occurs under claimList
         Form                      form                       Captiva Assigned                plug "pharmacy"
         Type                      type                       Captiva Assigned                plug "pharmacy"
 3       Header                    pPhrm                     occurs under claim
         Internal Control Number   num_icn                    Captiva Assigned                                              13
         PT LOC                    cde_patient_location               15                                                     2
         Other Coverage Code       ind_carrier_denied                 18                                                     1
         Other Coverage Amount     tpl_amt                            20             include decimal (100.00)               11
         Date Billed               dte_billed                 Captiva Assigned             Julian Date from ICN             10
         Date Prescribed           dte_prescribe                       9             Format CCYY-MM-DD                      10
         Date Filled               dte_dispense                       10             Format CCYY-MM-DD                      10
         Prescriber Number         id_prov_prescrb                     8                                                    10
         Prescription Number       num_prscrip                        14                                                     7

          Refill                   qty_refill                         11                                                       2
          Days Supply              num_day_supply                       Do                                                     not
                                                                      12 not zero fill e.g., if num_day_supply is two, pass 2, 3 02.
          Charge                   amt_billed                         19             include decimal (100.00)                 11
          Level of Effort          level_of_effort                    17                                                       2
          Detail Count             num_dtl_total               Captiva Assigned Calculated. Total detail lines on claim        3
          Certification            ind_prov_sign                      23                       Y - N. Default to N             1
          Quantity Dispensed       qty_dispense                       13                         Default to 0.000             11
          Claim Type               claim_type                  Captiva Assigned                     plug "Q"                   1
          Patient Paid Amount      amt_patnt_liab                     21                  include decimal (100.00)            11
        3 Header Key               phrmHdrKey                 Required Element
          Provider Number          id_provider                         2                                                   8 or 10
          Provider Last Name       clm_lst_nam_prov                    1             First two characters of Billing           2
                                                                                     Provider Name
                                   id_medicaid                                       Capture 10 digit MA ID#. Verify
         Recipient ID                                                  4             against stub file.                       10
         First Name                clm_recip_fst_nam                   5             Entire first name                        12
         Last Name                 clm_lst_nam_recip                   5             Entire last name                         15
         Program Code              id_payer_txn_sub       Captiva Assigned           Use WISC_TXIX for Medicaid.             15
                                                                                      WISC_WWWP for Wisconsin
                                                                                     Well Women's.
                                                                                      WISC_WCDP for Wisconsin
                                                                                     Chronic Disease Program.
                                                                                      Left justify, space fill.
 3       Detail                    detail                    occurs under header
    Ingredient Quantity   qty_dispense        Ingredient Quantity           Default to 0.000         11
    Ingredient Cost       amt_billed            Ingredient Cost         include decimal (25.32)      11
4     Detail Key          phrmDtlKey          occurs under detail
    Ingredient NDC        cde_ndc               Ingredient NDC                                       11
3   Diagnosis             diag               occurs under header
    Sequence              cde_diag_seq    Captiva Assigned          Always 1
                                                                                                     1
    Qualifier Code        qlf_code_list   Captiva Assigned          BK' since the code_diag_seq is
                                                                    1                                2
    Diagnosis Code        cde_diag        16                                                         7
                                                                                                                     Mapping /                             Slot
Level     Field Name                     XML Output Slot Name      Claim Form Box Location                          Translation                           Length

        1 XML Root                       claimList                                           Required Element
        2 Claim                          claim                                               Required Element
          Version                        version                   Captiva Assigned          plug "1.0"
        3 Header                         sDntl                                               Required Element
          ICN                            num_icn                   Captiva Assigned                                                                        13
          Detail Count                   num_dtl_total             Captiva Calculated                                                                       4
          Claim Type                     cde_clm_type              Captiva Assigned          plug "D" Dental Claims                                         1
          Patient Account #              num_pat_acct              23                                                                                      38
          Other Fee(s)                   tpl_amt                   32                        Include decimal (100.00)                                      11
          Date Billed                    dte_billed                Captiva Assigned          Julian date from ICN. Needs to be translated into valid       10
                                                                                             date format of CCYY-MM-DD.
          Billed amount                  amt_billed                Captiva Calculated        Sum of box 32 and box 33                                      11
          Remarks                        ind_emergency             35                        Valid Values: Y, N. Default to N. Set to Y if an E or e is     1
                                                                                             present on any line in box 35
          Provider Signature Indicator   ind_prov_sign             53                        Autoplug a "Y"                                                 1
          Place of Service               cde_pos                   38                        Office = 11                                                    2
                                                                                             Hospital = 22
                                                                                             ECF = 32
                                                                                             Other = 11
                                                                                             Any alpha value in box 11 goes in ind_carrier_denied.
          Other Carrier Name             ind_carrier_denied        11                        Other insurance indicator                                      1
                                                                                             Any numeric value in box 11 goes in
          Other Carrier Name             cde_medicare_disclaimer   11                        cde_medicare_disclaimer. T18 Disclaimer Codes                  1
          Provider Last Name             clm_lst_nam_prov          48                        First two characters of Billing Provider Name                  2
        4 Header Key                     dntlHdrKey                                          Required Element
          Subscriber Identifier          id_medicaid               15                                                                                      10
          Billing Provider Number        id_provider               49                                                                                      10
          Bene Last Name                 clm_lst_nam_recip         12                        Entire last name                                              35
          Bene First Name                clm_recip_fst_nam         12                        Entire first name                                             25
          Program Code                   id_payer_txn_sub          Captiva Assigned          Use WISC_TXIX for Medicaid. WISC_WWWP for                     15
                                                                                             Wisconsin Well Women's. WISC_WCDP for Wisconsin
                                                                                             Chronic Disease Program. Left justify, space fill.

