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837 Institutional Inbound - Puerto Rico Health Plan_ Inc

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					     1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 1 of 152
                                                                                              Detail Data Definition-837 Institutional

1                                                   HIPAA - 837 Institutional Claim                                                                                             PRHP Processing Field
2                                               REQ or R = Required; SIT or S = Situational
3     Seg ID    Segment                          Req/Loop Ref Desc Description                                               Use   Type   Len   Field   PRHP Processing Field

 4     ISA      Interchange Control Header          REQ
 5     ISA      Interchange Control Header          REQ         ISA01    Authorization Information Qualifier
 6     ISA      Interchange Control Header                               00, No Authorization Information Present
 7     ISA      Interchange Control Header                               03, Additional Data Identification
 8     ISA      Interchange Control Header          REQ         ISA02    Authorization Information
 9     ISA      Interchange Control Header          REQ         ISA03    Security Information Qualifier
10     ISA      Interchange Control Header                               00, No Security Information Present
11     ISA      Interchange Control Header                               01, Password
12     ISA      Interchange Control Header          REQ         ISA04    Security Information
13     ISA      Interchange Control Header          REQ         ISA05    Interchange ID Qualifier
14     ISA      Interchange Control Header                               01, Duns
15     ISA      Interchange Control Header                               14, Duns Plus Suffix
16     ISA      Interchange Control Header                               20, Health Industry Number (HIN)
17     ISA      Interchange Control Header                               27, Carrier Identification Number as assigned by
                                                                         HCFA
18     ISA      Interchange Control Header                               28, Fiscal Intermediary Identification Number as
                                                                         assigned by HCFA
19     ISA      Interchange Control Header                               29, Medicare Provider and Supplier Identification
                                                                         Number as assigned by HCFA
20     ISA      Interchange Control Header                               30, US Federal Tax ID Number
21     ISA      Interchange Control Header                               33, NAIC Code
22     ISA      Interchange Control Header                               ZZ, Mutually Defined
23     ISA      Interchange Control Header          REQ         ISA06    Interchange Sender ID
24     ISA      Interchange Control Header          REQ         ISA07    Interchange ID Qualifier
25     ISA      Interchange Control Header                               01, Duns
26     ISA      Interchange Control Header                               14, Duns Plus Suffix
27     ISA      Interchange Control Header                               20, Health Industry Number (HIN)
28     ISA      Interchange Control Header                               27, Carrier Identification Number as assigned by
                                                                         HCFA
29     ISA      Interchange Control Header                               28, Fiscal Intermediary Identification Number as
                                                                         assigned by HCFA
30     ISA      Interchange Control Header                               29, Medicare Provider and Supplier Identification
                                                                         Number as assigned by HCFA
31     ISA      Interchange Control Header                               30, US Federal Tax ID Number
32     ISA      Interchange Control Header                               33, NAIC Code
33     ISA      Interchange Control Header                               ZZ, Mutually Defined
34     ISA      Interchange Control Header          REQ         ISA08    Interchange Receiver ID
35     ISA      Interchange Control Header          REQ         ISA09    Interchange Date
36     ISA      Interchange Control Header          REQ         ISA10    Interchange Time
37     ISA      Interchange Control Header          REQ         ISA11    Interchange Control Standards Identifier
38     ISA      Interchange Control Header                               U, US EDI Community of ASC X12, TDCC, and
                                                                         UCS
39     ISA      Interchange Control Header          REQ         ISA12    Interchange Control Version Number
40     ISA      Interchange Control Header                               00401, Draft Standards for Trial Use Approved
                                                                         for Publication by ASC X12 Procedures Review
                                                                         Board through October 1997
41     ISA      Interchange Control Header          REQ         ISA13    Interchange Control Number
42     ISA      Interchange Control Header          REQ         ISA14    Acknowledgment Requested
43     ISA      Interchange Control Header                               0, No Acknowledgment Requested
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     1/22/2011, 6:51 AM                                                                                   Puerto Rico Health Plan, Inc.                                                                Page 2 of 152
                                                                                                      Detail Data Definition-837 Institutional

1                                                           HIPAA - 837 Institutional Claim                                                                                                 PRHP Processing Field
2                                                       REQ or R = Required; SIT or S = Situational
3     Seg ID    Segment                                  Req/Loop Ref Desc Description                                             Use   Type         Len   Field   PRHP Processing Field

44     ISA      Interchange Control Header                                       1, Interchange Acknowledgement Requested
45     ISA      Interchange Control Header                  REQ         ISA15    Usage Indicator
46     ISA      Interchange Control Header                                       P, Production Data
47     ISA      Interchange Control Header                                       T, Test Data
48     ISA      Interchange Control Header                  REQ         ISA16    Component Element Separator

49
50     GS       Functional Group Header                     REQ
51     GS       Functional Group Header                     REQ          GS01    Functional Identifier Code
52     GS       Functional Group Header                                          HC, Health Care Claim (837)
53     GS       Functional Group Header                     REQ          GS02    Application Sender's code
54     GS       Functional Group Header                     REQ          GS03    Application Receiver's code
55     GS       Functional Group Header                     REQ          GS04    Date

56     GS       Functional Group Header                     REQ          GS05    Time
57     GS       Functional Group Header                     REQ          GS06    Group Control Number
58     GS       Functional Group Header                     REQ          GS07    Responsible Agency Code
59     GS       Functional Group Header                                          X, Accredited Standards Committee X12
60     GS       Functional Group Header                     REQ          GS08    Version/Release/Industry Identifier Code
61     GS       Functional Group Header                                          004010X096, Draft Standards Approved for
                                                                                 Publication by ASC X12 Procedures Review b
                                                                                 oard through October 1997, as published in this
                                                                                 Implementation Guide.
62
63              Transaction Set Header                     REQ/NA
64      ST      Transaction Set Header                      REQ       ST01       Transaction Set Identifier Code                   R     ID     3/3          P      PRHP Processing Field
65      ST      Transaction Set Header                      REQ       ST02       Transaction Set Control Number                    R     AN     4/9          X
66
67              Beginning of Hierarchical Transaction      REQ/NA

68     BHT      Beginning of Hierarchical Transaction       REQ       BHT01      Hierarchical Structure Code                       R     ID     4/4          E      PRHP Processing Field
69                                                                               0019, Information Source, Sub scriber,
                                                                                 Dependent
70     BHT      Beginning of Hierarchical Transaction       REQ       BHT02      Transaction Set Purpose Code                      R     ID     2/2          E      PRHP Processing Field
71                                                                               00, Original
72                                                                               18, Reissue
73     BHT      Beginning of Hierarchical Transaction       REQ       BHT03      Reference Identification                          R     AN     1/30         E      PRHP Processing Field
74     BHT      Beginning of Hierarchical Transaction       REQ       BHT04      Date                                              R     DT     8/8          E      PRHP Processing Field
75     BHT      Beginning of Hierarchical Transaction       REQ       BHT05      Time                                              R     TM     4/8          E      PRHP Processing Field
76     BHT      Beginning of Hierarchical Transaction       REQ       BHT06      Transaction Type Code                             R     ID     2/2          X
77                                                                               CH, Chargeable
78                                                                               RP, Reporting
79              Transmission Type Identification           REQ/NA
80     REF      Transmission Type Identification            REQ       REF01      Reference Identification Qualifier                R     ID     2/3          X
81                                                                               87, Functional Category
82     REF      Transmission Type Identification           REQ        REF02      Reference Identification                          R     AN     1/30         E      PRHP Processing Field
83     REF      Transmission Type Identification          Not used    REF03      Description
84     REF      Transmission Type Identification          Not used    REF04      Reference Identifier
85

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      1/22/2011, 6:51 AM                                                                               Puerto Rico Health Plan, Inc.                                                             Page 3 of 152
                                                                                                   Detail Data Definition-837 Institutional

 1                                                       HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                   REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                              Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

86               Submitter Name                       REQ/1000A
87      NM1      Submitter Name                         REQ     NM101         Entity Identifier Code                        R      ID     2/3          X
88                                                                            41, Submitter
89      NM1      Submitter Name                          REQ       NM102      Entity Type Qualifier                         R      ID     1/1          X
90                                                                            1, Person
91                                                                            2, Non-person Entity
92      NM1      Submitter Name                         REQ        NM103      Name Last or Organization Name                R      AN     1/35         E      PRHP Processing Field
93      NM1      Submitter Name                          SIT       NM104      Name First                                    S      AN     1/25         X
94      NM1      Submitter Name                          SIT       NM105      Name Middle                                   S      AN     1/25         X
95      NM1      Submitter Name                        Not used    NM106      Name Prefix
96      NM1      Submitter Name                        Not used    NM107      Name Suffix
97      NM1      Submitter Name                         REQ        NM108      Identification Code Qualifier                 R      ID     1/2          X
98                                                                            46, ETIN
99      NM1      Submitter Name                          REQ       NM109      Identification Code                           R      AN     2/80         P      PRHP Processing Field

100     NM1      Submitter Name                        Not used    NM110      Entity Relationship Code                                                 X
101     NM1      Submitter Name                        Not used    NM111      Entity Identifier Code                                                   X
102
103              Submitter EDI Contact Information    REQ/1000A
104     PER      Submitter EDI Contact Information      REQ     PER01         Contact Function Code                         R      ID     2/2          X
105                                                                           IC, Information Contact
106     PER      Submitter EDI Contact Information       REQ       PER02      Name                                          R      AN     1/60         E      PRHP Processing Field
107     PER      Submitter EDI Contact Information       REQ       PER03      Communication Number Qualifier                R      ID     2/2          X
108                                                                           ED, EDI Access Number
109                                                                           EM, Electronic Mail
110                                                                           FX, Facsimile
111                                                                           TE, Telephone
112     PER      Submitter EDI Contact Information       REQ       PER04      Communication Number                          R      AN     1/80         E      PRHP Processing Field
113     PER      Submitter EDI Contact Information       SIT       PER05      Communication Number Qualifier                S      ID     2/2          X
114                                                                           ED, EDI Access Number
115                                                                           EM, Electronic Mail
116                                                                           EX, Telephone Extension
117                                                                           FX, Facsimile
118                                                                           TE, Telephone
119     PER      Submitter EDI Contact Information        SIT      PER06      Communication Number                          S      AN     1/80         E      PRHP Processing Field
120     PER      Submitter EDI Contact Information        SIT      PER07      Communication Number Qualifier                S      ID     2/2          X
121                                                                           ED, EDI Access Number
122                                                                           EM, Electronic Mail
123                                                                           EX, Telephone Extension
124                                                                           FX, Facsimile
125                                                                           TE, Telephone
126     PER      Submitter EDI Contact Information       SIT       PER08      Communication Number                          S      AN     1/80         E      PRHP Processing Field
127     PER      Submitter EDI Contact Information     Not used    PER09      Contact Inquiry Reference                                                X
128
129              Receiver Name                        REQ/1000B
130     NM1      Receiver Name                          REQ     NM101         Entity Identifier Code                        R      ID     2/3          X
131                                                                           40, Receiver
132     NM1      Receiver Name                           REQ       NM102      EntityType Qualifier                          R      ID     1/1          X
133                                                                           2, Non-person Entity

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      1/22/2011, 6:51 AM                                                                                        Puerto Rico Health Plan, Inc.                                                             Page 4 of 152
                                                                                                            Detail Data Definition-837 Institutional

 1                                                                HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                            REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                       Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

134     NM1      Receiver Name                                   REQ        NM103      Name Last or Organization Name                 R     AN     1/35         X
135     NM1      Receiver Name                                  Not used    NM104      Name First                                                               X
136     NM1      Receiver Name                                  Not used    NM105      Name Middle                                                              X
137     NM1      Receiver Name                                  Not used    NM106      Name Prefix                                                              X
138     NM1      Receiver Name                                  Not used    NM107      Name Suffix                                                              X
139     NM1      Receiver Name                                   REQ        NM108      Identification Code Qualifier                  R     ID     1/2          X
140                                                                                    46, ETIN
141     NM1      Receiver Name                                   REQ        NM109      Identification Code                            R     AN     2/80         E      PRHP Processing Field
142     NM1      Receiver Name                                  Not used    NM110      Entity Relationship Code                                                 X
143     NM1      Receiver Name                                  Not used    NM111      Entity Identifier Code                                                   X
144
145              Billing/Pay-To Provider Hierarchical          REQ/2000A
                 Level
146      HL      Billing/Pay-To Provider Hierarchical Level      REQ        HL01       Hierarchical ID Number                         R     AN     1/12         X
147      HL      Billing/Pay-To Provider Hierarchical Level     Not used    HL02       Hierarchical Parent ID Number                                            X
148      HL      Billing/Pay-To Provider Hierarchical Level      REQ        HL03       Hierarchical Level Code                        R     ID     1/2          X
149                                                                                    20, Information Source
150      HL      Billing/Pay-To Provider Hierarchical Level       REQ       HL04       Hierarchical Child Code                        R     ID     1/1          X
151                                                                                    1, Additional Subordinate HL Data Segment in
                                                                                       this Hierarchical Structure
152
153              Billing/Pay-To Provider Specialty Info         SIT/2000A
154     PRV      Billing/Pay-To Provider Specialty Info            REQ      PRV01      Provider Code                                  R     ID     1/3          E      PRHP Processing Field
155                                                                                    BI, Billing
156                                                                                    PT, Pay-to
157     PRV      Billing/Pay-To Provider Specialty Info           REQ       PRV02      Reference Identification Qualifier             R     ID     2/3          X
158                                                                                    ZZ, Mutually Defined
159     PRV      Billing/Pay-To Provider Specialty Info           REQ       PRV03      Reference Identification                       R     AN     1/30         E      PRHP Processing Field

160     PRV      Billing/Pay-To Provider Specialty Info         Not used    PRV04      State or Province Code                                                   X
161     PRV      Billing/Pay-To Provider Specialty Info         Not used    PRV05      Provider Specialty Information                                           X
162     PRV      Billing/Pay-To Provider Specialty Info         Not used    PRV06      Provider Organization Code                                               X
163
164              Foreign Currency Information                   SIT/2000A
165     CUR      Foreign Currency Information                      REQ      CUR01      Entity Identifier Code                         R     ID     2/3          X
166     CUR      Foreign Currency Information                      REQ      CUR02      Currency Code                                  R     ID     3/3          E      PRHP Processing Field
167     CUR      Foreign Currency Information                    Not used   CUR03      Exchange rate                                                            X
168     CUR      Foreign Currency Information                    Not used   CUR04      Entity Identifier Code                                                   X
169     CUR      Foreign Currency Information                    Not used   CUR05      Currency Code                                                            X
170     CUR      Foreign Currency Information                    Not used   CUR06      Currency Market/Exch Code                                                X
171     CUR      Foreign Currency Information                    Not used   CUR07      Date/Time Qualifier                                                      X
172     CUR      Foreign Currency Information                    Not used   CUR08      Date                                                                     X
173     CUR      Foreign Currency Information                    Not used   CUR09      Time                                                                     X
174     CUR      Foreign Currency Information                    Not used   CUR10      Date/Time Qualifier                                                      X
175     CUR      Foreign Currency Information                    Not used   CUR11      Date                                                                     X
176     CUR      Foreign Currency Information                    Not used   CUR12      Time                                                                     X
177     CUR      Foreign Currency Information                    Not used   CUR13      Date/Time Qualifier                                                      X
178     CUR      Foreign Currency Information                    Not used   CUR14      Date                                                                     X
179     CUR      Foreign Currency Information                    Not used   CUR15      Time                                                                     X

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      1/22/2011, 6:51 AM                                                                                       Puerto Rico Health Plan, Inc.                                                             Page 5 of 152
                                                                                                           Detail Data Definition-837 Institutional

 1                                                               HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                           REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

180     CUR      Foreign Currency Information                  Not used    CUR16      Date/Time Qualifier                                                      X
181     CUR      Foreign Currency Information                  Not used    CUR17      Date                                                                     X
182     CUR      Foreign Currency Information                  Not used    CUR18      Time                                                                     X
183     CUR      Foreign Currency Information                  Not used    CUR19      Date/Time Qualifier                                                      X
184     CUR      Foreign Currency Information                  Not used    CUR20      Date                                                                     X
185     CUR      Foreign Currency Information                  Not used    CUR21      Time                                                                     X
186
187              Billing Provider Name                       REQ/2010AA
188     NM1      Billing Provider Name                          REQ     NM101         Entity Identifier Code                        R      ID     2/3          X
189     NM1      Billing Provider Name                                                85, Billing Provider
190     NM1      Billing Provider Name                           REQ       NM102      Entity Type Qualifier                         R      ID     1/1          E      PRHP Processing Field
191     NM1      Billing Provider Name                                                2, Non-person Entity
192     NM1      Billing Provider Name                          REQ        NM103      Name Last or Organization Name                R      AN     1/35         E      PRHP Processing Field
193     NM1      Billing Provider Name                         Not used    NM104      Name First                                                               X
194     NM1      Billing Provider Name                         Not used    NM105      Name Middle                                                              X
195     NM1      Billing Provider Name                         Not used    NM106      Name Prefix                                                              X
196     NM1      Billing Provider Name                         Not used    MN107      Name Suffix                                                              X
197     NM1      Billing Provider Name                          REQ        NM108      Identification Code Qualifier                 R      ID     1/2          E      PRHP Processing Field
198     NM1      Billing Provider Name                                                24, Employer's ID Number
199     NM1      Billing Provider Name                                                34, SSN
200     NM1      Billing Provider Name                                                XX, HCFA NPI
201     NM1      Billing Provider Name                          REQ        NM109      Identification Code                           R      AN     2/80         P      PRHP Processing Field
202     NM1      Billing Provider Name                         Not used    NM110      Entity Relationship Code                                                 X
203     NM1      Billing Provider Name                         Not used    NM111      Entity Identifier Code                                                   X
204
205              Billing Provider Address                    REQ/2010AA
206      N3      Billing Provider Address                       REQ     N301          Address Information                           R      AN     1/55         E      PRHP Processing Field
207      N3      Billing Provider Address                       SIT     N302          Address Information                           S      AN     1/55         E      PRHP Processing Field
208
209              Billing Provider City/State/Zip Code        REQ/2010AA
210      N4      Billing Provider City/State/Zip Code           REQ        N401       City Name                                     R      AN     2/30         E      PRHP Processing Field
211      N4      Billing Provider City/State/Zip Code           REQ        N402       State or Province Code                        R      ID     2/2          E      PRHP Processing Field
212      N4      Billing Provider City/State/Zip Code           REQ        N403       Postal Code                                   R      ID     3/15         E      PRHP Processing Field
213      N4      Billing Provider City/State/Zip Code        SIT/2010AA    N404       Country Code                                  S      ID     2/3          E      PRHP Processing Field
214      N4      Billing Provider City/State/Zip Code         Not used     N405       Location Qualifier                                                       X
215      N4      Billing Provider City/State/Zip Code         Not used     N406       Location Identifier                                                      X
216
217              Billing Provider Secondary Identification SIT/2010AA

218     REF      Billing Provider Secondary Identification       REQ       REF01      Reference Identification Qualifier            R      ID     2/3          E      PRHP Processing Field
219     REF      Billing Provider Secondary Identification                            0B, State License Number
220     REF      Billing Provider Secondary Identification                            1A, Blue Cross Provider Number
221     REF      Billing Provider Secondary Identification                            1B, Blue Shield Provider Number
222     REF      Billing Provider Secondary Identification                            1C, Medicare Provider Number
223     REF      Billing Provider Secondary Identification                            1D, Medicaid Provider Number
224     REF      Billing Provider Secondary Identification                            1G, Provider UPIN Number
225     REF      Billing Provider Secondary Identification                            1H, CHAMPUS ID Number
226     REF      Billing Provider Secondary Identification                            1J, Facility ID Number
227     REF      Billing Provider Secondary Identification                            B3, PPO Number

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                                                                                                           Detail Data Definition-837 Institutional

 1                                                               HIPAA - 837 Institutional Claim                                                                                               PRHP Processing Field
 2                                                           REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                           Use   Type         Len   Field   PRHP Processing Field

228     REF      Billing Provider Secondary Identification                            BQ, HMO Code Number
229     REF      Billing Provider Secondary Identification                            EI, Employer's ID Number
230     REF      Billing Provider Secondary Identification                            FH, Clinic Number
231     REF      Billing Provider Secondary Identification                            G2, Provider Commerical Number
232     REF      Billing Provider Secondary Identification                            G5, Provider Site Number
233     REF      Billing Provider Secondary Identification                            LU, Location Number
234     REF      Billing Provider Secondary Identification                            SY, Social Security Number
235     REF      Billing Provider Secondary Identification                            X5, State Industrial Accident Provider Number
236     REF      Billing Provider Secondary Identification       REQ       REF02      Reference Identification                        R     AN     1/30         E      PRHP Processing Field

237     REF      Billing Provider Secondary Identification     Not used    REF03      Description                                                               X
238     REF      Billing Provider Secondary Identification     Not used    REF04      Reference Identifier                                                      X
239
240              Credit/Debit Card Billing Information        SIT/2010AA
241     REF      Credit/Debit Card Billing Information           REQ     REF01        Reference Identification Qualifier              R     ID     2/3          X
242     REF      Credit/Debit Card Billing Information                                06, System Number
243     REF      Credit/Debit Card Billing Information                                8U, Bank Assigned Security Identifier
244     REF      Credit/Debit Card Billing Information                                EM, Electronic Payment Reference Number
245     REF      Credit/Debit Card Billing Information                                IJ, SIC Code
246     REF      Credit/Debit Card Billing Information                                LU, Location Number
247     REF      Credit/Debit Card Billing Information                                RB, Rate Code Number
248     REF      Credit/Debit Card Billing Information                                ST, Store Number
249     REF      Credit/Debit Card Billing Information                                TT, Terminal Code
250     REF      Credit/Debit Card Billing Information          REQ        REF02      Reference Identification                        R     AN     1/30         X
251     REF      Credit/Debit Card Billing Information         Not used    REF03      Description                                                               X
252     REF      Credit/Debit Card Billing Information         Not used    REF04      Reference Identifier                                                      X
253
254              Billing Provider Contact Information         SIT/2010AA
255     PER      Billing Provider Contact Information            REQ     PER01        Contact Function Code                           R     ID     2/2          X
256     PER      Billing Provider Contact Information                                 IC, Information Contact
257     PER      Billing Provider Contact Information            REQ       PER02      Name                                            R     AN     1/60         E      PRHP Processing Field
258     PER      Billing Provider Contact Information            REQ       PER03      Communication Number Qualifier                  R     ID     2/2          X
259     PER      Billing Provider Contact Information                                 EM, Electronic Mail
260     PER      Billing Provider Contact Information                                 FX, Facsimile
261     PER      Billing Provider Contact Information                                 TE, Telephone
262     PER      Billing Provider Contact Information            REQ       PER04      Communication Number                            R     AN     1/80         E      PRHP Processing Field
263     PER      Billing Provider Contact Information            SIT       PER05      Communication Number Qualifier                  S     ID     2/2          X
264     PER      Billing Provider Contact Information                                 EM, Electronic Mail
265     PER      Billing Provider Contact Information                                 EX, Telephone Extension
266     PER      Billing Provider Contact Information                                 FX, Facsimile
267     PER      Billing Provider Contact Information                                 TE, Telephone
268     PER      Billing Provider Contact Information             SIT      PER06      Communication Number                            S     AN     1/80         E      PRHP Processing Field
269     PER      Billing Provider Contact Information             SIT      PER07      Communication Number Qualifier                  S     ID     2/2          X
270     PER      Billing Provider Contact Information                                 EM, Electronic Mail
271     PER      Billing Provider Contact Information                                 EX, Telephone Extension
272     PER      Billing Provider Contact Information                                 FX, Facsimile
273     PER      Billing Provider Contact Information                                 TE, Telephone
274     PER      Billing Provider Contact Information            SIT       PER08      Communication Number                            S     AN     1/80         E      PRHP Processing Field
275     PER      Billing Provider Contact Information          Not used    PER09      Contact Inquiry Reference                                                 X

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                                                                                                          Detail Data Definition-837 Institutional

 1                                                              HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                          REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                     Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

276
277              Pay-To Provider Name                        SIT/2010AB
278     NM1      Pay-To Provider Name                           REQ     NM101        Entity Identifier Code                        R      ID     2/3          X
279     NM1      Pay-To Provider Name                                                87, Pay-to Provider
280     NM1      Pay-To Provider Name                           REQ       NM102      Entity Type Qualifier                         R      ID     1/1          E      PRHP Processing Field
281     NM1      Pay-To Provider Name                                                2, Non-person Entity
282     NM1      Pay-To Provider Name                          REQ        NM103      Name Last or Organization Name                R      AN     1/35         E      PRHP Processing Field
283     NM1      Pay-To Provider Name                         Not used    NM104      Name First                                                               X
284     NM1      Pay-To Provider Name                         Not used    NM105      Name Middle                                                              X
285     NM1      Pay-To Provider Name                         Not used    NM106      Name Prefix                                                              X
286     NM1      Pay-To Provider Name                         Not used    NM107      Name Suffix                                                              X
287     NM1      Pay-To Provider Name                          REQ        NM108      Identification Code Qualifier                 R      ID     1/2          E      PRHP Processing Field
288     NM1      Pay-To Provider Name                                                24, Employer's ID Number
289     NM1      Pay-To Provider Name                                                34, SSN
290     NM1      Pay-To Provider Name                                                XX, HCFA NPI
291     NM1      Pay-To Provider Name                          REQ        NM109      Identification Code                           R      AN     2/80         P      PRHP Processing Field
292     NM1      Pay-To Provider Name                         Not used    NM110      Entity Relationship Code                                                 X
293     NM1      Pay-To Provider Name                         Not used    NM111      Entity Identifier Code                                                   X
294
295              Pay-To Provider Address                    REQ/2010AB
296      N3      Pay-To Provider Address                       REQ     N301          Address Information                           R      AN     1/55         E      PRHP Processing Field
297      N3      Pay-To Provider Address                       SIT     N302          Address Information                           S      AN     1/55         E      PRHP Processing Field
298
299              Pay-To Provider City/State/Zip Code        REQ2010AB
300      N4      Pay-To Provider City/State/Zip Code           REQ        N401       City Name                                     R      AN     2/30         E      PRHP Processing Field
301      N4      Pay-To Provider City/State/Zip Code           REQ        N402       State or Province Code                        R      ID     2/2          E      PRHP Processing Field
302      N4      Pay-To Provider City/State/Zip Code           REQ        N403       Postal Code                                   R      ID     3/15         E      PRHP Processing Field
303      N4      Pay-To Provider City/State/Zip Code           SIT        N404       Country Code                                  S      ID     2/3          E      PRHP Processing Field
304      N4      Pay-To Provider City/State/Zip Code         Not used     N405       Location Qualifier                                                       X
305      N4      Pay-To Provider City/State/Zip Code         Not used     N406       Location Identifier                                                      X
306
307              Pay-To Provider Secondary                   SIT/2010AB
                 Identification
308     REF      Pay-To Provider Secondary Identification       REQ       REF01      Reference Identification Qualifier            R      ID     2/3          E      PRHP Processing Field
309     REF      Pay-To Provider Secondary Identification                            0B, State License Number
310     REF      Pay-To Provider Secondary Identification                            1A, Blue Cross Provider Number
311     REF      Pay-To Provider Secondary Identification                            1B, Blue Shield Provider Number
312     REF      Pay-To Provider Secondary Identification                            1C, Medicare Provider Number
313     REF      Pay-To Provider Secondary Identification                            1D, Medicaid Provider Number
314     REF      Pay-To Provider Secondary Identification                            1G, Provider UPIN Number
315     REF      Pay-To Provider Secondary Identification                            1H, CHAMPUS ID Number
316     REF      Pay-To Provider Secondary Identification                            1J, Facility ID Number
317     REF      Pay-To Provider Secondary Identification                            B3, PPO Number
318     REF      Pay-To Provider Secondary Identification                            BQ, HMO Code Number
319     REF      Pay-To Provider Secondary Identification                            EI, Employer's ID Number
320     REF      Pay-To Provider Secondary Identification                            FH, Clinic Number
321     REF      Pay-To Provider Secondary Identification                            G2, Provider Commerical Number
322     REF      Pay-To Provider Secondary Identification                            G5, Provider Site Number
323     REF      Pay-To Provider Secondary Identification                            LU, Location Number

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                                                                                                          Detail Data Definition-837 Institutional

 1                                                              HIPAA - 837 Institutional Claim                                                                                               PRHP Processing Field
 2                                                          REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                     Req/Loop Ref Desc Description                                           Use   Type         Len   Field   PRHP Processing Field

324     REF      Pay-To Provider Secondary Identification                            SY, Social Security Number
325     REF      Pay-To Provider Secondary Identification                            X5, State Industrial Accident Provider Number
326     REF      Pay-To Provider Secondary Identification       REQ       REF02      Reference Identification                        R     AN     1/30         E      PRHP Processing Field

327     REF      Pay-To Provider Secondary Identification     Not used    REF03      Description                                                               X
328     REF      Pay-To Provider Secondary Identification     Not used    REF04      Reference Identifier                                                      X
329
330              Subscriber Hierarchical Level               REQ/2000B
331      HL      Subscriber Hierarchical Level                 REQ     HL01          Hierarchical ID Number                          R     AN     1/12         X
332      HL      Subscriber Hierarchical Level                 REQ     HL02          Hierarchical Parent ID Number                   R     AN     1/12         X
333      HL      Subscriber Hierarchical Level                 REQ     HL03          Hierarchical Level Code                         R     ID     1/2          X
334      HL      Subscriber Hierarchical Level                                       22, Subscriber
335      HL      Subscriber Hierarchical Level                  REQ       HL04       Hierarchical Child Code                         R     ID     1/1          X
336      HL      Subscriber Hierarchical Level                                       0, No Subordinate HL segment
337      HL      Subscriber Hierarchical Level                                       1, Additional Subordinate HL segment
338
339              Subscriber Information                      REQ/2000B
340     SBR      Subscriber Information                        REQ     SBR01         Payer Responsib Seq Num Code                    R     ID     1/1          E      PRHP Processing Field
341     SBR      Subscriber Information                                              P, Primary
342     SBR      Subscriber Information                                              S, Secondary
343     SBR      Subscriber Information                                              T, Tertiary
344     SBR      Subscriber Information                          SIT      SBR02      Individual Relationship Code                    S     ID     2/2          E      PRHP Processing Field
345     SBR      Subscriber Information                                              18, Self
346     SBR      Subscriber Information                         SIT       SBR03      Reference Identification                        S     AN     1/30         P      PRHP Processing Field
347     SBR      Subscriber Information                         SIT       SBR04      Name                                            S     AN     1/60         E      PRHP Processing Field
348     SBR      Subscriber Information                       Not used    SBR05      Insurance Type Code                                                       X
349     SBR      Subscriber Information                       Not used    SBR06      Coordination of Benefits Code                                             X
350     SBR      Subscriber Information                       Not used    SBR07      Yes/No Condition or Response Code                                         X
351     SBR      Subscriber Information                       Not used    SBR08      Employment Status Code                                                    X
352     SBR      Subscriber Information                         SIT       SBR09      Claim Filing Indicator Code                     S     ID     1/2          P      PRHP Processing Field
353     SBR      Subscriber Information                                              9, Self-pay
354     SBR      Subscriber Information                                              10, Central Certification
355     SBR      Subscriber Information                                              11, Other Non-Federal Programs
356     SBR      Subscriber Information                                              12, PPO
357     SBR      Subscriber Information                                              13, POS
358     SBR      Subscriber Information                                              14, Exclusive Provider Organization
359     SBR      Subscriber Information                                              15, Indemnity Insurance
360     SBR      Subscriber Information                                              16, HMO Medicare Risk
361     SBR      Subscriber Information                                              AM, Automobile Medical
362     SBR      Subscriber Information                                              BL, Blue Cross/Blue Shield
363     SBR      Subscriber Information                                              CH, CHAMPUS
364     SBR      Subscriber Information                                              CI, Commercial Insurance
365     SBR      Subscriber Information                                              DS, Disability
366     SBR      Subscriber Information                                              HM, HMO
367     SBR      Subscriber Information                                              LI, Liability
368     SBR      Subscriber Information                                              LM, Liability Medical
369     SBR      Subscriber Information                                              MA, Medicare Part A
370     SBR      Subscriber Information                                              MB, Medicare Part B
371     SBR      Subscriber Information                                              MC, Medicaid

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                                                                                                Detail Data Definition-837 Institutional

 1                                                    HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                           Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

372     SBR      Subscriber Information                                    OF, Other Federal Program
373     SBR      Subscriber Information                                    TV, Title V
374     SBR      Subscriber Information                                    VA, Veteran Administration Plan
375     SBR      Subscriber Information                                    WC, Worker's CompensationPlan
376     SBR      Subscriber Information                                    ZZ, Mutually Defined
377
378              Patient Information                SIT/2000B
379     PAT      Patient Information                 Not used   PAT01      Individual Relationship Code                                             X
380     PAT      Patient Information                 Not used   PAT02      Patient Location Code                                                    X
381     PAT      Patient Information                 Not used   PAT03      Employment Status Code                                                   X
382     PAT      Patient Information                 Not used   PAT04      Student Status Code                                                      X
383     PAT      Patient Information                 Not used   PAT05      Date Time Period Format Qualifier                                        X
384     PAT      Patient Information                 Not used   PAT06      Date Time Period                                                         X
385     PAT      Patient Information                   SIT      PAT07      Unit or Basis for Measurement Code            S      ID     2/2          X
386     PAT      Patient Information                                       GR, Gram
387     PAT      Patient Information                   SIT      PAT08      Weight                                        S      R      1/10         P      PRHP Processing Field
388     PAT      Patient Information                   SIT      PAT09      Y/N Condition or Response Code                S      ID     1/1          E      PRHP Processing Field
389                                                                        Y, Yes
390              Subscriber Name                  REQ/2010BA
391     NM1      Subscriber Name                     REQ     NM101         Entity Identifier Code                        R      ID     2/3          X
392                                                                        IL, Insured or Subscriber
393     NM1      Subscriber Name                      REQ       NM102      Entity Type Qualifier                         R      ID     1/1          E      PRHP Processing Field
394                                                                        1, Person
395                                                                        2, Non-person Entity
396     NM1      Subscriber Name                     REQ        NM103      Name Last or Organization Name                R      AN     1/35         P      PRHP Processing Field
397     NM1      Subscriber Name                      SIT       NM104      Name First                                    S      AN     1/25         P      PRHP Processing Field
398     NM1      Subscriber Name                      SIT       NM105      Name Middle                                   S      AN     1/25         P      PRHP Processing Field
399     NM1      Subscriber Name                    Not used    NM106      Name Prefix                                                              X
400     NM1      Subscriber Name                      SIT       NM107      Name Suffix                                   S      AN     1/10         P      PRHP Processing Field
401     NM1      Subscriber Name                      SIT       NM108      Identification Code Qualifier                 S      ID     1/2          E      PRHP Processing Field
402                                                                        MI, Membership ID Number
                                                                           ZZ, Mutually Defined
403     NM1      Subscriber Name                       SIT      NM109      Identification Code                           S      AN     2/80         P      PRHP Processing Field




404     NM1      Subscriber Name                    Not used    NM110      Entity Relationship Code                                                 X
405     NM1      Subscriber Name                    Not used    NM111      Entity Identifier Code                                                   X
406
407              Subscriber Address                SIT/2010BA
408      N3      Subscriber Address                   REQ     N301         Address Information                           R      AN     1/55         P      PRHP Processing Field
409      N3      Subscriber Address                    SIT    N302         Address Information                           S      AN     1/55         P      PRHP Processing Field
410
411              Subscriber City/State/Zip Code    SIT/2010BA
412      N4      Subscriber City/State/Zip Code       REQ       N401       City Name                                     R      AN     2/30         P      PRHP Processing Field
413      N4      Subscriber City/State/Zip Code       REQ       N402       State or Province Code                        R      ID     2/2          P      PRHP Processing Field
414      N4      Subscriber City/State/Zip Code       REQ       N403       Postal Code                                   R      ID     3/15         P      PRHP Processing Field
415      N4      Subscriber City/State/Zip Code        SIT      N404       Country Code                                  S      ID     2/3          P      PRHP Processing Field

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                                                                                                        Detail Data Definition-837 Institutional

 1                                                           HIPAA - 837 Institutional Claim                                                                                               PRHP Processing Field
 2                                                       REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                  Req/Loop Ref Desc Description                                           Use   Type         Len   Field   PRHP Processing Field

416      N4      Subscriber City/State/Zip Code            Not used    N405       Location Qualifier                                                        X
417      N4      Subscriber City/State/Zip Code            Not used    N406       Location Identifier                                                       X
418
419              Subscriber Demographic Information       SIT/2010BA
420     DMG      Subscriber Demographic Information          REQ     DMG01        Date Time Period Format Qualifier              R      ID     2/3          X
421                                                                               D8, Date Expressed in Format CCYYMMDD
422     DMG      Subscriber Demographic Information          REQ       DMG02      Date Time Period                               R      AN     1/35         P      PRHP Processing Field
423     DMG      Subscriber Demographic Information          REQ       DMG03      Gender Code                                    R      ID     1/1          P      PRHP Processing Field
424                                                                               F, Female
425                                                                               M, Male
426                                                                               U, Unknown
427     DMG      Subscriber Demographic Information        Not used    DMG04      Marital Status Code                                                       X
428     DMG      Subscriber Demographic Information        Not used    DMG05      Race or Ethnicity Code                                                    X
429     DMG      Subscriber Demographic Information        Not used    DMG06      Citizenship Status Code                                                   X
430     DMG      Subscriber Demographic Information        Not used    DMG07      Country Code                                                              X
431     DMG      Subscriber Demographic Information        Not used    DMG08      Basis of Verification Code                                                X
432     DMG      Subscriber Demographic Information        Not used    DMG09      Quantity                                                                  X
433
434              Subscriber Secondary Identification      SIT/2010BA
435     REF      Subscriber Secondary Identification         REQ     REF01        Reference Identification Qualifier             R      ID     2/3          E      PRHP Processing Field
436     REF      Subscriber Secondary Identification                              1W, Member Identification Number
437     REF      Subscriber Secondary Identification                              23, Client Number
438     REF      Subscriber Secondary Identification                              IG, Insurance Policy Number
439     REF      Subscriber Secondary Identification                              SY, SSN
440     REF      Subscriber Secondary Identification        REQ        REF02      Reference Identification                       R      AN     1/30         E      PRHP Processing Field
441     REF      Subscriber Secondary Identification       Not used    REF03      Description                                                               X
442     REF      Subscriber Secondary Identification       Not used    REF04      Reference Identifier                                                      X
443
444              Property And Casualty Claim Number       SIT/2010BA
445     REF      Property And Casualty Claim Number          REQ     REF01        Reference Identification Qualifier             R      ID     2/3          X
446     REF      Property And Casualty Claim Number                               Y4, Agency Claim Number
447     REF      Property And Casualty Claim Number         REQ        REF02      Reference Identification                       R      AN     1/30         E      PRHP Processing Field
448     REF      Property And Casualty Claim Number        Not used    REF03      Description                                                               X
449     REF      Property And Casualty Claim Number        Not used    REF04      Reference Identifier                                                      X
450
451              Credit/Debit Card Account Holder Name    SIT/2010BB

452     NM1      Individual or Organizational Name           REQ       NM101      Entity Identifier Code                         R      ID     2/3          X
453     NM1      Individual or Organizational Name                                Aom Account Of
454     NM1      Individual or Organizational Name           REQ       NM102      Entity Type Qualifier                          R      ID     1/1          X
455     NM1      Individual or Organizational Name                                1, Person
456     NM1      Individual or Organizational Name                                2, Non-person Entity
457     NM1      Individual or Organizational Name          REQ        NM103      Name Last or Organization Name                 R      AN     1/35         X
458     NM1      Individual or Organizational Name           SIT       NM104      Name First                                     S      AN     1/25         X
459     NM1      Individual or Organizational Name           SIT       NM105      Name Middle                                    S      AN     1/25         X
460     NM1      Individual or Organizational Name         Not used    NM106      Name Prefix                                                               X
461     NM1      Individual or Organizational Name           SIT       NM107      Name Suffix                                    S      AN     1/10         X
462     NM1      Individual or Organizational Name          REQ        NM108      Identification Code Qualifier                  R      ID     1/2          X
463     NM1      Individual or Organizational Name                                MI, Member Identification Number

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                                                                                                   Detail Data Definition-837 Institutional

 1                                                       HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                   REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                              Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

464     NM1      Individual or Organizational Name      REQ        NM109      Identification Code                           R      AN     2/80         X
465     NM1      Individual or Organizational Name     Not used    NM110      Entity Relationship Code                                                 X
466     NM1      Individual or Organizational Name     Not used    NM111      Entify Identifier Code                                                   X
467
468              Credit/Debit Card Information        SIT/2010BB
469     REF      Credit/Debit Card Information           REQ     REF01        Reference Identification Qualifier            R      ID     2/3          X
470     REF      Credit/Debit Card Information                                AB, Acceptable Source Purchaser ID
471     REF      Credit/Debit Card Information                                BB, Authorizationh Number
472     REF      Credit/Debit Card Information          REQ        REF02      Reference Identification                      R      AN     1/30         X
473     REF      Credit/Debit Card Information         Not used    REF03      Description                                                              X
474     REF      Credit/Debit Card Information         Not used    REF04      Reference Identifier                                                     X
475
476              Payer Name                          REQ/2010BC
477     NM1      Payer Name                             REQ     NM101         Entity Identifier Code                        R      ID     2/3          X
478     NM1      Payer Name                                                   PR, Payer
479     NM1      Payer Name                              REQ       NM102      Entity Type Qualifier                         R      ID     1/1          X
480     NM1      Payer Name                                                   2, Non-person Entity
481     NM1      Payer Name                             REQ        NM103      Name Last or Organization Name                R      AN     1/35         X
482     NM1      Payer Name                            Not used    NM104      First Name                                                               X
483     NM1      Payer Name                            Not used    NM105      Middle Name                                                              X
484     NM1      Payer Name                            Not used    NM106      Name Prefix                                                              X
485     NM1      Payer Name                            Not used    NM107      Name Suffix                                                              X
486     NM1      Payer Name                             REQ        NM108      Identification Code Qualifier                 R      ID     1/2          E      PRHP Processing Field
487     NM1      Payer Name                                                   PI, Payor Identification
488     NM1      Payer Name                                                   XV, HCFA NPI
489     NM1      Payer Name                             REQ        NM109      Identification Code                           R      AN     2/80         E      PRHP Processing Field
490     NM1      Payer Name                            Not used    NM110      Entity Relationship Code                                                 X
491     NM1      Payer Name                            Not used    NM111      Entity Identifier Code                                                   X
492
493              Payer Address                        SIT/2010BC
494      N3      Payer Address                           REQ     N301         Address Information                           R      AN     1/55         E      PRHP Processing Field
495      N3      Payer Address                        SIT/2010BC N302         Address Information                           S      AN     1/55         E      PRHP Processing Field
496
497              Payer City/State/Zip Code            SIT/2010BC
498      N4      Payer City/State/Zip Code               REQ       N401       City Name                                     R      AN     2/30         E      PRHP Processing Field
499      N4      Payer City/State/Zip Code               REQ       N402       State or Province Code                        R      ID     2/2          E      PRHP Processing Field
500      N4      Payer City/State/Zip Code               REQ       N403       Postal Code                                   R      ID     3/15         E      PRHP Processing Field
501      N4      Payer City/State/Zip Code                SIT      N404       Country Code                                  S      ID     2/3          E      PRHP Processing Field
502      N4      Payer City/State/Zip Code             Not used    N405       Location Qualifier                                                       X
503      N4      Payer City/State/Zip Code             Not used    N406       Location Identifier                                                      X
504
505              Payer Secondary Identification       SIT/2010BC
506     REF      Payer Secondary Identification          REQ     REF01        Reference Identification Qualifier            R      ID     2/3          E      PRHP Processing Field
507     REF      Payer Secondary Identification                               2U, Payer Identification Number
508     REF      Payer Secondary Identification                               FY, Claim Office Number
509     REF      Payer Secondary Identification                               NF, NAIC Code
510     REF      Payer Secondary Identification                               TJ, Federal Taxpayer's ID Number
511     REF      Payer Secondary Identification         REQ        REF02      Reference Identification                      R      AN     1/30         E      PRHP Processing Field
512     REF      Payer Secondary Identification        Not used    REF03      Description                                                              X

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                                                                                                       Detail Data Definition-837 Institutional

 1                                                           HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                       REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                  Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

513     REF      Payer Secondary Identification            Not used    REF04      Reference Identifier                                                     X
514
515              Responsible Party Name                  REQ/2010BD
516     NM1      Responsible Party Name                     REQ     NM101         Entity Identifier Code                        R      ID     2/3          X
517     NM1      Responsible Party Name                                           QD, Responsible Party
518     NM1      Responsible Party Name                      REQ       NM102      Entity Type Qualifier                         R      ID     1/1          E      PRHP Processing Field
519     NM1      Responsible Party Name                                           1, Person
520     NM1      Responsible Party Name                                           2, Non-person Entity
521     NM1      Responsible Party Name                     REQ        NM103      Name Last or Organization Name                R      AN     1/35         E      PRHP Processing Field
522     NM1      Responsible Party Name                      SIT       NM104      Name First                                    S      AN     1/25         E      PRHP Processing Field
523     NM1      Responsible Party Name                      SIT       NM105      Name Middle                                   S      AN     1/25         E      PRHP Processing Field
524     NM1      Responsible Party Name                    Not used    NM106      Name Prefix                                                              X
525     NM1      Responsible Party Name                      SIT       NM107      Name Suffix                                   S      AN     1/10         E      PRHP Processing Field
526     NM1      Responsible Party Name                    Not used    NM108      Identification Code Qualifier                                            X
527     NM1      Responsible Party Name                    Not used    NM109      Identificaion Code                                                       X
528     NM1      Responsible Party Name                    Not used    NM110      Entity Relationship Code                                                 X
529     NM1      Responsible Party Name                    Not used    NM111      Entity Identifier Code                                                   X
530
531              Responsible Party Address               REQ/2010BD
532      N3      Responsible Party Address                  REQ     N301          Address Information                           R      AN     1/55         E      PRHP Processing Field
533      N3      Responsible Party Address                  SIT     N302          Address Information                           S      AN     1/55         E      PRHP Processing Field
534
535              Responsible Party City/State/Zip Code   REQ/2010BD

536      N4      Responsible Party City/State/Zip Code      REQ        N401       City Name                                     R      AN     2/30         E      PRHP Processing Field
537      N4      Responsible Party City/State/Zip Code      REQ        N402       State or Province Code                        R      ID     2/2          E      PRHP Processing Field
538      N4      Responsible Party City/State/Zip Code      REQ        N403       Postal Code                                   R      ID     3/15         E      PRHP Processing Field
539      N4      Responsible Party City/State/Zip Code       SIT       N404       Country Code                                  S      ID     2/3          E      PRHP Processing Field
540      N4      Responsible Party City/State/Zip Code     Not used    N405       Location Qualifier                                                       X
541      N4      Responsible Party City/State/Zip Code     Not used    N406       Location Identifier                                                      X
542
543              Patient Hierarchical Level                SIT/2000C
544      HL      Patient Hierarchical Level                   REQ      HL01       Hierarchical ID Number                        R      AN     1/12         X
545      HL      Patient Hierarchical Level                   REQ      HL02       Hierarchical Parent ID Number                 R      AN     1/12         X
546      HL      Patient Hierarchical Level                   REQ      HL03       Hierarchical Level Code                       R      ID     1/2          X
547      HL      Patient Hierarchical Level                                       23, Dependent
548      HL      Patient Hierarchical Level                  REQ       HL04       Hierarchical Child Code                       R      ID     1/1          X
549      HL      Patient Hierarchical Level                                       0, No Subordinate HL Segment
550
551              Patient Information                      REQ/2000C
552     PAT      Patient Information                        REQ     PAT01         Individual Relationship Code                  R      ID     2/2          P      PRHP Processing Field
553     PAT      Patient Information                                              01, Spouse
554     PAT      Patient Information                                              04, Grandfather or Grandmother
555     PAT      Patient Information                                              05, Grandson or Granddaughter
556     PAT      Patient Information                                              07, Nephew or Niece
557     PAT      Patient Information                                              10, Foster Chils
558     PAT      Patient Information                                              15, Ward
559     PAT      Patient Information                                              17, Stepson or Stepdaughter
560     PAT      Patient Information                                              19, Child