        5 Billing Provider Taxonomy      clmEntity
          Sequence                       num_dtl                   Captiva Assigned          Always 0                                                       1
                                                                                             Only create if data in box 49 is exactly 10 digits long
          Qualifier Entity                                         Captiva Assigned          Only create if data in box 49 is exactly 10 digits long        2
                                                                                             Always 85
                                         qlf_entity_type                                     P 196 of 837d.pdf
        6 Billing Provider NPI           clmEntNmAdr
  Qualifier Entity                                   Captiva Assigned   Only create if data in box 49 is exactly 10 digits long       2
                                   qlf_entity_type                      Always 85
7 Billing Provider NPI             partyIdentifier
  Provider Number                  cde_party_id      49                 Only create if data in box 49 is exactly 10 digits long       10
  Identification Code Qualifier    qlf_id_type       Captiva Assigned   Only create if data in box 49 is exactly 10 digits long       2
                                                                        Always XX
7 Billing Provider NPI             clmAdrN3N4
  Zip CODE+4                       adr_zip_code      48                 Only create this if both                                      9
                                                                        1) zip code present in box 48
                                                                        2) data in box 49 is exactly 10 digits long
5 Performing Provider Taxonomy     clmEntity
  Sequence                         num_dtl           Captiva Assigned   Always 0                                                      1
                                                                        Only create if data in box 54 is exactly 10 digits long

  Qualifier Entity                                   Captiva Assigned   Only create if data in box 54 is exactly 10 digits long       2
                                                                        Always 82
                                                                        P 196 of 837d.pdf
                                   qlf_entity_type
6 Performing Provider NPI          clmEntNmAdr
  Qualifier Entity                                   Captiva Assigned   Only create if data in box 54 is exactly 10 digits long       2
                                                                        Always 82
                                   qlf_entity_type
7 Performing Provider Header NPI   partyIdentifier
  Provider Number                  cde_party_id      54                 Only create if data in box 54 is exactly 10 digits long       10

  Identification Code Qualifier    qlf_id_type       Captiva Assigned   Only create if data in box 54 is exactly 10 digits long       2
                                                                        Always XX
7 Performing Provider Header NPI   clmAdrN3N4
  Zip CODE+4                       adr_zip_code      56                 Only create this if both                                      9
                                                                        1) zip code present in box 56
                                                                        2) data in box 54 is exactly 10 digits long

4 Detail                           detail                               Required Element
                                                                        Format CCYY-MM-DD
  Service Date                     dte_first_svc     24                                                                               10
                                                                        If 1-9 is received, do not plug leading zero. If a single
  Tooth Number                     cde_tooth_nbr     27                 letter received, do not plug leading zero.                     2
  Units                            qty_billed        Captiva Assigned   Plug 1.00                                                     11
  Area of Oral Cavity              cde_quadrant      25                                                                                2
  Fee                              amt_billed        31                 Include decimal (100.00)                                      11
5 Detail Key                       dntlDtlKey
  Procedure Code                   cde_proc          29                                                                                5
  Performing Provider              id_prov_perf      54                                                                             8 or 10
5 Surface                          surface
                                    Captiva Assigned   Begin with 1 and increment by 1 for each surface. Do
                                                       not zero fill e.g., if num_seq is two, pass 2, not 02.
Sequence        num_seq                                                                                         2
                                                       Separate each character. If two surfaces, make two
Tooth Surface   cde_tooth_surface   28                 entries. If five, make five entries                      1

				
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