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                                                                                               Detail Data Definition-837 Institutional

 1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                               REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

561     PAT      Patient Information                                      20, Employee
562     PAT      Patient Information                                      21, Unknown
563     PAT      Patient Information                                      22, Handicapped Dependent
564     PAT      Patient Information                                      23, Sponsored Dependent
565     PAT      Patient Information                                      24, Dependent of a Minor Dependent
566     PAT      Patient Information                                      29, Significant Other
567     PAT      Patient Information                                      32, Mother
568     PAT      Patient Information                                      33, Father
569     PAT      Patient Information                                      36, Emancipated Minor
570     PAT      Patient Information                                      39, Organ Donor
571     PAT      Patient Information                                      40, Cadaver Donor
572     PAT      Patient Information                                      41, Injured Plaintiff
573     PAT      Patient Information                                      43, Child Where Insured Has No Financial
                                                                          Responsibility
574     PAT      Patient Information                                      53, Life Partner
575     PAT      Patient Information                                      G8, Other Relationship
576     PAT      Patient Information               Not used    PAT02      Patient Location Code
577     PAT      Patient Information               Not used    PAT03      Employment Status Code                                                   X
578     PAT      Patient Information               Not used    PAT04      Student Status Code                                                      X
579     PAT      Patient Information               Not used    PAT05      Date Time Period Format Qualifier                                        X
580     PAT      Patient Information               Not used    PAT06      Date Time Period                                                         E      PRHP Processing Field
581     PAT      Patient Information                 SIT       PAT07      Unit or Basis for Measurement Code            S      ID     2/2          X
582     PAT      Patient Information                                      GR, Gram
583     PAT      Patient Information                  SIT      PAT08      Weight                                        S      R      1/10         P      PRHP Processing Field
584     PAT      Patient Information                  SIT      PAT09      Yes/No Condition or Response Code             S      ID     1/1          E      PRHP Processing Field
585     PAT      Patient Information                                      Y, Yes
586
587              Patient Name                    REQ/2010CA
588     NM1      Patient Name                       REQ     NM101         Entity Identifier Code                        R      ID     2/3          X
589     NM1      Patient Name                                             QC, Patient
590     NM1      Patient Name                        REQ       NM102      Entity Type Qualifier                         R      ID     1/1          X
591     NM1      Patient Name                                             1, Person
592     NM1      Patient Name                       REQ        NM103      Name Last or Organization Name                R      AN     1/35         P      PRHP Processing Field
593     NM1      Patient Name                       REQ        NM104      Name First                                    R      AN     1/25         P      PRHP Processing Field
594     NM1      Patient Name                        SIT       NM105      Name Middle                                   S      AN     1/25         P      PRHP Processing Field
595     NM1      Patient Name                      Not used    NM106      Name Prefix                                                              X
596     NM1      Patient Name                        SIT       NM107      Name Suffix                                   S      AN     1/10         P      PRHP Processing Field
597     NM1      Patient Name                        SIT       NM108      Identification Code Qualifier                 S      ID     1/2          E      PRHP Processing Field
598     NM1      Patient Name                                             MI, Member Identification Number
599     NM1      Patient Name                                             ZZ, Mutually Defined
600     NM1      Patient Name                        SIT       NM109      Identification Code                           S      AN     2/80         P      PRHP Processing Field
601     NM1      Patient Name                      Not used    NM110      Entity Relationship Code                                                 X
602     NM1      Patient Name                      Not used    NM111      Entity Identifier Code                                                   X
603
604              Patient Address                 REQ/2010CA
605      N3      Patient Address                    REQ     N301          Address Information                           R      AN     1/55         P      PRHP Processing Field
606      N3      Patient Address                    SIT     N302          Address Information                           S      AN     1/55         P      PRHP Processing Field
607
608              Patient City/State/Zip Code     REQ/2010CA

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                                                                                                         Detail Data Definition-837 Institutional

 1                                                             HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                         REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                    Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

609      N4      Patient City/State/Zip Code                  REQ        N401       City Name                                     R      AN     2/30         P      PRHP Processing Field
610      N4      Patient City/State/Zip Code                  REQ        N402       State or Province Code                        R      ID     2/2          P      PRHP Processing Field
611      N4      Patient City/State/Zip Code                  REQ        N403       Postal Code                                   R      ID     3/15         P      PRHP Processing Field
612      N4      Patient City/State/Zip Code                   SIT       N404       Country Code                                  S      ID     2/3          P      PRHP Processing Field
613      N4      Patient City/State/Zip Code                 Not used    N405       Location Qualifier                                                       X
614      N4      Patient City/State/Zip Code                 Not used    N406       Location Identifier                                                      X
615
616              Patient Demographic Information           REQ/2010CA
617     DMG      Patient Demographic Information              REQ     DMG01         Date Time Period Format Qualifier             R      ID     2/3          X
618     DMG      Patient Demographic Information                                    D8, Date Expressed in Format CCYYMMDD
619     DMG      Patient Demographic Information               REQ       DMG02      Date Time Period                              R      AN     1/35         P      PRHP Processing Field
620     DMG      Patient Demographic Information               REQ       DMG03      Gender Code                                   R      ID     1/1          P      PRHP Processing Field
621     DMG      Patient Demographic Information                                    F, Female
622     DMG      Patient Demographic Information                                    M, Male
623     DMG      Patient Demographic Information                                    U, Unknown
624     DMG      Patient Demographic Information             Not used    DMG04      Marital Status Code                                                      X
625     DMG      Patient Demographic Information             Not used    DMG05      Race or Ethnicity Code                                                   X
626     DMG      Patient Demographic Information             Not used    DMG06      Citizenship Status Code                                                  X
627     DMG      Patient Demographic Information             Not used    DMG07      Country Code                                                             X
628     DMG      Patient Demographic Information             Not used    DMG08      Basis of Verification Code                                               X
629     DMG      Patient Demographic Information             Not used    DMG09      Quantity                                                                 X
630
631              Patient Secondary Identification Number SIT/2010CA

632     REF      Patient Secondary Identification Number       REQ       REF01      Reference Identification Qualifier            R      ID     2/3          E      PRHP Processing Field
633     REF      Patient Secondary Identification Number                            1W, Member ID Number
634     REF      Patient Secondary Identification Number                            23, Client Number
635     REF      Patient Secondary Identification Number                            IG, Insurance Policy Number
636     REF      Patient Secondary Identification Number                            SY, SSN
637     REF      Patient Secondary Identification Number      REQ        REF02      Reference Identification                      R      AN     1/30         E      PRHP Processing Field
638     REF      Patient Secondary Identification Number     Not used    REF03      Description                                                              X
639     REF      Patient Secondary Identification Number     Not used    REF04      Reference Identifier                                                     X
640
641              Property and Casuality Claim Number        SIT/2010CA

642     REF      Property and Casuality Claim   Number         REQ       REF01      Reference Identification Qualifier            R      ID     2/3          X
643     REF      Property and Casuality Claim   Number                              Y4, Agency Claim Number
644     REF      Property and Casuality Claim   Number        REQ        REF02      Reference Identification                      R      AN     1/30         E      PRHP Processing Field
645     REF      Property and Casuality Claim   Number       Not used    REF03      Description                                                              X
646     REF      Property and Casuality Claim   Number       Not used    REF04      Reference Identifier                                                     X
647
648              Claim Information                           REQ/2300
649     CLM      Claim Information                             REQ       CLM01      Claim Submitter's Identifier                  R      AN     1/38         P      PRHP Processing Field
650     CLM      Claim Information                                                  3, Patient Account Number
651     CLM      Claim Information                            REQ        CLM02      Monetary Amount                               R      R      1/18         P      PRHP Processing Field
652     CLM      Claim Information                           Not used    CLM03      Claim Filing Indicator Code                                              X
653     CLM      Claim Information                           Not used    CLM04      Non-Institutional Claim Type Code                                        X
654     CLM      Claim Information                            REQ        CLM05      Health Care Service Location Info             R      *      *
655     CLM      Claim Information                            REQ        CLM05-1    Facility Code Value                           R      AN     1/2          P      PRHP Processing Field

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                                                                                               Detail Data Definition-837 Institutional

 1                                                   HIPAA - 837 Institutional Claim                                                                                                  PRHP Processing Field
 2                                               REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                          Req/Loop Ref Desc Description                                              Use   Type         Len   Field   PRHP Processing Field

656     CLM      Claim Information                   REQ       CLM05-2    Facility Code Qualifier                            R     ID     1/2          X
657     CLM      Claim Information                                        A, UB Claim Form Bill Type
658     CLM      Claim Information                   REQ       CLM05-3    Claim Frecuency Type Code                          R     ID     1/1          P      PRHP Processing Field
659     CLM      Claim Information                   REQ       CLM06      Yes/No Condition or Response Code                  R     ID     1/1          P      PRHP Processing Field
660     CLM      Claim Information                                        N, No
661     CLM      Claim Information                                        Y, Yes
662     CLM      Claim Information                    SIT      CLM07      Provider Accept Assignment Code                    S     ID     1/1          P      PRHP Processing Field
663     CLM      Claim Information                                        A, Assigned
664     CLM      Claim Information                                        C, Not Assigned
665     CLM      Claim Information                   REQ       CLM08      Yes/No Condition or Response Code                  R     ID     1/1          P      PRHP Processing Field
666     CLM      Claim Information                                        N, No
667     CLM      Claim Information                                        Y, Yes
668     CLM      Claim Information                   REQ       CLM09      Release of Information Code                        R     ID     1/1          P      PRHP Processing Field
669     CLM      Claim Information                                        A, Appropriate Release of Information on File at
                                                                          Health Care Service Provider or at URO
670     CLM      Claim Information                                        I, Informed Consent to Release Medical
                                                                          Information
671     CLM      Claim Information                                        M, Provider has Limited or RestrictedAbility to
                                                                          Release Date related to a claim
672     CLM      Claim Information                                        N, No, Provider is not Allowed to Release Data

673     CLM      Claim Information                                        O, On File at Payor or Plan Sponsor
674     CLM      Claim Information                                        Y, Yes, Provider has Signed Statement
                                                                          Permitting Release of Medical Billing Data
                                                                          Related to a Claim
675     CLM      Claim Information                 Not used    CLM10      Patient Signature Source Code                                                P      PRHP Processing Field
676     CLM      Claim Information                   SIT       CLM11      Related Causes Information                         S     *      *
677     CLM      Claim Information                  REQ        CLM11-1    Related-Causes Code                                R     ID     2/3          P      PRHP Processing Field
678     CLM      Claim Information                                        AA, Auto Accident
679     CLM      Claim Information                                        AB, Abuse
680     CLM      Claim Information                                        AP, Another Party Responsible
681     CLM      Claim Information                                        EM, Employment
682     CLM      Claim Information                                        OA, Other Accident
683     CLM      Claim Information                    SIT      CLM11-2    Related-Causes Code                                S     ID     2/3          P      PRHP Processing Field
684     CLM      Claim Information                                        AA, Auto Accident
685     CLM      Claim Information                                        AB, Abuse
686     CLM      Claim Information                                        AP, Another Party Responsible
687     CLM      Claim Information                                        EM, Employment
688     CLM      Claim Information                                        OA, Other Accident
689     CLM      Claim Information                    SIT      CLM11-3    Related-Causes Code                                S     ID     2/3          P      PRHP Processing Field
690     CLM      Claim Information                                        AA, Auto Accident
691     CLM      Claim Information                                        AB, Abuse
692     CLM      Claim Information                                        AP, Another Party Responsible
693     CLM      Claim Information                                        EM, Employment
694     CLM      Claim Information                                        OA, Other Accident
695     CLM      Claim Information                    SIT      CLM11-4    State or Province Code                             S     ID     2/2          P      PRHP Processing Field
696     CLM      Claim Information                    SIT      CLM11-5    Country Code                                       S     ID     2/3          P      PRHP Processing Field
697     CLM      Claim Information                    SIT      CLM12      Special Program Code                               S     ID     2/3          E      PRHP Processing Field
698     CLM      Claim Information                                        01, ESPDT or CHAP

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                                                                                               Detail Data Definition-837 Institutional

 1                                                   HIPAA - 837 Institutional Claim                                                                                                  PRHP Processing Field
 2                                               REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                          Req/Loop Ref Desc Description                                              Use   Type         Len   Field   PRHP Processing Field

699     CLM      Claim Information                                        02, Physically Handicapped Children's Program

700     CLM      Claim Information                                        03, Special Federal Funding
701     CLM      Claim Information                                        05, Disability
702     CLM      Claim Information                                        07, Induced Abortion-Danger to Life
703     CLM      Claim Information                                        08, Induced Abortion-Rape or Incest
704     CLM      Claim Information                                        09, Second Opinion or Surgery
705     CLM      Claim Information                 Not used    CLM13      Yes/No Condition or Response Code                                            X
706     CLM      Claim Information                 Not used    CLM14      Level of Service Code                                                        X
707     CLM      Claim Information                 Not used    CLM15      Yes/No Condition or Response Code                                            X
708     CLM      Claim Information                 Not used    CLM16      Provider Agreement Code                                                      X
709     CLM      Claim Information                 Not used    CLM17      Claim Status Code                                                            X
710     CLM      Claim Information                  REQ        CLM18      Yes/No Condition or Response Code                  R     ID     1/1          P      PRHP Processing Field
711                                                                       Y, Yes
712                                                                       N, No
713     CLM      Claim Information                 Not used    CLM19      Claim Submission Reason Code                                                 X
714     CLM      Claim Information                   SIT       CLM20      Delay Reason Code                                  S     ID     1/2          E      PRHP Processing Field
715     CLM      Claim Information                                        1, Prof of Eligibility Unknown or Unavailable
716     CLM      Claim Information                                        2, Litigation
717     CLM      Claim Information                                        3, Authorization Delays
718     CLM      Claim Information                                        4, Delay in Certifying Provider
719     CLM      Claim Information                                        5, Delay in Supplying Billing Forms
720     CLM      Claim Information                                        6, Delay in Delivery of Custom-made
                                                                          Applicances
721     CLM      Claim Information                                        7, Third Party Processing Delay
722     CLM      Claim Information                                        8, Delay in Eligibility Determination
723     CLM      Claim Information                                        9, Original Claim Rejected or Denied due to a
                                                                          reason unrelated to the billing limitation rules
724     CLM      Claim Information                                        10, Administration Delay in the Prior Approval
                                                                          Process
725     CLM      Claim Information                                        11, Other
726
727              Discharge Hour                    SIT/2300
728     DTP      Discharge Hour                      REQ       DTP01      Date/Time Qualifier                                R     ID     3/3          X
729     DTP      Discharge Hour                                           096, Discharge
730     DTP      Discharge Hour                      REQ       DTP02      Date Time Period Format Qualifier                  R     ID     2/3          X
731     DTP      Discharge Hour                                           TM, Time Expressed in Format HHMM
732     DTP      Discharge Hour                      REQ       DTP03      Date Time Period                                   R     AN     1/35         P      PRHP Processing Field
733
734              Statement Dates                   REQ/2300
735     DTP      Statement Dates                     REQ       DTP01      Date/Time Qualifier                                R     ID     3/3          X
736     DTP      Statement Dates                                          434, Statement
737     DTP      Statement Dates                     REQ       DTP02      Date Time Period Formet Qualifier                  R`    ID     2/3          X
738     DTP      Statement Dates                                          D8, Date Expressed in Format CCYYMMDD
739     DTP      Statement Dates                                          RD8, Range of Dates Expressed in Format
                                                                          CCYYMMDD-CCYYMMDD
740     DTP      Statement Dates                     REQ       DTP03      Date Time Period                                   R     AN     1/35         P      PRHP Processing Field
741
742              Admission Date/Hour               SIT/2300
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                                                                                                Detail Data Definition-837 Institutional

 1                                                    HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                           Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

743     DTP      Admission Date/Hour                  REQ       DTP01      Date/Time Qualifier                           R      ID     3/3          X
744     DTP      Admission Date/Hour                                       435, Admission
745     DTP      Admission Date/Hour                  REQ       DTP02      Date Time Period Format Qualifier             R      ID     2/3          X
746     DTP      Admission Date/Hour                                       DT, Date and Time Expressed in Format
                                                                           CCYYMMDDHHMM
747     DTP      Admission Date/Hour                  REQ       DTP03      Date Time Period                              R      AN     1/35         P      PRHP Processing Field
748
749              Institutional Claim Code           SIT/2300
750     CL1      Claim Codes                          SIT       CL101      Admission Type Code                           S      ID     1/1          P      PRHP Processing Field
751     CL1      Claim Codes                          SIT       CL102      Admission Source Code                         S      ID     1/1          P      PRHP Processing Field
752     CL1      Claim Codes                          SIT       CL103      Patient Status Code                           S      ID     1/2          P      PRHP Processing Field
753     CL1      Claim Codes                        Not used    CL104      Nursing Home Residential Status Code                                     X
754
755              Claim Supplemental Information     SIT/2300
756     PWK      Claim Supplemental Information       REQ       PWK01      Report Type Code                              R      ID     2/2          E      PRHP Processing Field
757     PWK      Claim Supplemental Information                            AS, Admission Summary
758     PWK      Claim Supplemental Information                            B2, Prescription
759     PWK      Claim Supplemental Information                            B3, Physician Order
760     PWK      Claim Supplemental Information                            B4, Referral Form
761     PWK      Claim Supplemental Information                            CT, Certification
762     PWK      Claim Supplemental Information                            DA, Dental Models
763     PWK      Claim Supplemental Information                            DG, Diagnostic Report
764     PWK      Claim Supplemental Information                            DS, Discharge Summary
765     PWK      Claim Supplemental Information                            EB, EOB (COB or Medicare Secondary Payer)

766     PWK      Claim Supplemental Information                            MT, Models
767     PWK      Claim Supplemental Information                            NN, Nursing Notes
768     PWK      Claim Supplemental Information                            OB, Operative Note
769     PWK      Claim Supplemental Information                            OZ, Support Date for Claim
770     PWK      Claim Supplemental Information                            PN, Physical Therapy Notes
771     PWK      Claim Supplemental Information                            PO, Prosthetics or Orthotic Certification
772     PWK      Claim Supplemental Information                            PZ, Physical Therapy Certification
773     PWK      Claim Supplemental Information                            RB, Radiology Films
774     PWK      Claim Supplemental Information                            RR, Radiology Reports
775     PWK      Claim Supplemental Information                            RT, Report of Tests and Analysis Report
776     PWK      Claim Supplemental Information       REQ       PWK02      Report Transmission Code                      R      ID     1/2          E      PRHP Processing Field
777     PWK      Claim Supplemental Information                            AA, Available on Request at Provider Site
778     PWK      Claim Supplemental Information                            BM, By Mail
779     PWK      Claim Supplemental Information                            EL, Electronically Only
780     PWK      Claim Supplemental Information                            EM, E-mail
781     PWK      Claim Supplemental Information                            FX, By Fax
782     PWK      Claim Supplemental Information     Not used    PWK03      Report Copies Needed                                                     X
783     PWK      Claim Supplemental Information     Not used    PWK04      Entity Identifier Code                                                   X
784     PWK      Claim Supplemental Information     SIT/2300    PWK05      Identification Code Qualifier                 S      ID     1/2          X
785     PWK      Claim Supplemental Information                            AC, Attachment Control Number
786     PWK      Claim Supplemental Information     SIT/2300    PWK06      Identification Code                           S      AN     2/80         E      PRHP Processing Field
787     PWK      Claim Supplemental Information     SIT/2300    PWK07      Description                                   S      AN     1/80         E      PRHP Processing Field
788     PWK      Claim Supplemental Information     Not used    PWK08      Actions Indicated                                                        X
789     PWK      Claim Supplemental Information     Not used    PWK09      Request Category Code                                                    X

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                                                                                                  Detail Data Definition-837 Institutional

 1                                                      HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                  REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                             Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

790
791              Contract Information                 SIT/2300
792     CN1      Contract Information                   REQ       CN101      Contract Type Code                            R      ID     2/2          E      PRHP Processing Field
793     CN1      Contract Information                                        01, DRG
794     CN1      Contract Information                                        02, Per Diem
795     CN1      Contract Information                                        03, Variable Per Diem
796     CN1      Contract Information                                        04, Flat
797     CN1      Contract Information                                        05, Capitated
798     CN1      Contract Information                                        06, Percent
799     CN1      Contract Information                                        09, Other
800     CN1      Contract Information                    SIT      CN102      Monetary Amount                               S      R      1/18         E      PRHP Processing Field
801     CN1      Contract Information                    SIT      CN103      Percent                                       S      R      1/6          E      PRHP Processing Field
802     CN1      Contract Information                    SIT      CN104      Preference Identification                     S      AN     1/30         E      PRHP Processing Field
803     CN1      Contract Information                    SIT      CN105      Terms Discount Percent                        S      R      1/6          E      PRHP Processing Field
804     CN1      Contract Information                    SIT      CN106      Version Identifier                            S      AN     1/30         E      PRHP Processing Field
805
806              Payer Estimated Amount Due           SIT/2300
807     AMT      Payer Estimated Amount Due             REQ       AMT01      Amount Qualifier Code                         R      ID     1/3          X
808     AMT      Payer Estimated Amount Due                                  C5, Claim Amount Due Estimated
809     AMT      Payer Estimated Amount Due            REQ        AMT02      Monetary Amount                               R      R      1/18         P      PRHP Processing Field
810     AMT      Payer Estimated Amount Due           Not used    AMT03      Credit/Debit Flag Code                                                   X
811
812              Patient Estimated Amount Due         SIT/2300
813     AMT      Patient Estimated Amount Due           REQ       AMT01      Amount Qualifier Code                         R      ID     1/3          X
814     AMT      Patient Estimated Amount Due                                F3, Patient Responsibility Estimated
815     AMT      Patient Estimated Amount Due          REQ        AMT02      Monetary Amount                               R      R      1/18         P      PRHP Processing Field
816     AMT      Patient Estimated Amount Due         Not used    AMT03      Credit/Debit Flag Code                                                   X
817
818              Patient Paid Amount                  SIT/2300
819     AMT      Patient Paid Amount                    REQ       AMT01      Amount Qualifier Code                         R      ID     1/3          X
820     AMT      Patient Paid Amount                                         F5, Patient Responsibility Estimated          R      R      1/18
821     AMT      Patient Paid Amount                   REQ        AMT02      Monetary Amount                                                          P      PRHP Processing Field
822     AMT      Patient Paid Amount                  Not used    AMT03      Credit/Debit Flag Code                                                   X
823
824              Credit/Debit Card Maximum Amount     SIT/2300
825     AMT      Credit/Debit Card Maximum Amount       REQ       AMT01      Amount Qualifier Code                         R      ID     1/3          X
826     AMT      Credit/Debit Card Maximum Amount                            MA, Maximum Amount
827     AMT      Credit/Debit Card Maximum Amount      REQ        AMT02      Monetary Amount                               R      R      1/18         X
828     AMT      Credit/Debit Card Maximum Amount     Not used    AMT03      Credit/Debit Flag Code                                                   X
829
830              Adjusted Repriced Claim Number       SIT/2300
831     REF      Adjusted Repriced Claim Number         REQ       REF01      Reference Identification Qualifier           R       ID     2/3          X
832                                                                          9C, Adjusted Repriced Claim Reference Number

833     REF      Adjusted Repriced Claim Number        REQ        REF02      Reference Identification                      R      AN     1/30         E      PRHP Processing Field
834     REF      Adjusted Repriced Claim Number       Not used    REF03      Description                                                              X
835     REF      Adjusted Repriced Claim Number       Not used    REF04      Reference Identifier                                                     X
836
837              Repriced Claim Number                SIT/2300

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                                                                                                         Detail Data Definition-837 Institutional

 1                                                             HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                         REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                    Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

838     REF      Repriced Claim   Number                       REQ       REF01      Reference Identification Qualifier            R      ID     2/3          X
839     REF      Repriced Claim   Number                                            9A, Repriced Claim Reference Number
840     REF      Repriced Claim   Number                      REQ        REF02      Reference Identification                      R      AN     1/30         E      PRHP Processing Field
841     REF      Repriced Claim   Number                     Not used    REF03      Description                                                              X
842     REF      Repriced Claim   Number                     Not used    REF04      Reference Identifier                                                     X
843
844              Claim Identification Number for             SIT/2300
                 Clearinghouses & Other Transmission
                 Intermediaries
845     REF      Claim Identification Number for               REQ       REF01      Reference Identification Qualifier            R      ID     2/3          X
                 Clearinghouses & Other Transmission
                 Intermediaries
846     REF      Claim Identification Number for                                    D9, Claim Number
                 Clearinghouses & Other Transmission
                 Intermediaries
847     REF      Claim Identification Number for               REQ       REF02      Reference Identification                      R      AN     1/30         P      PRHP Processing Field
                 Clearinghouses & Other Transmission
                 Intermediaries
848     REF      Claim Identification Number for             Not used    REF03      Description                                                              X
                 Clearinghouses & Other Transmission
                 Intermediaries
849     REF      Claim Identification Number for             Not used    REF04      Reference Identifier                                                     X
                 Clearinghouses & Other Transmission
                 Intermediaries
850
851              Document Identification Code                SIT/2300
852     REF      Document Identification Code                  REQ       REF01      Reference Identification Qualifier            R      ID     2/3          X
853     REF      Document Identification Code                                       DD, Document Identification code
854     REF      Document Identification Code                 REQ        REF02      Reference Identification                      R      AN     1/30         E      PRHP Processing Field
855     REF      Document Identification Code                Not used    REF03      Description                                                              X
856     REF      Document Identification Code                Not used    REF04      Reference Identifier                                                     X
857
858
859              Original Reference Number(ICN/DCN)          SIT/2300
860     REF      Original Reference Number(ICN/DCN)            REQ       REF01      Reference Identification Qualifier            R      ID     2/3          X
861     REF      Original Reference Number(ICN/DCN)                                 F8, Document Identification code              R      AN     1/30
862     REF      Original Reference Number(ICN/DCN)           REQ        REF02      Reference Identification                                                 P      PRHP Processing Field
863     REF      Original Reference Number(ICN/DCN)          Not used    REF03      Description                                                              X
864     REF      Original Reference Number(ICN/DCN)          Not used    REF04      Reference Identifier                                                     X
865
866              Investigational Device Exemption            SIT/2300
                 Number
867     REF      Investigational Device Exemption Number       REQ       REF01      Reference Identification Qualifier            R      ID     2/3          X
868     REF      Investigational Device Exemption Number                            LX, Qualified Products List                   R      AN     1/30
869     REF      Investigational Device Exemption Number      REQ        REF02      Reference Identification                                                 E      PRHP Processing Field
870     REF      Investigational Device Exemption Number     Not used    REF03      Description                                                              X
871     REF      Investigational Device Exemption Number     Not used    REF04      Reference Identifier                                                     X
872


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                                                                                                        Detail Data Definition-837 Institutional

 1                                                            HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                        REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                                   Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

873              Service Authorization Exception Code       SIT/2300

874     REF      Service Authorization Exception Code         REQ       REF01      Reference Identification Qualifier             R     ID     2/3          X
875     REF      Service Authorization Exception Code                              4N, Special Payment Reference Number           R     AN     1/30
876     REF      Service Authorization Exception Code         REQ       REF02      Reference Identification                                                 E      PRHP Processing Field
877     REF      Service Authorization Exception Code                              1, Immediate/Urgent Care
878     REF      Service Authorization Exception Code                              2, Services Rendered in a Retroactive Period
879     REF      Service Authorization Exception Code                              3, Emergency Care
880     REF      Service Authorization Exception Code                              4, Client as Temporary Medicaid
881     REF      Service Authorization Exception Code                              5, Request from County for Second Opinion to
                                                                                   Recipient can Work
882     REF      Service Authorization Exception Code                              6, Request for Overrride Pending
883     REF      Service Authorization Exception Code                              7, Special Handling
884     REF      Service Authorization Exception Code       Not used    REF03      Description                                                              X
885     REF      Service Authorization Exception Code       Not used    REF04      Reference Identifier                                                     X
886
887
888              Peer Review Organization(PRO)              SIT/2300
                 Approval Number
889     REF      Peer Review Organization(PRO) Approval       REQ       REF01      Reference Identification Qualifier             R     ID     2/3          X
                 Number
890     REF      Peer Review Organization(PRO) Approval                            G4, PRO Approval Number                        R     AN     1/30
                 Number
891     REF      Peer Review Organization(PRO) Approval       REQ       REF02      Reference Identification                                                 E      PRHP Processing Field
                 Number
892     REF      Peer Review Organization(PRO) Approval     Not used    REF03      Description                                                              X
                 Number
893     REF      Peer Review Organization(PRO) Approval     Not used    REF04      Reference Identifier                                                     X
                 Number
894
895              Prior Authorization or Refferal Number     SIT/2300

896     REF      Prior Authorization or Refferal Number       REQ       REF01      Reference Identification Qualifier             R     ID     2/3          X
897     REF      Prior Authorization or Refferal Number                            9F, Referral Number                            R     AN     1/30
898     REF      Prior Authorization or Refferal Number                            G1, Prior Authorization Number
899     REF      Prior Authorization or Refferal Number       REQ       REF02      Reference Identification                                                 P      PRHP Processing Field
900     REF      Prior Authorization or Refferal Number                            63, (A-C) Treatment Authorization Code
901     REF      Prior Authorization or Refferal Number     Not used    REF03      Description                                                              X
902     REF      Prior Authorization or Refferal Number     Not used    REF04      Reference Identifier                                                     X
903
904              Medical Record Number                      SIT/2300
905     REF      Medical Record Number                        REQ       REF01      Reference Identification Qualifier                                       X
906     REF      Medical Record Number                                             EA, Medical Record Identificaion Number
907     REF      Medical Record Number                       REQ        REF02      Reference Identification                                                 P      PRHP Processing Field
908     REF      Medical Record Number                      Not used    REF03      Description                                                              X
909     REF      Medical Record Number                      Not used    REF04      Reference Identifier                                                     X
910
911              Demonstration Project Identifier           SIT/2300
912     REF      Demonstration Project Identifier             REQ       REF01      Reference Identification Qualifier                                       X
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                                                                                                  Detail Data Definition-837 Institutional

 1                                                      HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
 2                                                  REQ or R = Required; SIT or S = Situational
 3     Seg ID    Segment                             Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

913     REF      Demonstration Project Identifier                            P4, Project Code
914     REF      Demonstration Project Identifier      REQ        REF02      Reference Identification                                                 E      PRHP Processing Field
915     REF      Demonstration Project Identifier     Not used    REF03      Description                                                              X
916     REF      Demonstration Project Identifier     Not used    REF04      Reference Identifier                                                     X
917
918              File Information                     SIT/2300
919      K3      File Information                       REQ       K301       Fixed Format Information                      R      AN     1/80         X
920      K3      File Information                     Not used    K302       Record Format Code                                                       X
921      K3      File Information                     Not used    K303       Composite Unit of Measure                                                X
922
923              Claim Note                           SIT/2300
924     NTE      Claim Note                             REQ       NTE01      Note Reference Code                           R      ID     3/3          E      PRHP Processing Field
925     NTE      Claim Note                                                  ALG, Allergies
926     NTE      Claim Note                                                  DCP, Goals, Rehabilitation Potential, or
                                                                             Discharge Plans
927     NTE      Claim Note                                                  DGN, Diagnosis Description
928     NTE      Claim Note                                                  DME, DME and Supplies
929     NTE      Claim Note                                                  MED, Medications
930     NTE      Claim Note                                                  NTR, Nutritional Requirements
931     NTE      Claim Note                                                  ODT, Orders for Disciplines and Treatments
932     NTE      Claim Note                                                  RHB, Functional Limitations, Reason
                                                                             Homebound, or Both
933     NTE      Claim Note                                                  RLH, Reasons Patient Leaves Home
934     NTE      Claim Note                                                  RNH, Times and Reasons Patient Not at Home

935     NTE      Claim Note                                                  SET, Unusual Home, Social Environment or
                                                                             Both
936     NTE      Claim Note                                                  SFM, Safety Measures
937     NTE      Claim Note                                                  SPT, Supplementary Plan of Treatment
938     NTE      Claim Note                                                  UPI, Updated Information
939     NTE      Claim Note                             REQ       NTE02      Description                                   R      AN     1/80         P      PRHP Processing Field
940
941              Billing Note                         SIT/2300
942     NTE      Billing Note                           REQ       NTE01      Note Reference Code                           R      ID     3/3          X
943     NTE      Billing Note                                                ADD, Additional Information
944     NTE      Billing Note                           REQ       NTE02      Description                                   R      AN     1/80         E      PRHP Processing Field
945
946              Home Health Care Information         SIT/2300
947     CR6      Home Health Care Information           REQ       CR601      Prognosis Code                                R      ID     1/1          P      PRHP Processing Field
948     CR6      Home Health Care Information                                1, Poor
949     CR6      Home Health Care Information                                2, Guarded
950     CR6      Home Health Care Information                                3, Fair
951     CR6      Home Health Care Information                                4, Good
952     CR6      Home Health Care Information                                5, Very Good
953     CR6      Home Health Care Information                                6, Excellent
954     CR6      Home Health Care Information                                7, Less than 6 Months to Live
955     CR6      Home Health Care Information                                8, Terminal
956     CR6      Home Health Care Information           REQ       CR602      Date                                          R      DT     8/8          P      PRHP Processing Field
957     CR6      Home Health Care Information           SIT       CR603      Date Time Period Format Qualifier             S      ID     2/3          X

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                                                                                                     Detail Data Definition-837 Institutional

  1                                                        HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                    REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                               Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

958      CR6      Home Health Care Information                                  RD8 Range dates expressed format ccyymmdd                                P      PRHP Processing Field

959      CR6      Home Health Care Information             SIT       CR604      Date Time Period                              S      AN     1/35         P      PRHP Processing Field
960      CR6      Home Health Care Information             REQ       CR605      Date                                          R      DT     8/8          P      PRHP Processing Field
961      CR6      Home Health Care Information             REQ       CR606      Yes/No Condition or Response Code             R      ID     1/1          P      PRHP Processing Field
962      CR6      Home Health Care Information                                  N, No
963      CR6      Home Health Care Information                                  U, Unknown
964      CR6      Home Health Care Information                                  Y, Yes
965      CR6      Home Health Care Information             REQ       CR607      Yes/No Condition or Response Code             R      ID     1/1          P      PRHP Processing Field
966      CR6      Home Health Care Information                                  N, No
967      CR6      Home Health Care Information                                  Y, Yes
968      CR6      Home Health Care Information             REQ       CR608      Certification Type Code                       R      ID     1/1          P      PRHP Processing Field
969      CR6      Home Health Care Information                                  I, Initial
970      CR6      Home Health Care Information                                  R, Renewal
971      CR6      Home Health Care Information                                  S, Revised
972      CR6      Home Health Care Information              SIT      CR609      Date                                          S      DT     8/8          P      PRHP Processing Field
973      CR6      Home Health Care Information              SIT      CR610      Product/Service ID Qualifier                  S      ID     2/2          X
974      CR6      Home Health Care Information                                  HC, HCPCS codes
975      CR6      Home Health Care Information                                  ID, ICD-9-CM Procedure
976      CR6      Home Health Care Information              SIT      CR611      Medical Code Value                            S      AN     1/15         P      PRHP Processing Field
977      CR6      Home Health Care Information              SIT      CR612      Date                                          S      DT     8/8          P      PRHP Processing Field
978      CR6      Home Health Care Information              SIT      CR613      Date                                          S      DT     8/8          P      PRHP Processing Field
979      CR6      Home Health Care Information              SIT      CR614      Date                                          S      DT     8/8          P      PRHP Processing Field
980      CR6      Home Health Care Information              SIT      CR615      Date Time Period Format Qualifier             S      ID     2/3          X
981      CR6      Home Health Care Information                                  RD8 Range Date Expres Format CCYYMMDD

 982     CR6      Home Health Care Information             SIT       CR616      Date Time Period                              S      AN     1/35         P      PRHP Processing Field
 983     CR6      Home Health Care Information             REQ       CR617      Patient Location Code                         R      ID     1/1          P      PRHP Processing Field
 984     CR6      Home Health Care Information                                  A, Acute Care Facility
 985     CR6      Home Health Care Information                                  B, Boarding Home
 986     CR6      Home Health Care Information                                  C, Hospice
 987     CR6      Home Health Care Information                                  D, Intermidiate Care Facility
 988     CR6      Home Health Care Information                                  E, Long-term or Extended Care Facility
 989     CR6      Home Health Care Information                                  F, Not Specified
 990     CR6      Home Health Care Information                                  G, Nursing Home
 991     CR6      Home Health Care Information                                  H, Sub-acute Care Facility
 992     CR6      Home Health Care Information                                  L , Other Location
 993     CR6      Home Health Care Information                                  M, Rehabilitation Facility
 994     CR6      Home Health Care Information                                  O, Outpatient Facility
 995     CR6      Home Health Care Information                                  R, Residential Treatment Facility
 996     CR6      Home Health Care Information                                  S, Skilled Nursing home
 997     CR6      Home Health Care Information                                  T , Rest Home
 998     CR6      Home Health Care Information              SIT      CR618      Date                                          S      DT     8/8          P      PRHP Processing Field
 999     CR6      Home Health Care Information              SIT      CR619      Date                                          S      DT     8/8          P      PRHP Processing Field
1000     CR6      Home Health Care Information              SIT      CR620      Date                                          S      DT     8/8          P      PRHP Processing Field
1001     CR6      Home Health Care Information              SIT      CR621      Date                                          S      DT     8/8          P      PRHP Processing Field
1002
1003              Home Health Functional Limitations     SIT/2300
1004     CRC      Home Health Functional Limitations       REQ       CRC01      Code Category                                 R      ID     2/2          X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                Puerto Rico Health Plan, Inc.                                                            Page 23 of 152
                                                                                                     Detail Data Definition-837 Institutional

  1                                                        HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                    REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                               Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1005     CRC      Home Health Functional Limitations                            75, Functional Limitations
1006     CRC      Home Health Functional Limitations       REQ       CRC02      Yes/No Condition or Response Code             R      ID     1/1          P      PRHP Processing Field
1007     CRC      Home Health Functional Limitations                            N, No
1008     CRC      Home Health Functional Limitations                            Y, Yes
1009     CRC      Home Health Functional Limitations       REQ       CRC03      Condition Indicator                           R      ID     2/2          P      PRHP Processing Field
1010     CRC      Home Health Functional Limitations                            AA, Amputation
1011     CRC      Home Health Functional Limitations                            AL, Ambulation Limitation
1012     CRC      Home Health Functional Limitations                            BL, Bowel Limit, Bladder Limit, or Both
1013     CRC      Home Health Functional Limitations                            CO, Contracture
1014     CRC      Home Health Functional Limitations                            DY, Dyspnea with Minimal Exertion
1015     CRC      Home Health Functional Limitations                            EL, Endurance Limitations
1016     CRC      Home Health Functional Limitations                            HL, Hearing Limitations
1017     CRC      Home Health Functional Limitations                            LB, Legally Blind
1018     CRC      Home Health Functional Limitations                            OL, Other Limitation
1019     CRC      Home Health Functional Limitations                            PA, Paralysis
1020     CRC      Home Health Functional Limitations                            SL, Speech Limitations
1021     CRC      Home Health Functional Limitations        SIT      CRC04      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1022     CRC      Home Health Functional Limitations        SIT      CRC05      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1023     CRC      Home Health Functional Limitations        SIT      CRC06      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1024     CRC      Home Health Functional Limitations        SIT      CRC07      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1025
1026              Home Health Activites Permitted        SIT/2300
1027     CRC      Home Health Activites Permitted          REQ       CRC01      Code Category                                 R      ID     2/2          X
1028     CRC      Home Health Activites Permitted                               76, Activities Permitted
1029     CRC      Home Health Activites Permitted          REQ       CRC02      Yes/No Condition or Response Code             R      ID     1/1          P      PRHP Processing Field
1030     CRC      Home Health Activites Permitted                               N, No
1031     CRC      Home Health Activites Permitted                               Y, Yes
1032     CRC      Home Health Activites Permitted          REQ       CRC03      Condition Indicator                           R      ID     2/2          P      PRHP Processing Field
1033     CRC      Home Health Activites Permitted                               BR, Bedrest BPR (Bathroom Privileges)
1034     CRC      Home Health Activites Permitted                               CA, Cane Required
1035     CRC      Home Health Activites Permitted                               CB, Complete Bedrest
1036     CRC      Home Health Activites Permitted                               CR, Crutches Required
1037     CRC      Home Health Activites Permitted                               EP, Exercises Prescribed
1038     CRC      Home Health Activites Permitted                               IH, Independent at Home
1039     CRC      Home Health Activites Permitted                               NR, No Restrictions
1040     CRC      Home Health Activites Permitted                               RW, Partial Weight Bearing
1041     CRC      Home Health Activites Permitted                               TR, Transfer to Bed, Chair or Both
1042     CRC      Home Health Activites Permitted                               UT, Up as Tolerated
1043     CRC      Home Health Activites Permitted                               WA, Walker Required
1044     CRC      Home Health Activites Permitted                               WR, Wheelchair Required
1045     CRC      Home Health Activites Permitted           SIT      CRC04      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1046     CRC      Home Health Activites Permitted           SIT      CRC05      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1047     CRC      Home Health Activites Permitted           SIT      CRC06      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1048     CRC      Home Health Activites Permitted           SIT      CRC07      Condition Indicator                           S      ID     2/2          P      PRHP Processing Field
1049
1050              Home Health Mental Status              SIT/2300
1051     CRC      Home Health Mental Status                REQ       CRC01      Code Category                                 R      ID     2/2          X
1052     CRC      Home Health Mental Status                                     77, Mental Status
1053     CRC      Home Health Mental Status                REQ       CRC02      Yes/No Condition or Response Code             R      ID     1/1          P      PRHP Processing Field

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       1/22/2011, 6:51 AM                                                                                    Puerto Rico Health Plan, Inc.                                                                Page 24 of 152
                                                                                                         Detail Data Definition-837 Institutional

  1                                                            HIPAA - 837 Institutional Claim                                                                                                  PRHP Processing Field
  2                                                        REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                   Req/Loop Ref Desc Description                                          Use       Type         Len   Field   PRHP Processing Field

1054     CRC      Home Health Mental Status                                         N, No
1055     CRC      Home Health Mental Status                                         Y, Yes
1056     CRC      Home Health Mental Status                    REQ       CRC03      Condition Indicator                           R      ID         2/2          P      PRHP Processing Field
1057     CRC      Home Health Mental Status                                         AG, Agitated
1058     CRC      Home Health Mental Status                                         CM, Comatose
1059     CRC      Home Health Mental Status                                         DI, Disoriented
1060     CRC      Home Health Mental Status                                         DP, Depressed
1061     CRC      Home Health Mental Status                                         FO, Forgetful
1062     CRC      Home Health Mental Status                                         LE, Lethargic
1063     CRC      Home Health Mental Status                                         MC, Other Mental Condition
1064     CRC      Home Health Mental Status                                         OT, Oriented
1065     CRC      Home Health Mental Status                     SIT      CRC04      Condition Indicator                           S      ID         2/2          P      PRHP Processing Field
1066     CRC      Home Health Mental Status                     SIT      CRC05      Condition Indicator                           S      ID         2/2          P      PRHP Processing Field
1067     CRC      Home Health Mental Status                     SIT      CRC06      Condition Indicator                           S      ID         2/2          P      PRHP Processing Field
1068     CRC      Home Health Mental Status                     SIT      CRC07      Condition Indicator                           S      ID         2/2          P      PRHP Processing Field
1069
1070              Principal, Admitting, E-Code & Patient     REQ/2300
                  Reason for Visit Dx
1071      HI      Principal, Admitting, E-Code & Patient       REQ       HI01       Health Care Code Information                  R      *          *
                  Reason for Visit Dx
1072      HI      Principal, Admitting, E-Code & Patient       REQ       HI01-1     1270 Code List Qualifier Code                 R      ID         1/3          X
                  Reason for Visit Dx
1073      HI      Principal, Admitting, E-Code & Patient                            BK    Principal Diagnosis
                  Reason for Visit Dx
1074      HI      Principal, Admitting, E-Code & Patient       REQ       HI01-2     1271 Industry Code                            R      AN         1/30         P      PRHP Processing Field
                  Reason for Visit Dx
1075      HI      Principal, Admitting, E-Code & Patient     Not used    HI01-3     Date Time Period Format Qualifier                                            X
                  Reason for Visit Dx
1076      HI      Principal, Admitting, E-Code & Patient     Not used    HI01-4     Date Time Period                                                             X
                  Reason for Visit Dx
1077      HI      Principal, Admitting, E-Code & Patient     Not used    HI01-5     Monetary Amount                                                              X
                  Reason for Visit Dx
1078      HI      Principal, Admitting, E-Code & Patient     Not used    HI01-6     Quantity                                                                     X
                  Reason for Visit Dx
1079      HI      Principal, Admitting, E-Code & Patient     Not used    HI01-7     Version Identifier                                                           X
                  Reason for Visit Dx
1080      HI      Principal, Admitting, E-Code & Patient        SIT      HI02       Health Care Code Information                  S      *          *
                  Reason for Visit Dx
1081      HI      Principal, Admitting, E-Code & Patient       REQ       HI02-1     1270 Code List Qualifier Code                 R      ID         1/3          X
                  Reason for Visit Dx
1082      HI      Principal, Admitting, E-Code & Patient                            BJ    Admitting Diagnosis
                  Reason for Visit Dx
1083      HI      Principal, Admitting, E-Code & Patient                            ZZ     Mutually Defined
                  Reason for Visit Dx
1084      HI      Principal, Admitting, E-Code & Patient       REQ       HI02-2     1271 Industry Code                            R      AN         1/30         P      PRHP Processing Field
                  Reason for Visit Dx
1085      HI      Principal, Admitting, E-Code & Patient     Not used    HI02-3     Date Time Period Format Qualifier                                            X
                  Reason for Visit Dx


       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                      Puerto Rico Health Plan, Inc.                                                                Page 25 of 152
                                                                                                           Detail Data Definition-837 Institutional

  1                                                              HIPAA - 837 Institutional Claim                                                                                                  PRHP Processing Field
  2                                                          REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                     Req/Loop Ref Desc Description                                          Use       Type         Len   Field   PRHP Processing Field

1086      HI      Principal, Admitting, E-Code &   Patient     Not used    HI02-4     Date Time Period                                                             X
                  Reason for Visit Dx
1087      HI      Principal, Admitting, E-Code &   Patient     Not used    HI02-5     Monetary Amount                                                              X
                  Reason for Visit Dx
1088      HI      Principal, Admitting, E-Code &   Patient     Not used    HI02-6     Quantity                                                                     X
                  Reason for Visit Dx
1089      HI      Principal, Admitting, E-Code &   Patient     Not used    HI02-7     Version Identifier                                                           X
                  Reason for Visit Dx
1090      HI      Principal, Admitting, E-Code &   Patient        SIT      HI03       Health Care Code Information                  S      *          *
                  Reason for Visit Dx
1091      HI      Principal, Admitting, E-Code &   Patient       REQ       HI03-1     1270 Code List Qualifier Code                 R      ID         1/3          X
                  Reason for Visit Dx
1092      HI      Principal, Admitting, E-Code &   Patient                            BN - Ecode
                  Reason for Visit Dx
1093      HI      Principal, Admitting, E-Code &   Patient       REQ       HI03-2     1271    Industry Code                         R      AN         1/30         P      PRHP Processing Field
                  Reason for Visit Dx
1094      HI      Principal, Admitting, E-Code &   Patient     Not used    HI03-3     Date Time Period Format Qualifier                                            X
                  Reason for Visit Dx
1095      HI      Principal, Admitting, E-Code &   Patient     Not used    HI03-4     Date Time Period                                                             X
                  Reason for Visit Dx
1096      HI      Principal, Admitting, E-Code &   Patient     Not used    HI03-5     Monetary Amount                                                              X
                  Reason for Visit Dx
1097      HI      Principal, Admitting, E-Code &   Patient     Not used    HI03-6     Quantity                                                                     X
                  Reason for Visit Dx
1098      HI      Principal, Admitting, E-Code &   Patient     Not used    HI03-7     Version Identifier                                                           X
                  Reason for Visit Dx
1099      HI      Principal, Admitting, E-Code &   Patient     Not used    HI04       Health Care Code Information                                                 X
                  Reason for Visit Dx
1100      HI      Principal, Admitting, E-Code &   Patient     Not used    HI05       Health Care Code Information                                                 X
                  Reason for Visit Dx
1101      HI      Principal, Admitting, E-Code &   Patient     Not used    HI06       Health Care Code Information                                                 X
                  Reason for Visit Dx
1102      HI      Principal, Admitting, E-Code &   Patient     Not used    HI07       Health Care Code Information                                                 X
                  Reason for Visit Dx
1103      HI      Principal, Admitting, E-Code &   Patient     Not used    HI08       Health Care Code Information                                                 X
                  Reason for Visit Dx
1104      HI      Principal, Admitting, E-Code &   Patient     Not used    HI09       Health Care Code Information                                                 X
                  Reason for Visit Dx
1105      HI      Principal, Admitting, E-Code &   Patient     Not used    HI10       Health Care Code Information                                                 X
                  Reason for Visit Dx
1106      HI      Principal, Admitting, E-Code &   Patient     Not used    HI11       Health Care Code Information                                                 X
                  Reason for Visit Dx
1107      HI      Principal, Admitting, E-Code &   Patient     Not used    HI12       Health Care Code Information                                                 X
                  Reason for Visit Dx
1108
1109              DRG Information                              SIT/2300
1110      HI      DRG Information                                REQ       HI01       Health Care Code Information                  R      *          *
1111      HI      DRG Information                                REQ       HI01-1     Diagnosis Type Code                           R      ID         1/3          X
1112      HI      DRG Information                                                     DR, DRG
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       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 26 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1113      HI      DRG Information                    REQ        HI01-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1114      HI      DRG Information                   Not used    HI01-3     Date Time Period Format Qualifier
1115      HI      DRG Information                   Not used    HI01-4     Date Time Period
1116      HI      DRG Information                   Not used    HI01-5     Monetary Amount
1117      HI      DRG Information                   Not used    HI01-6     Quantity
1118      HI      DRG Information                   Not used    HI01-7     Version Identifier
1119      HI      DRG Information                   Not used    HI02       Health Care Code Information
1120      HI      DRG Information                   Not used    HI03       Health Care Code Information
1121      HI      DRG Information                   Not used    HI04       Health Care Code Information
1122      HI      DRG Information                   Not used    HI05       Health Care Code Information
1123      HI      DRG Information                   Not used    HI06       Health Care Code Information
1124      HI      DRG Information                   Not used    HI07       Health Care Code Information
1125      HI      DRG Information                   Not used    HI08       Health Care Code Information
1126      HI      DRG Information                   Not used    HI09       Health Care Code Information
1127      HI      DRG Information                   Not used    HI10       Health Care Code Information
1128      HI      DRG Information                   Not used    HI11       Health Care Code Information
1129      HI      DRG Information                   Not used    HI12       Health Care Code Information
1130
1131              Other Diagnosis Information       SIT/2300




1132      HI      Other Diagnosis Information         REQ       HI01       Health Care Code Information
1133      HI      Other Diagnosis Information         REQ       HI01-1     1270 Code List Qualifier                      R      AN     1/30         X
1134      HI      Other Diagnosis Information                              BF, Diagnosis
1135      HI      Other Diagnosis Information        REQ        HI01-2     1271 Industry Code                                                       P      PRHP Processing Field
1136      HI      Other Diagnosis Information       Not used    HI01-3     Date Time Period Format Qualifier                                        X
1137      HI      Other Diagnosis Information       Not used    HI01-4     Date Time Period                                                         X
1138      HI      Other Diagnosis Information       Not used    HI01-5     Monetary Amount                                                          X
1139      HI      Other Diagnosis Information       Not used    HI01-6     Quantity                                                                 X
1140      HI      Other Diagnosis Information       Not used    HI01-7     Version Identifier                                                       X
1141      HI      Other Diagnosis Information         SIT       HI02       Health Care Code Information                  S      *      *
1142      HI      Other Diagnosis Information        REQ        HI02-1     1270 Code List Qualifier                      R      ID     1/3          X
1143      HI      Other Diagnosis Information                              BF, Diagnosis
1144      HI      Other Diagnosis Information        REQ        HI02-2     1271 Industry Code                            R      An     1/30         P      PRHP Processing Field
1145      HI      Other Diagnosis Information       Not used    HI02-3     Date Time Period Format Qualifier                                        X
1146      HI      Other Diagnosis Information       Not used    HI02-4     Date Time Period                                                         X
1147      HI      Other Diagnosis Information       Not used    HI02-5     Monetary Amount                                                          X
1148      HI      Other Diagnosis Information       Not used    HI02-6     Quantity                                                                 X
1149      HI      Other Diagnosis Information       Not used    HI02-7     Version Identifier                                                       X
1150      HI      Other Diagnosis Information         SIT       HI03       Health Care Code Information                  S      *      *
1151      HI      Other Diagnosis Information        REQ        HI03-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1152      HI      Other Diagnosis Information                              BF, Diagnosis
1153      HI      Other Diagnosis Information        REQ        HI03-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1154      HI      Other Diagnosis Information       Not used    HI03-3     Date Time Period Format Qualifier                                        X
1155      HI      Other Diagnosis Information       Not used    HI03-4     Date Time Period                                                         X
1156      HI      Other Diagnosis Information       Not used    HI03-5     Monetary Amount                                                          X
1157      HI      Other Diagnosis Information       Not used    HI03-6     Quantity                                                                 X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 27 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1158      HI      Other Diagnosis Information       Not used    HI03-7     Version Identifier                                                       X
1159      HI      Other Diagnosis Information         SIT       HI04       Health Care Code Information                  S      *      *
1160      HI      Other Diagnosis Information        REQ        HI04-1     1270     Code List Qualifier Code             R      ID     1/3          X
1161      HI      Other Diagnosis Information                              BF, Diagnosis
1162      HI      Other Diagnosis Information        REQ        HI04-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1163      HI      Other Diagnosis Information       Not used    HI04-3     Date Time Period Format Qualifier                                        X
1164      HI      Other Diagnosis Information       Not used    HI04-4     Date Time Period                                                         X
1165      HI      Other Diagnosis Information       Not used    HI04-5     Monetary Amount                                                          X
1166      HI      Other Diagnosis Information       Not used    HI04-6     Quantity                                                                 X
1167      HI      Other Diagnosis Information       Not used    HI04-7     Version Identifier                                                       X
1168      HI      Other Diagnosis Information         SIT       HI05       Health Care Code Information                  S      *      *
1169      HI      Other Diagnosis Information        REQ        HI05-1     1270     Code List Qualifier                  R      ID     1/3          X
1170      HI      Other Diagnosis Information                              BF, Diagnosis
1171      HI      Other Diagnosis Information        REQ        HI05-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1172      HI      Other Diagnosis Information       Not used    HI05-3     Date Time Period Format Qualifier                                        X
1173      HI      Other Diagnosis Information       Not used    HI05-4     Date Time Period                                                         X
1174      HI      Other Diagnosis Information       Not used    HI05-5     Monetary Amount                                                          X
1175      HI      Other Diagnosis Information       Not used    HI05-6     Quantity                                                                 X
1176      HI      Other Diagnosis Information       Not used    HI05-7     Version Identifier                                                       X
1177      HI      Other Diagnosis Information         SIT       HI06       Health Care Code Information                  S      *      *
1178      HI      Other Diagnosis Information        REQ        HI06-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1179      HI      Other Diagnosis Information                              BF, Diagnosis
1180      HI      Other Diagnosis Information        REQ        HI06-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1181      HI      Other Diagnosis Information       Not used    HI06-3     Date Time Period Format Qualifier                                        X
1182      HI      Other Diagnosis Information       Not used    HI06-4     Date Time Period                                                         X
1183      HI      Other Diagnosis Information       Not used    HI06-5     Monetary Amount                                                          X
1184      HI      Other Diagnosis Information       Not used    HI06-6     Quantity                                                                 X
1185      HI      Other Diagnosis Information       Not used    HI06-7     Version Identifier                                                       X
1186      HI      Other Diagnosis Information         SIT       HI07       Health Care Code Information                  S      *      *
1187      HI      Other Diagnosis Information        REQ        HI07-1     1270     Code List Qualifier Code             R      ID     1/3          X
1188      HI      Other Diagnosis Information                              BF, Diagnosis
1189      HI      Other Diagnosis Information        REQ        HI07-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1190      HI      Other Diagnosis Information       Not used    HI07-3     Date Time Period Format Qualifier                                        X
1191      HI      Other Diagnosis Information       Not used    HI07-4     Date Time Period                                                         X
1192      HI      Other Diagnosis Information       Not used    HI07-5     Monetary Amount                                                          X
1193      HI      Other Diagnosis Information       Not used    HI07-6     Quantity                                                                 X
1194      HI      Other Diagnosis Information       Not used    HI07-7     Version Identifier                                                       X
1195      HI      Other Diagnosis Information         SIT       HI08       Health Care Code Information                  S      *      *
1196      HI      Other Diagnosis Information        REQ        HI08-1     1270     Code List Qualifier                  R      ID     1/3          X
1197      HI      Other Diagnosis Information                              BF, Diagnosis
1198      HI      Other Diagnosis Information        REQ        HI08-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1199      HI      Other Diagnosis Information       Not used    HI08-3     Date Time Period Format Qualifier                                        X
1200      HI      Other Diagnosis Information       Not used    HI08-4     Date Time Period                                                         X
1201      HI      Other Diagnosis Information       Not used    HI08-5     Monetary Amount                                                          X
1202      HI      Other Diagnosis Information       Not used    HI08-6     Quantity                                                                 X
1203      HI      Other Diagnosis Information       Not used    HI08-7     Version Identifier                                                       X
1204      HI      Other Diagnosis Information         SIT       HI09       Health Care Code Information                  S      *      *
1205      HI      Other Diagnosis Information        REQ        HI09-1     1270     Code List Qualifier Code             R      ID     1/3          X
1206      HI      Other Diagnosis Information                              BF, Diagnosis

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                             Puerto Rico Health Plan, Inc.                                                            Page 28 of 152
                                                                                                  Detail Data Definition-837 Institutional

  1                                                     HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                 REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                            Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1207      HI      Other Diagnosis Information          REQ        HI09-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1208      HI      Other Diagnosis Information         Not used    HI09-3     Date Time Period Format Qualifier                                        X
1209      HI      Other Diagnosis Information         Not used    HI09-4     Date Time Period                                                         X
1210      HI      Other Diagnosis Information         Not used    HI09-5     Monetary Amount                                                          X
1211      HI      Other Diagnosis Information         Not used    HI09-6     Quantity                                                                 X
1212      HI      Other Diagnosis Information         Not used    HI09-7     Version Identifier                                                       X
1213      HI      Other Diagnosis Information           SIT       HI10       Health Care Code Information                  S      *      *
1214      HI      Other Diagnosis Information          REQ        HI10-1     1270     Code List Qualifier Code             R      ID     1/3          X
1215      HI      Other Diagnosis Information                                BF, Diagnosis
1216      HI      Other Diagnosis Information          REQ        HI10-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1217      HI      Other Diagnosis Information         Not used    HI10-3     Date Time Period Format Qualifier                                        X
1218      HI      Other Diagnosis Information         Not used    HI10-4     Date Time Period                                                         X
1219      HI      Other Diagnosis Information         Not used    HI10-5     Monetary Amount                                                          X
1220      HI      Other Diagnosis Information         Not used    HI10-6     Quantity                                                                 X
1221      HI      Other Diagnosis Information         Not used    HI10-7     Version Identifier                                                       X
1222      HI      Other Diagnosis Information           SIT       HI11       Health Care Code Information                  S      *      *
1223      HI      Other Diagnosis Information          REQ        HI11-1     1270     Code List Qualifier                  R      ID     1/3          X
1224      HI      Other Diagnosis Information                                BF, Diagnosis
1225      HI      Other Diagnosis Information          REQ        HI11-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1226      HI      Other Diagnosis Information         Not used    HI11-3     Date Time Period Format Qualifier                                        X
1227      HI      Other Diagnosis Information         Not used    HI11-4     Date Time Period                                                         X
1228      HI      Other Diagnosis Information         Not used    HI11-5     Monetary Amount                                                          X
1229      HI      Other Diagnosis Information         Not used    HI11-6     Quantity                                                                 X
1230      HI      Other Diagnosis Information         Not used    HI11-7     Version Identifier                                                       X
1231      HI      Other Diagnosis Information           SIT       HI12       Health Care Code Information                  S      *      *
1232      HI      Other Diagnosis Information          REQ        HI12-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1233      HI      Other Diagnosis Information                                BF, Diagnosis
1234      HI      Other Diagnosis Information          REQ        HI12-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1235      HI      Other Diagnosis Information         Not used    HI12-3     Date Time Period Format Qualifier                                        X
1236      HI      Other Diagnosis Information         Not used    HI12-4     Date Time Period                                                         X
1237      HI      Other Diagnosis Information         Not used    HI12-5     Monetary Amount                                                          X
1238      HI      Other Diagnosis Information         Not used    HI12-6     Quantity                                                                 X
1239      HI      Other Diagnosis Information         Not used    HI12-7     Version Identifier                                                       X
1240
1241              Principal Procedure Information     SIT/2300
1242      HI      Principal Procedure Information       REQ       HI01       Health Care Code Information                  R      *      *
1243      HI      Principal Procedure Information       REQ       HI01-1     1270     Code List Qualifier Code             R      ID     1/3          X
1244      HI      Principal Procedure Information                            BP, HCPCS
1245      HI      Principal Procedure Information                            BR, ICD-9-CM Principal Procedure
1246      HI      Principal Procedure Information       REQ       HI01-2     1271, Industry Code                           R      AN     1/30         P      PRHP Processing Field
1247      HI      Principal Procedure Information       SIT       HI01-3     125, Date Time Period Format Qualifier        S      ID     2/3          X
1248      HI      Principal Procedure Information                            D8     Date Expressed in Format CCYYMM
1249      HI      Principal Procedure Information       SIT       HI01-4     1251      Date Time Period                    S      AN     1/35         P      PRHP Processing Field
1250      HI      Principal Procedure Information     Not used    HI01-5     Monetary Amount                                                          X
1251      HI      Principal Procedure Information     Not used    HI01-6     Quantity                                                                 X
1252      HI      Principal Procedure Information     Not used    HI01-7     Version Identifier                                                       X
1253      HI      Principal Procedure Information     Not used    HI02       Health Care Code Information                                             X
1254      HI      Principal Procedure Information     Not used    HI03       Health Care Code Information                                             X
1255      HI      Principal Procedure Information     Not used    HI04       Health Care Code Information                                             X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                             Puerto Rico Health Plan, Inc.                                                            Page 29 of 152
                                                                                                  Detail Data Definition-837 Institutional

  1                                                     HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                 REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                            Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1256      HI      Principal Procedure Information     Not used    HI05       Health Care Code Information                                             X
1257      HI      Principal Procedure Information     Not used    HI06       Health Care Code Information                                             X
1258      HI      Principal Procedure Information     Not used    HI07       Health Care Code Information                                             X
1259      HI      Principal Procedure Information     Not used    HI08       Health Care Code Information                                             X
1260      HI      Principal Procedure Information     Not used    HI09       Health Care Code Information                                             X
1261      HI      Principal Procedure Information     Not used    HI10       Health Care Code Information                                             X
1262      HI      Principal Procedure Information     Not used    HI11       Health Care Code Information                                             X
1263      HI      Principal Procedure Information     Not used    HI12       Health Care Code Information                                             X
1264
1265              Other Procedure Information         SIT/2300
1266      HI      Other Procedure Information           REQ       HI01       Health Care Code Information                  R      *      *
1267      HI      Other Procedure Information           REQ       HI01-1     1270     Code List Qualifier Code             R      ID     1/3          X
1268      HI      Other Procedure Information                                BO     HCFA Procedural Coding System
1269      HI      Other Procedure Information                                BQ     ICD-9-CM Procedure
1270      HI      Other Procedure Information          REQ        HI01-2     1271       Industry Code                      R      AN     1/30         P      PRHP Processing Field
1271      HI      Other Procedure Information           SIT       HI01-3     1250      Date Time Period Form Qualifier     S      ID     2/3          X
1272      HI      Other Procedure Information           SIT       HI01-4     1251       Date Time Period                   S      AN     1/35         P      PRHP Processing Field
1273      HI      Other Procedure Information         Not used    HI01-5     Monetary Amount                                                          X
1274      HI      Other Procedure Information         Not used    HI01-6     Quantity                                                                 X
1275      HI      Other Procedure Information         Not used    HI01-7     Version Identifier                                                       X
1276      HI      Other Procedure Information           SIT       HI02       Health Care Code Information                  S      *      *
1277      HI      Other Procedure Information          REQ        HI02-1     1270     Code List Qualifier Code             R      ID     1/3          X
1278      HI      Other Procedure Information          REQ        HI02-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1279      HI      Other Procedure Information           SIT       HI02-3     1250     Date Time Period Formay Qua          S      ID     2/3          X
1280      HI      Other Procedure Information           SIT       HI02-4     1251      Date Time Period                    S      AN     1/35         P      PRHP Processing Field
1281      HI      Other Procedure Information         Not used    HI02-5     Monetary Amount                                                          X
1282      HI      Other Procedure Information         Not used    HI02-6     Quantity                                                                 X
1283      HI      Other Procedure Information         Not used    HI02-7     Version Identifier                                                       X
1284      HI      Other Procedure Information          REQ        HI03       Health Care Code Information                  S      AN     1/30
1285      HI      Other Procedure Information          REQ        HI03-1     1270     Code List Qualifier Code             R      ID     1/3          X
1286      HI      Other Procedure Information          REQ        HI03-2     1271       Industry Code                      R      AN     1/30         P      PRHP Processing Field
1287      HI      Other Procedure Information           SIT       HI03-3     1250      Date Time Period Format Qua         S      ID     2/3          X
1288      HI      Other Procedure Information           SIT       HI03-4     1251       Date Time Period                   S      AN     1/35         P      PRHP Processing Field
1289      HI      Other Procedure Information         Not used    HI03-5     Monetary Amount                                                          X
1290      HI      Other Procedure Information         Not used    HI03-6     Quantity                                                                 X
1291      HI      Other Procedure Information         Not used    HI03-7     Version Identifier                                                       X
1292      HI      Other Procedure Information           SIT       HI04                                                     S      *      *
1293      HI      Other Procedure Information          REQ        HI04-1     1270     Code List Qualifier Code             R      ID     1/3          X
1294      HI      Other Procedure Information          REQ        HI04-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1295      HI      Other Procedure Information           SIT       HI04-3     1250     Date Time Period Format Qua          S      ID     2/3          X
1296      HI      Other Procedure Information           SIT       HI04-4     1251      Date Time Period                    S      AN     1/35         P      PRHP Processing Field
1297      HI      Other Procedure Information         Not used    HI04-5     Monetary Amount                                                          X
1298      HI      Other Procedure Information         Not used    HI04-6     Quantity                                                                 X
1299      HI      Other Procedure Information         Not used    HI04-7     Version Identifier                                                       X
1300      HI      Other Procedure Information           SIT       HI05       Health Care Code Information                  S      *      *
1301      HI      Other Procedure Information          REQ        HI05-1     1270     Code List Qualifier Code             R      ID     1/3          X
1302      HI      Other Procedure Information          REQ        HI05-2     1271     Industry Code                        R      AN     1/30         P      PRHP Processing Field
1303      HI      Other Procedure Information           SIT       HI05-3     1250     Date Time Period Format Qua          S      ID     2/3          X
1304      HI      Other Procedure Information           SIT       HI05-4     1251     Date Time Period                     S      AN     1/35         P      PRHP Processing Field

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                          Page 30 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                            PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type       Len   Field   PRHP Processing Field

1305      HI      Other Procedure Information       Not used    HI05-5     Monetary Amount                                                        X
1306      HI      Other Procedure Information       Not used    HI05-6     Quantity                                                               X
1307      HI      Other Procedure Information       Not used    HI05-7     Version Identifier                                                     X
1308      HI      Other Procedure Information         SIT       HI06       Health Care Code Information                  S      *      *
1309      HI      Other Procedure Information        REQ        HI06-1     1270     Code List Qualifier                  R      ID     1/3        X
1310      HI      Other Procedure Information        REQ        HI06-2     1271      Industry Code                       R      AN     1/30       E      PRHP Processing Field
1311      HI      Other Procedure Information         SIT       HI06-3     1250     Date Time Period Format Qua          S      ID     2/3        X
1312      HI      Other Procedure Information         SIT       HI06-4     1251      Date Time Period                    S      AN     1/35       E      PRHP Processing Field
1313      HI      Other Procedure Information       Not used    HI06-5     Monetary Amount                                                        X
1314      HI      Other Procedure Information       Not used    HI06-6     Quantity                                                               X
1315      HI      Other Procedure Information       Not used    HI06-7     Version Identifier                                                     X
1316      HI      Other Procedure Information         SIT       HI07       Health Care Code Information                  S      *      *
1317      HI      Other Procedure Information        REQ        HI07-1     1270     Code List Qualifier Code             R      ID     1/3        X
1318      HI      Other Procedure Information        REQ        HI07-2     1271      Industry Code                       R      AN     1/30       E      PRHP Processing Field
1319      HI      Other Procedure Information         SIT       HI07-3     1250     Date Time Period Format Qua          S      ID     2/3        X
1320      HI      Other Procedure Information         SIT       HI07-4     1251      Date Time Period                    S      AN     1/35       E      PRHP Processing Field
1321      HI      Other Procedure Information       Not used    HI07-5     Monetary Amount                                                        X
1322      HI      Other Procedure Information       Not used    HI07-6     Quantity                                                               X
1323      HI      Other Procedure Information       Not used    HI07-7     Version Identifier                                                     X
1324      HI      Other Procedure Information         SIT       HI08       Health Care Code Information                  S      *      *
1325      HI      Other Procedure Information        REQ        HI08-1     1270     Code List Qualifier Code             R      ID     1/3        X
1326      HI      Other Procedure Information        REQ        HI08-2     1271      Industry Code                       R      AN     1/30       E      PRHP Processing Field
1327      HI      Other Procedure Information         SIT       HI08-3     1250     Date Time Period Format Qua          S      ID     2/3        X
1328      HI      Other Procedure Information         SIT       HI08-4     1251      Date Time Period                    S      AN     1/35       E      PRHP Processing Field
1329      HI      Other Procedure Information       Not used    HI08-5     Monetary Amount                                                        X
1330      HI      Other Procedure Information       Not used    HI08-6     Quantity                                                               X
1331      HI      Other Procedure Information       Not used    HI08-7     Version Identifier                                                     X
1332      HI      Other Procedure Information         SIT       HI09       Health Care Code Information                  S      *      *
1333      HI      Other Procedure Information        REQ        HI09-1     1270     Code List Qualifier Code             R      ID     1/3        X
1334      HI      Other Procedure Information        REQ        HI09-2     1271      Industry Code                       R      AN     1/30       E      PRHP Processing Field
1335      HI      Other Procedure Information         SIT       HI09-3     1250     Date Time Period Format Qua          S      ID     2/3        X
1336      HI      Other Procedure Information         SIT       HI09-4     1251      Date Time Period                                             E      PRHP Processing Field
1337      HI      Other Procedure Information       Not used    HI09-5     Monetary Amount                                                        X
1338      HI      Other Procedure Information       Not used    HI09-6     Quantity                                                               X
1339      HI      Other Procedure Information       Not used    HI09-7     Version Identifier                                                     X
1340      HI      Other Procedure Information         SIT       HI10       Health Care Code Information                  S      *      *
1341      HI      Other Procedure Information        REQ        HI10-1     1270     Code List Qualifier Code             R      ID     1/3        X
1342      HI      Other Procedure Information        REQ        HI10-2     1271      Industry Code                       R      AN     1/30       E      PRHP Processing Field
1343      HI      Other Procedure Information         SIT       HI10-3     1250     Date Time Period Format Qua          S      ID     2/3        X
1344      HI      Other Procedure Information         SIT       HI10-4     1251      Date Time Period                    S      AN     1/35       E      PRHP Processing Field
1345      HI      Other Procedure Information       Not used    HI10-5     Monetary Amount                                                        X
1346      HI      Other Procedure Information       Not used    HI10-6     Quantity                                                               X
1347      HI      Other Procedure Information       Not used    HI10-7     Version Identifier                                                     X
1348      HI      Other Procedure Information         SIT       HI11       Health Care Code Information                  S      *      *
1349      HI      Other Procedure Information        REQ        HI11-1     1270     Code List Qualifier Code             R      ID     1/3        X
1350      HI      Other Procedure Information        REQ        HI11-2     1271      Industry Code                       R      AN     1/30       E      PRHP Processing Field
1351      HI      Other Procedure Information         SIT       HI11-3     1250     Date Time Period Format Qua          S      ID     2/3        X
1352      HI      Other Procedure Information         SIT       HI11-4     1251      Date Time Period                    S      AN     1/35       E      PRHP Processing Field
1353      HI      Other Procedure Information       Not used    HI11-5     Monetary Amount                                                        X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 31 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1354      HI      Other Procedure Information       Not used    HI11-6     Quantity                                                                 X
1355      HI      Other Procedure Information       Not used    HI11-7     Version Identifier                                                       X
1356      HI      Other Procedure Information         SIT       HI12       Health Care Code Information                  S      *      *
1357      HI      Other Procedure Information        REQ        HI12-1     1270     Code List Qualifier Code             R      ID     1/3          X
1358      HI      Other Procedure Information        REQ        HI12-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1359      HI      Other Procedure Information         SIT       HI12-3     1250     Date Time Period Format Qua          S      ID     2/3          X
1360      HI      Other Procedure Information         SIT       HI1204     1251      Date Time Period                    S      AN     1/35         E      PRHP Processing Field
1361      HI      Other Procedure Information       Not used    HI12-5     Monetary Amount                                                          X
1362      HI      Other Procedure Information       Not used    HI12-6     Quantity                                                                 X
1363      HI      Other Procedure Information       Not used    HI12-7     Version Identifier                                                       X
1364
1365              Occurrence Span Information       SIT/2300
1366      HI      Occurrence Span Information         REQ       HI01       Health Care Code Information                  R      *      *
1367      HI      Occurrence Span Information         REQ       HI01-1     1270     Code List Qualifier Code             R      ID     1/3          X
1368      HI      Occurrence Span Information                              BI    Occurrence Span
1369      HI      Occurrence Span Information         REQ       HI01-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1370      HI      Occurrence Span Information         REQ       HI01-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1371      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMMDD-
                                                                           CCYYMMDD
1372      HI      Occurrence Span Information        REQ        HI01-4     1251      Date Time Period                    R      AN     1/35         P      PRHP Processing Field
1373      HI      Occurrence Span Information       Not used    HI01-5     Monetary Amount                                                          X
1374      HI      Occurrence Span Information       Not used    HI01-6     Quantity                                                                 X
1375      HI      Occurrence Span Information       Not used    HI01-7     Version Identifier                                                       X
1376      HI      Occurrence Span Information         SIT       HI02       Health Care Code Information                  S      *      *
1377      HI      Occurrence Span Information        REQ        HI02-1     1270     Code List Qualifier Code             R      ID     1/3          X
1378      HI      Occurrence Span Information                              BI    Occurrence Span
1379      HI      Occurrence Span Information         REQ       HI02-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1380      HI      Occurrence Span Information         REQ       HI02-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1381      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1382      HI      Occurrence Span Information        REQ        HI02-4     1251      Date Time Period                    R      AN     1/35         P      PRHP Processing Field
1383      HI      Occurrence Span Information       Not used    HI02-5     Monetary Amount                                                          X
1384      HI      Occurrence Span Information       Not used    HI02-6     Quantity                                                                 X
1385      HI      Occurrence Span Information       Not used    HI02-7     Version Identifier                                                       X
1386      HI      Occurrence Span Information         SIT       HI03       Health Care Code Information                  S      *      *
1387      HI      Occurrence Span Information        REQ        HI03-1     1270     Code List Qualifier Code             R      ID     1/3          X
1388      HI      Occurrence Span Information                              BI    Occurrence Span
1389      HI      Occurrence Span Information         REQ       HI03-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1390      HI      Occurrence Span Information         REQ       HI03-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1391      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1392      HI      Occurrence Span Information        REQ        HI03-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1393      HI      Occurrence Span Information       Not used    HI03-5     Monetary Amount                                                          X
1394      HI      Occurrence Span Information       Not used    HI03-6     Quantity                                                                 X
1395      HI      Occurrence Span Information       Not used    HI03-7     Version Identifier                                                       X
1396      HI      Occurrence Span Information         SIT       HI04       Health Care Code Information                  S      *      *
1397      HI      Occurrence Span Information        REQ        HI04-1     1270     Code List Qualifier Code             R      AN     1/30         X
1398      HI      Occurrence Span Information                              BI    Occurrence Span
1399      HI      Occurrence Span Information         REQ       HI04-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1400      HI      Occurrence Span Information         REQ       HI04-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1401      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 32 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1402      HI      Occurrence Span Information        REQ        HI04-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1403      HI      Occurrence Span Information       Not used    HI04-5     Monetary Amount                                                          X
1404      HI      Occurrence Span Information       Not used    HI04-6     Quantity                                                                 X
1405      HI      Occurrence Span Information       Not used    HI04-7     Version Identifier                                                       X
1406      HI      Occurrence Span Information         SIT       HI05       Health Care Code Information                  S      *      *
1407      HI      Occurrence Span Information        REQ        HI05-1     1270     Code List Qualifier Code             R      AN     1/30         X
1408      HI      Occurrence Span Information                              BI    Occurrence Span
1409      HI      Occurrence Span Information         REQ       HI05-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1410      HI      Occurrence Span Information         REQ       HI05-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1411      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1412      HI      Occurrence Span Information        REQ        HI05-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1413      HI      Occurrence Span Information       Not used    HI05-5     Monetary Amount                                                          X
1414      HI      Occurrence Span Information       Not used    HI05-6     Quantity                                                                 X
1415      HI      Occurrence Span Information       Not used    HI05-7     Version Identifier                                                       X
1416      HI      Occurrence Span Information         SIT       HI06       Health Care Code Information                  S      *      *
1417      HI      Occurrence Span Information        REQ        HI06-1     1270     Code List Qualifier Code             R      AN     1/30         X
1418      HI      Occurrence Span Information                              BI    Occurrence Span
1419      HI      Occurrence Span Information         REQ       HI06-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1420      HI      Occurrence Span Information         REQ       HI06-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1421      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1422      HI      Occurrence Span Information        REQ        HI06-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1423      HI      Occurrence Span Information       Not used    HI06-5     Monetary Amount                                                          X
1424      HI      Occurrence Span Information       Not used    HI06-6     Quantity                                                                 X
1425      HI      Occurrence Span Information       Not used    HI06-7     Version Identifier                                                       X
1426      HI      Occurrence Span Information         SIT       HI07       Health Care Code Information                  S      *      *
1427      HI      Occurrence Span Information        REQ        HI07-1     1270     Code List Qualifier Code             R      ID     1/3          X
1428      HI      Occurrence Span Information                              BI    Occurrence Span
1429      HI      Occurrence Span Information         REQ       HI07-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1430      HI      Occurrence Span Information         REQ       HI07-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1431      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1432      HI      Occurrence Span Information        REQ        HI07-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1433      HI      Occurrence Span Information       Not used    HI07-5     Monetary Amount                                                          X
1434      HI      Occurrence Span Information       Not used    HI07-6     Quantity                                                                 X
1435      HI      Occurrence Span Information       Not used    HI07-7     Version Identifier                                                       X
1436      HI      Occurrence Span Information         SIT       HI08       Health Care Code Information                  S      *      *
1437      HI      Occurrence Span Information        REQ        HI08-1     1270     Code List Qualifier Code             R      ID     1/3          X
1438      HI      Occurrence Span Information                              BI    Occurrence Span
1439      HI      Occurrence Span Information         REQ       HI08-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1440      HI      Occurrence Span Information         REQ       HI08-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1441      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1442      HI      Occurrence Span Information        REQ        HI08-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1443      HI      Occurrence Span Information       Not used    HI08-5     Monetary Amount                                                          X
1444      HI      Occurrence Span Information       Not used    HI08-6     Quantity                                                                 X
1445      HI      Occurrence Span Information       Not used    HI08-7     Version Identifier                                                       X
1446      HI      Occurrence Span Information         SIT       HI09       Health Care Code Information                  S      *      *
1447      HI      Occurrence Span Information        REQ        HI09-1     1270     Code List Qualifier Code             R      ID     1/3          X
1448      HI      Occurrence Span Information                              BI    Occurrence Span
1449      HI      Occurrence Span Information         REQ       HI09-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1450      HI      Occurrence Span Information         REQ       HI09-3     1250     Date Time Period Format Qua          R      ID     2/3          X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 33 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1451      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1452      HI      Occurrence Span Information        REQ        HI09-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1453      HI      Occurrence Span Information       Not used    HI09-5     Monetary Amount                                                          X
1454      HI      Occurrence Span Information       Not used    HI09-6     Quantity                                                                 X
1455      HI      Occurrence Span Information       Not used    HI09-7     Version Identifier                                                       X
1456      HI      Occurrence Span Information         SIT       HI10       Health Care Code Information                  S      *      *
1457      HI      Occurrence Span Information        REQ        HI10-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1458      HI      Occurrence Span Information                              BI    Occurrence Span
1459      HI      Occurrence Span Information         REQ       HI10-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1460      HI      Occurrence Span Information         REQ       HI10-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1461      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1462      HI      Occurrence Span Information        REQ        HI10-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1463      HI      Occurrence Span Information       Not used    HI10-5     Monetary Amount                                                          X
1464      HI      Occurrence Span Information       Not used    HI10-6     Quantity                                                                 X
1465      HI      Occurrence Span Information       Not used    HI10-7     Version Identifier                                                       X
1466      HI      Occurrence Span Information         SIT       HI11       Health Care Code Information                  S      *      *
1467      HI      Occurrence Span Information        REQ        HI11-1     1270     Code List Qualifier Code             R      ID     1/3          X
1468      HI      Occurrence Span Information                              BI    Occurrence Span
1469      HI      Occurrence Span Information         REQ       HI11-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1470      HI      Occurrence Span Information         REQ       HI11-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1471      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1472      HI      Occurrence Span Information        REQ        HI11-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1473      HI      Occurrence Span Information       Not used    HI11-5     Monetary Amount                                                          X
1474      HI      Occurrence Span Information       Not used    HI11-6     Quantity                                                                 X
1475      HI      Occurrence Span Information       Not used    HI11-7     Version Identifier                                                       X
1476      HI      Occurrence Span Information         SIT       HI12       Health Care Code Information                  S      *      *
1477      HI      Occurrence Span Information        REQ        HI12-1     1270     Code List Qualifier Code             R      ID     1/3          X
1478      HI      Occurrence Span Information                              BI    Occurrence Span
1479      HI      Occurrence Span Information         REQ       HI12-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1480      HI      Occurrence Span Information         REQ       HI12-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1481      HI      Occurrence Span Information                              RD8 Range Date Express Format CCMM
1482      HI      Occurrence Span Information        REQ        HI12-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1483      HI      Occurrence Span Information       Not used    HI12-5     Monetary Amount                                                          X
1484      HI      Occurrence Span Information       Not used    HI12-6     Quantity                                                                 X
1485      HI      Occurrence Span Information       Not used    HI12-7     Version Identifier                                                       X
1486
1487              Occurrence Information            SIT/2300
1488      HI      Occurrence Information              REQ       HI01       Health Care Code Information                  R      *      *
1489      HI      Occurrence Information              REQ       HI01-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1490      HI      Occurrence Information                                   BH      Occurrence
1491      HI      Occurrence Information              REQ       HI01-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1492      HI      Occurrence Information              REQ       HI01-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1493      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1494      HI      Occurrence Information             REQ        HI01-4     1251      Date Time Period                    R      AN     1/35         P      PRHP Processing Field
1495      HI      Occurrence Information            Not used    HI01-5     Monetary Amount                                                          X
1496      HI      Occurrence Information            Not used    HI01-6     Quantity                                                                 X
1497      HI      Occurrence Information            Not used    HI01-7     Version Identifier                                                       X
1498      HI      Occurrence Information             REQ        HI02       Health Care Code Information                  R      *      *
1499      HI      Occurrence Information             REQ        HI02-1     1270 Code List Qualifier Code                 R      ID     1/3          X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                                Page 34 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                                  PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use       Type         Len   Field   PRHP Processing Field

1500      HI      Occurrence Information                                   BH      Occurrence
1501      HI      Occurrence Information              REQ       HI02-2     1271      Industry Code                       R      AN         1/30         P      PRHP Processing Field
1502      HI      Occurrence Information              REQ       HI02-3     1250     Date Time Period Format Qua          R      ID         2/3          X
1503      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1504      HI      Occurrence Information             REQ        HI02-4     1251      Date Time Period                    R      AN         1/35         P      PRHP Processing Field
1505      HI      Occurrence Information            Not used    HI02-5     Monetary Amount                                                              X
1506      HI      Occurrence Information            Not used    HI02-6     Quantity                                                                     X
1507      HI      Occurrence Information            Not used    HI02-7     Version Identifier                                                           X
1508      HI      Occurrence Information             REQ        HI03       Health Care Code Information                  R      *          *
1509      HI      Occurrence Information             REQ        HI03-1     1270 Code List Qualifier Code                 R      ID         1/3          X
1510      HI      Occurrence Information                                   BH      Occurrence
1511      HI      Occurrence Information              REQ       HI03-2     1271      Industry Code                       R      AN         1/30         P      PRHP Processing Field
1512      HI      Occurrence Information              REQ       HI03-3     1250     Date Time Period Format Qua          R      ID         2/3          X
1513      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1514      HI      Occurrence Information             REQ        HI03-4     1251      Date Time Period                    R      AN         1/35         P      PRHP Processing Field
1515      HI      Occurrence Information            Not used    HI03-5     Monetary Amount                                                              X
1516      HI      Occurrence Information            Not used    HI03-6     Quantity                                                                     X
1517      HI      Occurrence Information            Not used    HI03-7     Version Identifier                                                           X
1518      HI      Occurrence Information             REQ        HI04       Health Care Code Information                  R      *          *
1519      HI      Occurrence Information             REQ        HI04-1     1270 Code List Qualifier Code                 R      ID         1/3          X
1520      HI      Occurrence Information                                   BH      Occurrence
1521      HI      Occurrence Information              REQ       HI04-2     1271      Industry Code                       R      AN         1/30         P      PRHP Processing Field
1522      HI      Occurrence Information              REQ       HI04-3     1250     Date Time Period Format Qua          R      ID         2/3          X
1523      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1524      HI      Occurrence Information             REQ        HI04-4     1251      Date Time Period                    R      AN         1/35         P      PRHP Processing Field
1525      HI      Occurrence Information            Not used    HI04-5     Monetary Amount                                                              X
1526      HI      Occurrence Information            Not used    HI04-6     Quantity                                                                     X
1527      HI      Occurrence Information            Not used    HI04-7     Version Identifier                                                           X
1528      HI      Occurrence Information             REQ        HI05       Health Care Code Information                  R      *          *
1529      HI      Occurrence Information             REQ        HI05-1     1270 Code List Qualifier Code                 R      ID         1/3          X
1530      HI      Occurrence Information                                   BH      Occurrence
1531      HI      Occurrence Information              REQ       HI05-2     1271      Industry Code                       R      AN         1/30         P      PRHP Processing Field
1532      HI      Occurrence Information              REQ       HI05-3     1250     Date Time Period Format Qua          R      ID         2/3          X
1533      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1534      HI      Occurrence Information             REQ        HI05-4     1251      Date Time Period                    R      AN         1/35         P      PRHP Processing Field
1535      HI      Occurrence Information            Not used    HI05-5     Monetary Amount                                                              X
1536      HI      Occurrence Information            Not used    HI05-6     Quantity                                                                     X
1537      HI      Occurrence Information            Not used    HI05-7     Version Identifier                                                           X
1538      HI      Occurrence Information             REQ        HI06       Health Care Code Information                  R      *          *
1539      HI      Occurrence Information             REQ        HI06-1     1270 Code List Qualifier Code                 R      ID         1/3          X
1540      HI      Occurrence Information                                   BH      Occurrence
1541      HI      Occurrence Information              REQ       HI06-2     1271      Industry Code                       R      AN         1/30         P      PRHP Processing Field
1542      HI      Occurrence Information              REQ       HI06-3     1250     Date Time Period Format Qua          R      ID         2/3          X
1543      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1544      HI      Occurrence Information             REQ        HI06-4     1251      Date Time Period                    R      AN         1/35         P      PRHP Processing Field
1545      HI      Occurrence Information            Not used    HI06-5     Monetary Amount                                                              X
1546      HI      Occurrence Information            Not used    HI06-6     Quantity                                                                     X
1547      HI      Occurrence Information            Not used    HI06-7     Version Identifier                                                           X
1548      HI      Occurrence Information             REQ        HI07       Health Care Code Information                  R      *          *

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 35 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1549      HI      Occurrence Information              REQ       HI07-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1550      HI      Occurrence Information                                   BH      Occurrence
1551      HI      Occurrence Information              REQ       HI07-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1552      HI      Occurrence Information              REQ       HI07-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1553      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1554      HI      Occurrence Information             REQ        HI07-4     1251      Date Time Period                    R      AN     1/35         P      PRHP Processing Field
1555      HI      Occurrence Information            Not used    HI07-5     Monetary Amount                                                          X
1556      HI      Occurrence Information            Not used    HI07-6     Quantity                                                                 X
1557      HI      Occurrence Information            Not used    HI07-7     Version Identifier                                                       X
1558      HI      Occurrence Information             REQ        HI08       Health Care Code Information                  R      *      *
1559      HI      Occurrence Information             REQ        HI08-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1560      HI      Occurrence Information                                   BH      Occurrence
1561      HI      Occurrence Information              REQ       HI08-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1562      HI      Occurrence Information              REQ       HI08-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1563      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1564      HI      Occurrence Information             REQ        HI08-4     1251      Date Time Period                    R      AN     1/35         P      PRHP Processing Field
1565      HI      Occurrence Information            Not used    HI08-5     Monetary Amount                                                          X
1566      HI      Occurrence Information            Not used    HI08-6     Quantity                                                                 X
1567      HI      Occurrence Information            Not used    HI08-7     Version Identifier                                                       X
1568      HI      Occurrence Information             REQ        HI09       Health Care Code Information                  R      *      *
1569      HI      Occurrence Information             REQ        HI09-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1570      HI      Occurrence Information                                   BH      Occurrence
1571      HI      Occurrence Information              REQ       HI09-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1572      HI      Occurrence Information              REQ       HI09-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1573      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1574      HI      Occurrence Information             REQ        HI09-4     1251      Date Time Period                    R      AN     1/35         P      PRHP Processing Field
1575      HI      Occurrence Information            Not used    HI09-5     Monetary Amount                                                          X
1576      HI      Occurrence Information            Not used    HI09-6     Quantity                                                                 X
1577      HI      Occurrence Information            Not used    HI09-7     Version Identifier                                                       X
1578      HI      Occurrence Information             REQ        HI10       Health Care Code Information                  R      *      *
1579      HI      Occurrence Information             REQ        HI10-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1580      HI      Occurrence Information                                   BH      Occurrence
1581      HI      Occurrence Information              REQ       HI10-2     1271      Industry Code                       R      AN     1/30         P      PRHP Processing Field
1582      HI      Occurrence Information              REQ       HI10-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1583      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1584      HI      Occurrence Information             REQ        HI10-4     1251      Date Time Period                    R      AN     1/35         P      PRHP Processing Field
1585      HI      Occurrence Information            Not used    HI10-5     Monetary Amount                                                          X
1586      HI      Occurrence Information            Not used    HI10-6     Quantity                                                                 X
1587      HI      Occurrence Information            Not used    HI10-7     Version Identifier                                                       X
1588      HI      Occurrence Information             REQ        HI11       Health Care Code Information                  R      *      *
1589      HI      Occurrence Information             REQ        HI11-1     1270 Code List Qualifier Code                 R      ID     1/3          X
1590      HI      Occurrence Information                                   BH      Occurrence
1591      HI      Occurrence Information              REQ       HI11-2     1271      Industry Code                       R      AN     1/30         E      PRHP Processing Field
1592      HI      Occurrence Information              REQ       HI11-3     1250     Date Time Period Format Qua          R      ID     2/3          X
1593      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1594      HI      Occurrence Information             REQ        HI11-4     1251      Date Time Period                    R      AN     1/35         E      PRHP Processing Field
1595      HI      Occurrence Information            Not used    HI11-5     Monetary Amount                                                          X
1596      HI      Occurrence Information            Not used    HI11-6     Quantity                                                                 X
1597      HI      Occurrence Information            Not used    HI11-7     Version Identifier                                                       X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                                Page 36 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                                  PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use       Type         Len   Field   PRHP Processing Field

1598      HI      Occurrence Information              REQ       HI12       Health Care Code Information                  R      *          *
1599      HI      Occurrence Information              REQ       HI12-1     1270 Code List Qualifier Code                 R      ID         1/3          X
1600      HI      Occurrence Information                                   BH      Occurrence
1601      HI      Occurrence Information              REQ       HI12-2     1271      Industry Code                       R      AN         1/30         E      PRHP Processing Field
1602      HI      Occurrence Information              REQ       HI12-3     1250     Date Time Period Format Qua          R      ID         2/3          X
1603      HI      Occurrence Information                                   D8    Date Expressed Format CCYYMMD
1604      HI      Occurrence Information             REQ        HI12-4     1251      Date Time Period                    R      AN         1/35         E      PRHP Processing Field
1605      HI      Occurrence Information            Not used    HI12-5     Monetary Amount                                                              X
1606      HI      Occurrence Information            Not used    HI12-6     Quantity                                                                     X
1607      HI      Occurrence Information            Not used    HI12-7     Version Identifier                                                           X
1608
1609              VALUE INFORMATION                 SIT/2300
1610      HI      Value Information                   REQ       HI01       Health Care Code Information                  R      *          *
1611      HI      Value Information                   REQ       HI01-1     Code List Qualifier code                      R      ID         1/3          X
1612      HI      Value Information                                        BE, Value
1613      HI      Value Information                  REQ        HI01-2     1271 Industry Code                            R      AN         1/30         P      PRHP Processing Field
1614      HI      Value Information                 Not used    HI01-3     Date Time Period Format Qualifier                                            X
1615      HI      Value Information                 Not used    HI01-4     Date Time Period                                                             X
1616      HI      Value Information                  REQ        HI01-5     Monetary Amount                               R      R          1/18         P      PRHP Processing Field
1617      HI      Value Information                 Not used    HI01-6     Quantity                                                                     X
1618      HI      Value Information                 Not used    HI01-7     Version Identifier                                                           X
1619      HI      Value Information                   SIT       HI02       Health Care Code Information                  R      *          *
1620      HI      Value Information                  REQ        HI02-1     Code List Qualifier code                      R      ID         1/3          X
1621      HI      Value Information                                        BE, Value
1622      HI      Value Information                  REQ        HI02-2     1271 Industry Code                            R      AN         1/30         P      PRHP Processing Field
1623      HI      Value Information                 Not used    HI02-3     Date Time Period Format Qualifier                                            X
1624      HI      Value Information                 Not used    HI02-4     Date Time Period                                                             X
1625      HI      Value Information                  REQ        HI02-5     Monetary Amount                               R      R          1/18         P      PRHP Processing Field
1626      HI      Value Information                 Not used    HI02-6     Quantity                                                                     X
1627      HI      Value Information                 Not used    HI02-7     Version Identifier                                                           X
1628      HI      Value Information                   SIT       HI03       Health Care Code Information                  R      *          *
1629      HI      Value Information                  REQ        HI03-1     Code List Qualifier code                      R      ID         1/3          X
1630      HI      Value Information                                        BE, Value
1631      HI      Value Information                  REQ        HI03-2     1271 Industry Code                            R      AN         1/30         P      PRHP Processing Field
1632      HI      Value Information                 Not used    HI03-3     Date Time Period Format Qualifier                                            X
1633      HI      Value Information                 Not used    HI03-4     Date Time Period                                                             X
1634      HI      Value Information                  REQ        HI03-5     Monetary Amount                               R      R          1/18         P      PRHP Processing Field
1635      HI      Value Information                 Not used    HI03-6     Quantity                                                                     X
1636      HI      Value Information                 Not used    HI03-7     Version Identifier                                                           X
1637      HI      Value Information                   SIT       HI04       Health Care Code Information                  R      *          *
1638      HI      Value Information                  REQ        HI04-1     Code List Qualifier code                      R      ID         1/3          X
1639      HI      Value Information                                        BE, Value
1640      HI      Value Information                  REQ        HI04-2     1271 Industry Code                            R      AN         1/30         P      PRHP Processing Field
1641      HI      Value Information                 Not used    HI04-3     Date Time Period Format Qualifier                                            X
1642      HI      Value Information                 Not used    HI04-4     Date Time Period                                                             X
1643      HI      Value Information                  REQ        HI04-5     Monetary Amount                               R      R          1/18         P      PRHP Processing Field
1644      HI      Value Information                 Not used    HI04-5     Quantity                                                                     X
1645      HI      Value Information                 Not used    HI04-7     Version Identifier                                                           X
1646      HI      Value Information                   SIT       HI05       Health Care Code Information                  R      *          *

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 37 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1647      HI      Value Information                   REQ       HI05-1     Code List Qualifier code                      R      ID     1/3          X
1648      HI      Value Information                                        BE, Value
1649      HI      Value Information                  REQ        HI05-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1650      HI      Value Information                 Not used    HI05-3     Date Time Period Format Qualifier                                        X
1651      HI      Value Information                 Not used    HI05-4     Date Time Period                                                         X
1652      HI      Value Information                  REQ        HI05-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1653      HI      Value Information                 Not used    HI05-6     Quantity                                                                 X
1654      HI      Value Information                 Not used    HI05-7     Version Identifier                                                       X
1655      HI      Value Information                   SIT       HI06       Health Care Code Information                  R      *      *
1656      HI      Value Information                  REQ        HI06-1     Code List Qualifier code                      R      ID     1/3          X
1657      HI      Value Information                                        BE, Value
1658      HI      Value Information                  REQ        HI06-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1659      HI      Value Information                 Not used    HI06-3     Date Time Period Format Qualifier                                        X
1660      HI      Value Information                 Not used    HI06-4     Date Time Period                                                         X
1661      HI      Value Information                  REQ        HI06-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1662      HI      Value Information                 Not used    HI06-6     Quantity                                                                 X
1663      HI      Value Information                 Not used    HI06-7     Version Identifier                                                       X
1664      HI      Value Information                   SIT       HI07       Health Care Code Information                  R      *      *
1665      HI      Value Information                  REQ        HI07-1     Code List Qualifier code                      R      ID     1/3          X
1666      HI      Value Information                                        BE, Value
1667      HI      Value Information                  REQ        HI07-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1668      HI      Value Information                 Not used    HI07-3     Date Time Period Format Qualifier                                        X
1669      HI      Value Information                 Not used    HI07-4     Date Time Period                                                         X
1670      HI      Value Information                  REQ        HI07-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1671      HI      Value Information                 Not used    HI07-6     Quantity                                                                 X
1672      HI      Value Information                 Not used    HI07-7     Version Identifier                                                       X
1673      HI      Value Information                   SIT       HI08       Health Care Code Information                  R      *      *
1674      HI      Value Information                  REQ        HI08-1     Code List Qualifier code                      R      ID     1/3          X
1675      HI      Value Information                                        BE, Value
1676      HI      Value Information                  REQ        HI08-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1677      HI      Value Information                 Not used    HI08-3     Date Time Period Format Qualifier                                        X
1678      HI      Value Information                 Not used    HI08-4     Date Time Period                                                         X
1679      HI      Value Information                  REQ        HI08-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1680      HI      Value Information                 Not used    HI08-6     Quantity                                                                 X
1681      HI      Value Information                 Not used    HI08-7     Version Identifier                                                       X
1682      HI      Value Information                   SIT       HI09       Health Care Code Information                  R      *      *
1683      HI      Value Information                  REQ        HI09-1     Code List Qualifier code                      R      ID     1/3          X
1684      HI      Value Information                                        BE, Value
1685      HI      Value Information                  REQ        HI09-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1686      HI      Value Information                 Not used    HI09-3     Date Time Period Format Qualifier                                        X
1687      HI      Value Information                 Not used    HI09-4     Date Time Period                                                         X
1688      HI      Value Information                  REQ        HI09-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1689      HI      Value Information                 Not used    HI09-6     Quantity                                                                 X
1690      HI      Value Information                 Not used    HI09-7     Version Identifier                                                       X
1691      HI      Value Information                   SIT       HI10       Health Care Code Information                  R      *      *
1692      HI      Value Information                  REQ        HI10-1     Code List Qualifier code                      R      ID     1/3          X
1693      HI      Value Information                                        BE, Value
1694      HI      Value Information                  REQ        HI10-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1695      HI      Value Information                 Not used    HI10-3     Date Time Period Format Qualifier                                        X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 38 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1696      HI      Value Information                 Not used    HI10-4     Date Time Period                                                         X
1697      HI      Value Information                  REQ        HI10-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1698      HI      Value Information                 Not used    HI10-6     Quantity                                                                 X
1699      HI      Value Information                 Not used    HI10-7     Version Identifier                                                       X
1700      HI      Value Information                   SIT       HI11       Health Care Code Information                  R      *      *
1701      HI      Value Information                  REQ        HI11-1     Code List Qualifier code                      R      ID     1/3          X
1702      HI      Value Information                                        BE, Value
1703      HI      Value Information                  REQ        HI11-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1704      HI      Value Information                 Not used    HI11-3     Date Time Period Format Qualifier                                        X
1705      HI      Value Information                 Not used    HI11-4     Date Time Period                                                         X
1706      HI      Value Information                  REQ        HI11-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1707      HI      Value Information                 Not used    HI11-6     Quantity                                                                 X
1708      HI      Value Information                 Not used    HI11-7     Version Identifier                                                       X
1709      HI      Value Information                   SIT       HI12       Health Care Code Information                  R      *      *
1710      HI      Value Information                  REQ        HI12-1     Code List Qualifier code                      R      ID     1/3          X
1711      HI      Value Information                                        BE, Value
1712      HI      Value Information                  REQ        HI12-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1713      HI      Value Information                 Not used    HI12-3     Date Time Period Format Qualifier                                        X
1714      HI      Value Information                 Not used    HI12-4     Date Time Period                                                         X
1715      HI      Value Information                  REQ        HI12-5     Monetary Amount                               R      R      1/18         P      PRHP Processing Field
1716      HI      Value Information                 Not used    HI12-6     Quantity                                                                 X
1717      HI      Value Information                 Not used    HI12-7     Version Identifier                                                       X
1718
1719      HI      CONDITION INFORMATION             SIT/2300
1720      HI      Condition Information               REQ       HI01       Health Care Code Information                  R      *      *
1721      HI      Condition Information               REQ       HI01-1     Code List Qualifier code                      R      ID     1/3          X
1722      HI      Condition Information                                    BG, Condition
1723      HI      Condition Information              REQ        HI01-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1724      HI      Condition Information             Not used    HI01-3     Date Time Period Format Qualifier                                        X
1725      HI      Condition Information             Not used    HI01-4     Date Time Period                                                         X
1726      HI      Condition Information             Not used    HI01-5     Monetary Amount                                                          X
1727      HI      Condition Information             Not used    HI01-6     Quantity                                                                 X
1728      HI      Condition Information             Not used    HI01-7     Version Identifier                                                       X
1729      HI      Condition Information               SIT       HI02       Health Care Code Information                  R      *      *
1730      HI      Condition Information              REQ        HI02-1     Code List Qualifier code                      R      ID     1/3          X
1731      HI      Condition Information                                    BG, Condition
1732      HI      Condition Information              REQ        HI02-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1733      HI      Condition Information             Not used    HI02-3     Date Time Period Format Qualifier                                        X
1734      HI      Condition Information             Not used    HI02-4     Date Time Period                                                         X
1735      HI      Condition Information             Not used    HI02-5     Monetary Amount                                                          X
1736      HI      Condition Information             Not used    HI02-6     Quantity                                                                 X
1737      HI      Condition Information             Not used    HI02-7     Version Identifier                                                       X
1738      HI      Condition Information               SIT       HI03       Health Care Code Information                  R      *      *
1739      HI      Condition Information              REQ        HI03-1     Code List Qualifier code                      R      ID     1/3          X
1740      HI      Condition Information                                    BG, Condition
1741      HI      Condition Information              REQ        HI03-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1742      HI      Condition Information             Not used    HI03-3     Date Time Period Format Qualifier                                        X
1743      HI      Condition Information             Not used    HI03-4     Date Time Period                                                         X
1744      HI      Condition Information             Not used    HI03-5     Monetary Amount                                                          X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 39 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1745      HI      Condition Information             Not used    HI03-6     Quantity                                                                 X
1746      HI      Condition Information             Not used    HI03-7     Version Identifier                                                       X
1747      HI      Condition Information               SIT       HI04       Health Care Code Information                  R      *      *
1748      HI      Condition Information              REQ        HI04-1     Code List Qualifier code                      R      ID     1/3          X
1749      HI      Condition Information                                    BG, Condition
1750      HI      Condition Information              REQ        HI04-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1751      HI      Condition Information             Not used    HI04-3     Date Time Period Format Qualifier                                        X
1752      HI      Condition Information             Not used    HI04-4     Date Time Period                                                         X
1753      HI      Condition Information             Not used    HI04-5     Monetary Amount                                                          X
1754      HI      Condition Information             Not used    HI04-6     Quantity                                                                 X
1755      HI      Condition Information             Not used    HI04-7     Version Identifier                                                       X
1756      HI      Condition Information               SIT       HI05       Health Care Code Information                  R      *      *
1757      HI      Condition Information              REQ        HI05-1     Code List Qualifier code                      R      ID     1/3          X
1758      HI      Condition Information                                    BG, Condition
1759      HI      Condition Information              REQ        HI05-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1760      HI      Condition Information             Not used    HI05-3     Date Time Period Format Qualifier                                        X
1761      HI      Condition Information             Not used    HI05-4     Date Time Period                                                         X
1762      HI      Condition Information             Not used    HI05-5     Monetary Amount                                                          X
1763      HI      Condition Information             Not used    HI05-6     Quantity                                                                 X
1764      HI      Condition Information             Not used    HI05-7     Version Identifier                                                       X
1765      HI      Condition Information               SIT       HI06       Health Care Code Information                  R      *      *
1766      HI      Condition Information              REQ        HI06-1     Code List Qualifier code                      R      ID     1/3          X
1767      HI      Condition Information                                    BG, Condition
1768      HI      Condition Information              REQ        HI06-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1769      HI      Condition Information             Not used    HI06-3     Date Time Period Format Qualifier                                        X
1770      HI      Condition Information             Not used    HI06-4     Date Time Period                                                         X
1771      HI      Condition Information             Not used    HI06-5     Monetary Amount                                                          X
1772      HI      Condition Information             Not used    HI06-6     Quantity                                                                 X
1773      HI      Condition Information             Not used    HI06-7     Version Identifier                                                       X
1774      HI      Condition Information               SIT       HI07       Health Care Code Information                  R      *      *
1775      HI      Condition Information              REQ        HI07-1     Code List Qualifier code                      R      ID     1/3          X
1776      HI      Condition Information                                    BG, Condition
1777      HI      Condition Information              REQ        HI07-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1778      HI      Condition Information             Not used    HI07-3     Date Time Period Format Qualifier                                        X
1779      HI      Condition Information             Not used    HI07-4     Date Time Period                                                         X
1780      HI      Condition Information             Not used    HI07-5     Monetary Amount                                                          X
1781      HI      Condition Information             Not used    HI07-6     Quantity                                                                 X
1782      HI      Condition Information             Not used    HI07-7     Version Identifier                                                       X
1783      HI      Condition Information               SIT       HI08       Health Care Code Information                  R      *      *
1784      HI      Condition Information              REQ        HI08-1     Code List Qualifier code                      R      ID     1/3          X
1785      HI      Condition Information                                    BG, Condition
1786      HI      Condition Information              REQ        HI08-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1787      HI      Condition Information             Not used    HI08-3     Date Time Period Format Qualifier                                        X
1788      HI      Condition Information             Not used    HI08-4     Date Time Period                                                         X
1789      HI      Condition Information             Not used    HI08-5     Monetary Amount                                                          X
1790      HI      Condition Information             Not used    HI08-6     Quantity                                                                 X
1791      HI      Condition Information             Not used    HI08-7     Version Identifier                                                       X
1792      HI      Condition Information               SIT       HI09       Health Care Code Information                  R      *      *
1793      HI      Condition Information              REQ        HI09-1     Code List Qualifier code                      R      ID     1/3          X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 40 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1794      HI      Condition Information                                    BG, Condition
1795      HI      Condition Information              REQ        HI09-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1796      HI      Condition Information             Not used    HI09-3     Date Time Period Format Qualifier                                        X
1797      HI      Condition Information             Not used    HI09-4     Date Time Period                                                         X
1798      HI      Condition Information             Not used    HI09-5     Monetary Amount                                                          X
1799      HI      Condition Information             Not used    HI09-6     Quantity                                                                 X
1800      HI      Condition Information             Not used    HI09-7     Version Identifier                                                       X
1801      HI      Condition Information               SIT       HI10       Health Care Code Information                  R      *      *
1802      HI      Condition Information              REQ        HI10-1     Code List Qualifier code                      R      ID     1/3          X
1803      HI      Condition Information                                    BG, Condition
1804      HI      Condition Information              REQ        HI10-2     1271 Industry Code                            R      AN     1/30         P      PRHP Processing Field
1805      HI      Condition Information             Not used    HI10-3     Date Time Period Format Qualifier                                        X
1806      HI      Condition Information             Not used    HI10-4     Date Time Period                                                         X
1807      HI      Condition Information             Not used    HI10-5     Monetary Amount                                                          X
1808      HI      Condition Information             Not used    HI10-6     Quantity                                                                 X
1809      HI      Condition Information             Not used    HI10-7     Version Identifier                                                       X
1810      HI      Condition Information               SIT       HI11       Health Care Code Information                  R      *      *
1811      HI      Condition Information              REQ        HI11-1     Code List Qualifier code                      R      ID     1/3          X
1812      HI      Condition Information                                    BG, Condition
1813      HI      Condition Information              REQ        HI11-2     1271 Industry Code                            R      AN     1/30         E      PRHP Processing Field
1814      HI      Condition Information             Not used    HI11-3     Date Time Period Format Qualifier                                        X
1815      HI      Condition Information             Not used    HI11-4     Date Time Period                                                         X
1816      HI      Condition Information             Not used    HI11-5     Monetary Amount                                                          X
1817      HI      Condition Information             Not used    HI11-6     Quantity                                                                 X
1818      HI      Condition Information             Not used    HI11-7     Version Identifier                                                       X
1819      HI      Condition Information               SIT       HI12       Health Care Code Information                  R      *      *
1820      HI      Condition Information              REQ        HI12-1     Code List Qualifier code                      R      ID     1/3          X
1821      HI      Condition Information                                    BG, Condition
1822      HI      Condition Information              REQ        HI12-2     1271 Industry Code                            R      AN     1/30         E      PRHP Processing Field
1823      HI      Condition Information             Not used    HI12-3     Date Time Period Format Qualifier                                        X
1824      HI      Condition Information             Not used    HI12-4     Date Time Period                                                         X
1825      HI      Condition Information             Not used    HI12-5     Monetary Amount                                                          X
1826      HI      Condition Information             Not used    HI12-6     Quantity                                                                 X
1827      HI      Condition Information             Not used    HI12-7     Version Identifier                                                       X
1828
1829              TREATMENT CODE INFORMATION        SIT/2300
1830      HI      Treatment Code Information          REQ       HI01       Health Care Code Information                  R      *      *
1831      HI      Treatment Code Information          REQ       HI01-1     Code List Qualifier code                      R      ID     1/3          X
1832      HI      Treatment Code Information                               TC, Treatment Codes
1833      HI      Treatment Code Information         REQ        HI01-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1834      HI      Treatment Code Information        Not used    HI01-3     Date Time Period Format Qualifier                                        X
1835      HI      Treatment Code Information        Not used    HI01-4     Date Time Period                                                         X
1836      HI      Treatment Code Information        Not used    HI01-5     Monetary Amount                                                          X
1837      HI      Treatment Code Information        Not used    HI01-6     Quantity                                                                 X
1838      HI      Treatment Code Information        Not used    HI01-7     Version Identifier                                                       X
1839      HI      Treatment Code Information          SIT       HI02       Health Care Code Information                  R      *      *
1840      HI      Treatment Code Information         REQ        HI02-1     Code List Qualifier code                      R      ID     1/3          X
1841      HI      Treatment Code Information                               TC, Treatment Codes
1842      HI      Treatment Code Information          REQ       HI02-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 41 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1843      HI      Treatment Code Information        Not used    HI02-3     Date Time Period Format Qualifier                                        X
1844      HI      Treatment Code Information        Not used    HI02-4     Date Time Period                                                         X
1845      HI      Treatment Code Information        Not used    HI02-5     Monetary Amount                                                          X
1846      HI      Treatment Code Information        Not used    HI02-6     Quantity                                                                 X
1847      HI      Treatment Code Information        Not used    HI02-7     Version Identifier                                                       X
1848      HI      Treatment Code Information          SIT       HI03       Health Care Code Information                  R      *      *
1849      HI      Treatment Code Information         REQ        HI03-1     Code List Qualifier code                      R      ID     1/3          X
1850      HI      Treatment Code Information                               TC, Treatment Codes
1851      HI      Treatment Code Information         REQ        HI03-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1852      HI      Treatment Code Information        Not used    HI03-3     Date Time Period Format Qualifier                                        X
1853      HI      Treatment Code Information        Not used    HI03-4     Date Time Period                                                         X
1854      HI      Treatment Code Information        Not used    HI03-5     Monetary Amount                                                          X
1855      HI      Treatment Code Information        Not used    HI03-6     Quantity                                                                 X
1856      HI      Treatment Code Information        Not used    HI03-7     Version Identifier                                                       X
1857      HI      Treatment Code Information          SIT       HI04       Health Care Code Information                  R      *      *
1858      HI      Treatment Code Information         REQ        HI04-1     Code List Qualifier code                      R      ID     1/3          X
1859      HI      Treatment Code Information                               TC, Treatment Codes
1860      HI      Treatment Code Information         REQ        HI04-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1861      HI      Treatment Code Information        Not used    HI04-3     Date Time Period Format Qualifier                                        X
1862      HI      Treatment Code Information        Not used    HI04-4     Date Time Period                                                         X
1863      HI      Treatment Code Information        Not used    HI04-5     Monetary Amount                                                          X
1864      HI      Treatment Code Information        Not used    HI04-6     Quantity                                                                 X
1865      HI      Treatment Code Information        Not used    HI04-7     Version Identifier                                                       X
1866      HI      Treatment Code Information          SIT       HI05       Health Care Code Information                  R      *      *
1867      HI      Treatment Code Information         REQ        HI05-1     Code List Qualifier code                      R      ID     1/3          X
1868      HI      Treatment Code Information                               TC, Treatment Codes
1869      HI      Treatment Code Information         REQ        HI05-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1870      HI      Treatment Code Information        Not used    HI05-3     Date Time Period Format Qualifier                                        X
1871      HI      Treatment Code Information        Not used    HI05-4     Date Time Period                                                         X
1872      HI      Treatment Code Information        Not used    HI05-5     Monetary Amount                                                          X
1873      HI      Treatment Code Information        Not used    HI05-6     Quantity                                                                 X
1874      HI      Treatment Code Information        Not used    HI05-7     Version Identifier                                                       X
1875      HI      Treatment Code Information          SIT       HI06       Health Care Code Information                  R      *      *
1876      HI      Treatment Code Information         REQ        HI06-1     Code List Qualifier code                      R      ID     1/3          X
1877      HI      Treatment Code Information                               TC, Treatment Codes
1878      HI      Treatment Code Information         REQ        HI06-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1879      HI      Treatment Code Information        Not used    HI06-3     Date Time Period Format Qualifier                                        X
1880      HI      Treatment Code Information        Not used    HI06-4     Date Time Period                                                         X
1881      HI      Treatment Code Information        Not used    HI06-5     Monetary Amount                                                          X
1882      HI      Treatment Code Information        Not used    HI06-6     Quantity                                                                 X
1883      HI      Treatment Code Information        Not used    HI06-7     Version Identifier                                                       X
1884      HI      Treatment Code Information          SIT       HI07       Health Care Code Information                  R      *      *
1885      HI      Treatment Code Information         REQ        HI07-1     Code List Qualifier code                      R      ID     1/3          X
1886      HI      Treatment Code Information                               TC, Treatment Codes
1887      HI      Treatment Code Information         REQ        HI07-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1888      HI      Treatment Code Information        Not used    HI07-3     Date Time Period Format Qualifier                                        X
1889      HI      Treatment Code Information        Not used    HI07-4     Date Time Period                                                         X
1890      HI      Treatment Code Information        Not used    HI07-5     Monetary Amount                                                          X
1891      HI      Treatment Code Information        Not used    HI07-6     Quantity                                                                 X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 42 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1892      HI      Treatment Code Information        Not used    HI07-7     Version Identifier                                                       X
1893      HI      Treatment Code Information          SIT       HI08       Health Care Code Information                  R      *      *
1894      HI      Treatment Code Information         REQ        HI08-1     Code List Qualifier code                      R      ID     1/3          X
1895      HI      Treatment Code Information                               TC, Treatment Codes
1896      HI      Treatment Code Information         REQ        HI08-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1897      HI      Treatment Code Information        Not used    HI08-3     Date Time Period Format Qualifier                                        X
1898      HI      Treatment Code Information        Not used    HI08-4     Date Time Period                                                         X
1899      HI      Treatment Code Information        Not used    HI08-5     Monetary Amount                                                          X
1900      HI      Treatment Code Information        Not used    HI08-6     Quantity                                                                 X
1901      HI      Treatment Code Information        Not used    HI08-7     Version Identifier                                                       X
1902      HI      Treatment Code Information          SIT       HI09       Health Care Code Information                  R      *      *
1903      HI      Treatment Code Information         REQ        HI09-1     Code List Qualifier code                      R      ID     1/3          X
1904      HI      Treatment Code Information                               TC, Treatment Codes
1905      HI      Treatment Code Information         REQ        HI09-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1906      HI      Treatment Code Information        Not used    HI09-3     Date Time Period Format Qualifier                                        X
1907      HI      Treatment Code Information        Not used    HI09-4     Date Time Period                                                         X
1908      HI      Treatment Code Information        Not used    HI09-5     Monetary Amount                                                          X
1909      HI      Treatment Code Information        Not used    HI09-6     Quantity                                                                 X
1910      HI      Treatment Code Information        Not used    HI09-7     Version Identifier                                                       X
1911      HI      Treatment Code Information          SIT       HI10       Health Care Code Information                  R      *      *
1912      HI      Treatment Code Information         REQ        HI10-1     Code List Qualifier code                      R      ID     1/3          X
1913      HI      Treatment Code Information                               TC, Treatment Codes
1914      HI      Treatment Code Information         REQ        HI10-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1915      HI      Treatment Code Information        Not used    HI10-3     Date Time Period Format Qualifier                                        X
1916      HI      Treatment Code Information        Not used    HI10-4     Date Time Period                                                         X
1917      HI      Treatment Code Information        Not used    HI10-5     Monetary Amount                                                          X
1918      HI      Treatment Code Information        Not used    HI10-6     Quantity                                                                 X
1919      HI      Treatment Code Information        Not used    HI10-7     Version Identifier                                                       X
1920      HI      Treatment Code Information          SIT       HI11       Health Care Code Information                  R      *      *
1921      HI      Treatment Code Information         REQ        HI11-1     Code List Qualifier code                      R      ID     1/3          X
1922      HI      Treatment Code Information                               TC, Treatment Codes
1923      HI      Treatment Code Information         REQ        HI11-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1924      HI      Treatment Code Information        Not used    HI11-3     Date Time Period Format Qualifier                                        X
1925      HI      Treatment Code Information        Not used    HI11-4     Date Time Period                                                         X
1926      HI      Treatment Code Information        Not used    HI11-5     Monetary Amount                                                          X
1927      HI      Treatment Code Information        Not used    HI11-6     Quantity                                                                 X
1928      HI      Treatment Code Information        Not used    HI11-7     Version Identifier                                                       X
1929      HI      Treatment Code Information          SIT       HI12       Health Care Code Information                  R      *      *
1930      HI      Treatment Code Information         REQ        HI12-1     Code List Qualifier code                      R      ID     1/3          X
1931      HI      Treatment Code Information                               TC, Treatment Codes
1932      HI      Treatment Code Information         REQ        HI12-2     Industry Code                                 R      AN     1/30         P      PRHP Processing Field
1933      HI      Treatment Code Information        Not used    HI12-3     Date Time Period Format Qualifier                                        X
1934      HI      Treatment Code Information        Not used    HI12-4     Date Time Period                                                         X
1935      HI      Treatment Code Information        Not used    HI12-5     Monetary Amount                                                          X
1936      HI      Treatment Code Information        Not used    HI12-6     Quantity                                                                 X
1937      HI      Treatment Code Information        Not used    HI12-7     Version Identifier                                                       X
1938
1939              CLAIM QUANTITY                    SIT/2300
1940     QTY      Claim Quantity                      REQ       QTY01      QUANTITY QUALIFIER                            R      ID     2/2          X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                 Puerto Rico Health Plan, Inc.                                                            Page 43 of 152
                                                                                                      Detail Data Definition-837 Institutional

  1                                                         HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                     REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

1941     QTY      Claim Quantity                                                 CA - COVERED - ACTUAL
1942     QTY      Claim Quantity                                                 CD - CO-INSURED-ACTUAL
1943     QTY      Claim Quantity                                                 LA - LIFE-TIME RESERVE-ACTUAL
1944     QTY      Claim Quantity                                                 NA - NUMBER OF NON-COVERED DAYS
1945     QTY      Claim Quantity                            REQ       QTY02      QUANTITY                                      R      R      1/15         P      PRHP Processing Field
1946     QTY      Claim Quantity                            REQ       QTY03      COMPOSITE UNIT OF MEASURE                     R      -      -            X
1947     QTY      Claim Quantity                            REQ       QTY03-1    UNIT OR BASIS FOR MEASUREMENT CODE            R      ID     2/2          X

1948     QTY      Claim Quantity                                                 DA, Days
1949     QTY      Claim Quantity                          Not used    QTY03-2    Exponent                                                                 X
1950     QTY      Claim Quantity                          Not used    QTY03-3    Multiplier                                                               X
1951     QTY      Claim Quantity                          Not used    QTY03-4    Unit or Basis for Measurement Code                                       X
1952     QTY      Claim Quantity                          Not used    QTY03-5    Exponent                                                                 X
1953     QTY      Claim Quantity                          Not used    QTY03-6    Multiplier                                                               X
1954     QTY      Claim Quantity                          Not used    QTY03-7    Unit or Basis for Measurement Code                                       X
1955     QTY      Claim Quantity                          Not used    QTY03-8    Exponent                                                                 X
1956     QTY      Claim Quantity                          Not used    QTY03-9    Multiplier                                                               X
1957     QTY      Claim Quantity                          Not used    QTY03-10   Unit or Basis for Measurement Code                                       X
1958     QTY      Claim Quantity                          Not used    QTY03-11   Exponent                                                                 X
1959     QTY      Claim Quantity                          Not used    QTY03-12   Multiplier                                                               X
1960     QTY      Claim Quantity                          Not used    QTY03-13   Unit or Basis for Measurement Code                                       X
1961     QTY      Claim Quantity                          Not used    QTY03-14   Exponent                                                                 X
1962     QTY      Claim Quantity                          Not used    QTY03-14   Multiplier                                                               X
1963     QTY      Claim Quantity                          Not used    QTY04      Free Form Message                                                        X
1964
1965              CLAIM PRICING/REPRICNG                  SIT/2300
                  INFORMATION
1966     HCP      Claim Pricing/Repricing Information       REQ       HCP01      Pricing Methodology                           R      ID     2/2          P      PRHP Processing Field
1967     HCP      Claim Pricing/Repricing Information                            00 -ZERO PRICING(NOT COVEREDUNDER
                                                                                 CONTRACT)
1968     HCP      Claim Pricing/Repricing Information                            01- PRICED AS BILLED AT 100%
1969     HCP      Claim Pricing/Repricing Information                            02 - PRICED AT THE STANDARD FEE
                                                                                 SCHEDULE
1970     HCP      Claim Pricing/Repricing Information                            03 - PRICED AT A CONTRACTUAL
                                                                                 PERCENTAGE
1971     HCP      Claim Pricing/Repricing Information                            04 - BUNDLED PRICING
1972     HCP      Claim Pricing/Repricing Information                            05 - PEER REVIEW PRICING
1973     HCP      Claim Pricing/Repricing Information                            06 - PER DIEM PRICING
1974     HCP      Claim Pricing/Repricing Information                            07 - FLAT RATE PRICING
1975     HCP      Claim Pricing/Repricing Information                            08 - COMBINATION PRICING
1976     HCP      Claim Pricing/Repricing Information                            09 - MATERNITY PRICING
1977     HCP      Claim Pricing/Repricing Information                            10 - OTHER PRICING
1978     HCP      Claim Pricing/Repricing Information                            11 - LOWER OF COST
1979     HCP      Claim Pricing/Repricing Information                            12 - RATIO OF COST
1980     HCP      Claim Pricing/Repricing Information                            13 - COST REIMBURSED
1981     HCP      Claim Pricing/Repricing Information                            14 - ADJUSTMENT PRICING
1982     HCP      Claim Pricing/Repricing Information       REQ       HCP02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
1983     HCP      Claim Pricing/Repricing Information       SIT       HCP03      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
1984     HCP      Claim Pricing/Repricing Information       SIT       HCP04      REFERENCE IDENTIFICATION                      S      AN     1/30         E      PRHP Processing Field
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       1/22/2011, 6:51 AM                                                                                 Puerto Rico Health Plan, Inc.                                                               Page 44 of 152
                                                                                                      Detail Data Definition-837 Institutional

  1                                                         HIPAA - 837 Institutional Claim                                                                                                 PRHP Processing Field
  2                                                     REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                Req/Loop Ref Desc Description                                             Use   Type         Len   Field   PRHP Processing Field

1985     HCP      Claim Pricing/Repricing Information        SIT      HCP05      RATE                                              S     R      1/19         E      PRHP Processing Field
1986     HCP      Claim Pricing/Repricing Information        SIT      HCP06      REFERENCE IDENTIFICATION                          S     AN     1/30         P      PRHP Processing Field
1987     HCP      Claim Pricing/Repricing Information        SIT      HCP07      MONETARY AMOUNT                                   S     R      1/18         P      PRHP Processing Field
1988     HCP      Claim Pricing/Repricing Information        SIT      HCP08      PRODUCT/SERVICE ID                                S     AN     1/48         E      PRHP Processing Field
1989     HCP      Claim Pricing/Repricing Information        SIT      HCP09      PRODUCT/SERVICE ID QUALIFIER                      S     ID     2/2          X
1990     HCP      Claim Pricing/Repricing Information                            HC - HEALTH CARE FINANCING
                                                                                 ADMINISTATION COMMON
1991     HCP      Claim Pricing/Repricing Information                            PROCEDURAL CODING SYSTEM (HCPCS)
                                                                                 CODES
1992     HCP      Claim Pricing/Repricing Information                            INCLUDES CPT AND HCPCS CODING
1993     HCP      Claim Pricing/Repricing Information        SIT      HCP10      PRODUCT/SERVICE ID                                S     AN     1/48         E      PRHP Processing Field
1994     HCP      Claim Pricing/Repricing Information        SIT      HCP11      UNIT OR BASIS FOR MEASUREMENT CODE                S     ID     2/2          E      PRHP Processing Field

1995     HCP      Claim Pricing/Repricing Information                            DA - DAYS
1996     HCP      Claim Pricing/Repricing Information                            UN - UNIT
1997     HCP      Claim Pricing/Repricing Information        SIT      HCP12      QUANTITY                                          S     R      1/15         E      PRHP Processing Field
1998     HCP      Claim Pricing/Repricing Information        SIT      HCP13      Reject Reason code                                S     ID     2/2          E      PRHP Processing Field
1999     HCP      Claim Pricing/Repricing Information                            T1, Cannot identify provider as TPO participant

2000     HCP      Claim Pricing/Repricing Information                            T2, Cannot identify payer as TPO participant
2001     HCP      Claim Pricing/Repricing Information                            T3, Cannot identify insured as TPO participant
2002     HCP      Claim Pricing/Repricing Information                            T4, Payer name or identifier missing
2003     HCP      Claim Pricing/Repricing Information                            T5, Certification Information missing
2004     HCP      Claim Pricing/Repricing Information                            T6, Claim does not contain enough information
                                                                                 for repricing
2005     HCP      Claim Pricing/Repricing Information        SIT      HCP14      Policy Compliance Code                          S       ID     1/2          E      PRHP Processing Field
2006     HCP      Claim Pricing/Repricing Information                            1, Procedure followed (compliance)
2007     HCP      Claim Pricing/Repricing Information                            2, Not followed-call not made (non-compliance
                                                                                 call not made
2008     HCP      Claim Pricing/Repricing Information                            3, Not medically necessary (non-compliance non-
                                                                                 medically necessary)
2009     HCP      Claim Pricing/Repricing Information                            4, Not followed Other (non-compliance other)
2010     HCP      Claim Pricing/Repricing Information                            5, Emergency admit to non-network hospital
2011     HCP      Claim Pricing/Repricing Information        SIT      HCP15      Exception Code                                  S       ID     1/2          E      PRHP Processing Field
2012     HCP      Claim Pricing/Repricing Information                            1, Non-network professional provider in network
                                                                                 hospital
2013     HCP      Claim Pricing/Repricing Information                            2, Emergency care
2014     HCP      Claim Pricing/Repricing Information                            3, Services or specialist not in network
2015     HCP      Claim Pricing/Repricing Information                            4, Out-of-Service area
2016     HCP      Claim Pricing/Repricing Information                            5, State mandates
2017     HCP      Claim Pricing/Repricing Information                            6, Other
2018
2019              HOME HEALTH CARE PLAN                   SIT/2305
                  INFORMATION
2020     CR7      Home Health Care Plan Information         REQ       CR701      DISCIPLINE TYPE CODE                              R     ID     2/2          P      PRHP Processing Field
2021     CR7      Home Health Care Plan Information                              AI, Home Health Aide
2022     CR7      Home Health Care Plan Information                              MS, Medical Social Worker
2023     CR7      Home Health Care Plan Information                              OT, Occupational Therapy
2024     CR7      Home Health Care Plan Information                              PT, Physical Therapy
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                                                                                                    Detail Data Definition-837 Institutional

  1                                                       HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                   REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                              Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2025     CR7      Home Health Care Plan Information                            SN, Skilled Nursing
2026     CR7      Home Health Care Plan Information                            ST, Speech Therapy
2027     CR7      Home Health Care Plan Information       REQ       CR702      NUMBER                                        R      NO     1/9          P      PRHP Processing Field
2028     CR7      Home Health Care Plan Information       REQ       CR703      NUMBER                                        R      NO     1/9          P      PRHP Processing Field
2029
2030              HEALTH CARE SERVICES DELIVERY         SIT/2305                                                             S
2031     HSD      Health Care Services Delivery           SIT       HSD01      QUANTITY QUALIFIER                            S      ID     2/2          X
2032     HSD      Health Care Services Delivery                                VS, Visits
2033     HSD      Health Care Services Delivery            SIT      HSD02      QUANTITY                                      S      R      1/15         P      PRHP Processing Field
2034     HSD      Health Care Services Delivery            SIT      HSD03      UNIT OR BASIS FOR MEASUREMENT CODE            S      ID     2/2          P      PRHP Processing Field

2035     HSD      Health Care Services Delivery                                DA, Days
2036     HSD      Health Care Services Delivery                                MO, Months
2037     HSD      Health Care Services Delivery                                Q1, Quarter (Time)
2038     HSD      Health Care Services Delivery                                WK, Week
2039     HSD      Health Care Services Delivery            SIT      HSD04      SAMPLE SELECTION MODULUS                      S      R      1/6          P      PRHP Processing Field
2040     HSD      Health Care Services Delivery            SIT      HSD05      TIME PERIOD QUALIFIER                         S      ID     1/2          P      PRHP Processing Field
2041     HSD      Health Care Services Delivery                                7, Day
2042     HSD      Health Care Services Delivery                                35, Week
2043     HSD      Health Care Services Delivery            SIT      HSD06      NUMBER OF PERIOD                              S      NO     1/3          P      PRHP Processing Field
2044     HSD      Health Care Services Delivery            SIT      HSD07      SHIP/DELIVERY OR CALENDAR PATTERN             S      ID     1/2          P      PRHP Processing Field
                                                                               CODE
2045     HSD      Health Care Services Delivery                                1, 1ST WEEK OF THE MONTH
2046     HSD      Health Care Services Delivery                                2, 2nd WEEK OF THE MONTH
2047     HSD      Health Care Services Delivery                                3, 3rd WEEK OF THE MONTH
2048     HSD      Health Care Services Delivery                                4, 4th WEEK OF THE MONTH
2049     HSD      Health Care Services Delivery                                5, 5th WEEK OF THE MONTH
2050     HSD      Health Care Services Delivery                                6, 1ST & 3RD WEEK OF THE MONTH
2051     HSD      Health Care Services Delivery                                7, 2nd & 4TH WEEK OF THE MONTH
2052     HSD      Health Care Services Delivery                                8, 1ST WORKING DAY OF PERIOD
2053     HSD      Health Care Services Delivery                                9, LAST WORKING DAY OF PERIOD
2054     HSD      Health Care Services Delivery                                A, MONDAY THROUGH FRIDAY
2055     HSD      Health Care Services Delivery                                B, MONDAY THROUGH SATURDAY
2056     HSD      Health Care Services Delivery                                C, MONDAY THROUGH SUNDAY
2057     HSD      Health Care Services Delivery                                D, MONDAY
2058     HSD      Health Care Services Delivery                                E, TUESDAY
2059     HSD      Health Care Services Delivery                                F, WEDNESDAY
2060     HSD      Health Care Services Delivery                                G, THURSDAY
2061     HSD      Health Care Services Delivery                                H, FRIDAY
2062     HSD      Health Care Services Delivery                                J, SATURDAY
2063     HSD      Health Care Services Delivery                                K, SUNDAY
2064     HSD      Health Care Services Delivery                                L, MONDAY THROUGH THURSDAY
2065     HSD      Health Care Services Delivery                                N, AS DIRECTED
2066     HSD      Health Care Services Delivery                                O, DAILY MON. THROUGH FRI.
2067     HSD      Health Care Services Delivery                                S, ONCE ANYTIME MON. THROUGH FRI.
2068     HSD      Health Care Services Delivery                                SA, SUN. MON.THRUS.FRI.SATURDAY
2069     HSD      Health Care Services Delivery                                SB, TUESDAY THROUGH SATURDAY
2070     HSD      Health Care Services Delivery                                SC, SUN, WED, THURS,FRI, SATURDAY
2071     HSD      Health Care Services Delivery                                SD, MON, WED, THURS,FRI, SATURDAY

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                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2072     HSD      Health Care Services Delivery                                        SG, TUESDAY THROUGH FRIDAY
2073     HSD      Health Care Services Delivery                                        SL, MONDAY, TUESDAY AND THURSDAY
2074     HSD      Health Care Services Delivery                                        SP, MONDAY, TUESDAY AND FRIDAY
2075     HSD      Health Care Services Delivery                                        SX, WEDNESDAY AND THURSDAY
2076     HSD      Health Care Services Delivery                                        SY, MONDAY, WEDNESDAY AND THURSDAY

2077     HSD      Health Care Services Delivery                                        SZ, TUESDAY,THURSDAY AND FRIDAY
2078     HSD      Health Care Services Delivery                                        W, WHENEVER NECESSARY
2079     HSD      Health Care Services Delivery                    SIT      HSD08      SHIP/DELIVERY PATTERN TIME CODE               S      ID     1/1          P      PRHP Processing Field
2080     HSD      Health Care Services Delivery                                        D, A.M.
2081     HSD      Health Care Services Delivery                                        E, P.M.
2082     HSD      Health Care Services Delivery                                        F, AS DIRECTED
2083
2084              ATTENDING PHYSICIAN NAME                      SIT/2310A                                                            S
2085     NM1      Attending Physician Name                         REQ      NM101      ENTITY ID CODE                                R      ID     2/3          X
2086     NM1      Attending Physician Name                                             71, ATTENDING PHYSICIAN
2087     NM1      Attending Physician Name                        REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          E      PRHP Processing Field
2088     NM1      Attending Physician Name                                             1, PERSON
2089     NM1      Attending Physician Name                                             2, NON-PERSON ENTITY
2090     NM1      Attending Physician Name                       REQ        NM103      NAME LAST OR ORGANIZATION NAME                R      AN     1/35         P      PRHP Processing Field
2091     NM1      Attending Physician Name                        SIT       NM104      NAME FIRST                                    R      AN     1/25         P      PRHP Processing Field
2092     NM1      Attending Physician Name                        SIT       NM105      NAME MIDDLE                                   S      AN     1/25         P      PRHP Processing Field
2093     NM1      Attending Physician Name                      Not used    NM106      Name Prefix
2094     NM1      Attending Physician Name                        SIT       NM107      NAME SUFFIX                                   S      AN     1/10         P      PRHP Processing Field
2095     NM1      Attending Physician Name                       REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
2096     NM1      Attending Physician Name                                             24 - EMPLOYER'S IDENTIFICATION NUMBER

2097     NM1      Attending Physician Name                                             34 - SOCIAL SECURITY NUMBER
2098     NM1      Attending Physician Name                                             XX - HEALTH CARE FINANCING ADM. NPI
2099     NM1      Attending Physician Name                       REQ        NM109      IDENTIFICATION CODE                           R      AN     2/80         P      PRHP Processing Field
2100     NM1      Attending Physician Name                      Not used    NM110      Entity Relationship Code
2101     NM1      Attending Physician Name                      Not used    NM111      Entity Identifier code
2102
2103              ATTENDING PHYSICIAN SPECIALTY                REQ/2310A
                  INFORMATION
2104     PRV      Attending Physician Specialty Information       REQ       PRV01      PROVIDER CODE                                 R      ID     1/3          E      PRHP Processing Field

2105     PRV      Attending Physician Specialty Information                            AT, Attending

2106     PRV      Attending Physician Specialty Information                            SU, Supervising

2107     PRV      Attending Physician Specialty Information       REQ       PRV02      REFERENCE IDENTIFICATION QUALIFIER            R      ID     2/3          X

2108     PRV      Attending Physician Specialty Information                            ZZ, Mutually Defined ( Provider Taxonomy
                                                                                       Code)
2109     PRV      Attending Physician Specialty Information       REQ       PRV03      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field

2110     PRV      Attending Physician Specialty Information     Not used    PRV04      State or Province Code                                                   X


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                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                                PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                            Use   Type         Len   Field   PRHP Processing Field

2111     PRV      Attending Physician Specialty Information     Not used    PRV05      Provider Specialty Information                                             X

2112     PRV      Attending Physician Specialty Information     Not used    PRV06      Provider Organization Code                                                 X

2113
2114              ATTENDING PHYSICIAN SECONDARY                 SIT/2310A
                  IDENTIFICATION
2115     REF      Attending Physician Secondary ID                REQ       REF01      Reference Identification Qualifier              R      ID     2/3          E      PRHP Processing Field
2116     REF      Attending Physician Secondary ID                                     OB, State License Number
2117     REF      Attending Physician Secondary ID                                     1A, Blue Cross Provider Number
2118     REF      Attending Physician Secondary ID                                     1B, Blue Shield Provider Number
2119     REF      Attending Physician Secondary ID                                     1C, Medicare Provider Number
2120     REF      Attending Physician Secondary ID                                     1D, Medicaid Provider Number
2121     REF      Attending Physician Secondary ID                                     1G, Provider UPIN Number
2122     REF      Attending Physician Secondary ID                                     1H, CHAMPUS Identification Number
2123     REF      Attending Physician Secondary ID                                     EI, Employer's Identification Number
2124     REF      Attending Physician Secondary ID                                     G2, Provider Commercial Number
2125     REF      Attending Physician Secondary ID                                     LU, Location Number
2126     REF      Attending Physician Secondary ID                                     N5, Provider Plan Network Identification Number

2127     REF      Attending Physician Secondary ID                                     SY, SSN
2128     REF      Attending Physician Secondary ID                                     X5, State Industrical Accident Provider Number

2129     REF      Attending Physician Secondary ID                REQ       REF02      REFERENCE IDENTIFICATION                         R     AN     1/30         E      PRHP Processing Field

2130     REF      Attending Physician Secondary ID              Not used    REF03      Description                                                                X
2131     REF      Attending Physician Secondary ID              Not used    REF04      Reference Identifier                                                       X
2132
2133              OPERATING PHYSICIAN NAME                      SIT/2310B
2134     NM1      Operating Physician Name                         REQ      NM101      ENTITY IDENTIFIER CODE                           R     ID     2/3          X
2135     NM1      Operating Physician Name                                             72 - OPERATING PHYSICIAN
2136     NM1      Operating Physician Name                        REQ       NM102      ENTITY TYPE QUALIFIER                            R     ID     1/1          X
2137     NM1      Operating Physician Name                                             1, PERSON
2138     NM1      Operating Physician Name                       REQ        NM103      NAME LAST OR ORGANIZATION NAME                   R     AN     1/35         P      PRHP Processing Field
2139     NM1      Operating Physician Name                       REQ        NM104      NAME FIRST                                       R     AN     1/25         P      PRHP Processing Field
2140     NM1      Operating Physician Name                        SIT       NM105      NAME MIDDLE                                      S     AN     1/25         P      PRHP Processing Field
2141     NM1      Operating Physician Name                      Not used    NM106      Name Prefix
2142     NM1      Operating Physician Name                        SIT       NM107      NAME SUFFIX (REQ.IF KNOW)                        S     AN     1/10         P      PRHP Processing Field
2143     NM1      Operating Physician Name                       REQ        NM108      IDENTIFICATION CODE QUALIFIER                    R     ID     1/2          E      PRHP Processing Field
2144     NM1      Operating Physician Name                                             24, Employer's Identification Number
2145     NM1      Operating Physician Name                                             34, SSN
2146     NM1      Operating Physician Name                                             XX, HCFA NPI
2147     NM1      Operating Physician Name                        REQ       NM109      IDENTIFICATION CODE                              R     AN     2/80         P      PRHP Processing Field
2148     NM1      Operating Physician Name                                             Line a, Other Physician ID
2149     NM1      Operating Physician Name                      Not used    NM110      Entity Relationship Code                                                   X
2150     NM1      Operating Physician Name                      Not used    NM111      Entity Identifier code                                                     X
2151
2152              OPERATING PHYSICIAN SPECIALTY                 SIT/2310B
                  INFORMATION
       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                       Puerto Rico Health Plan, Inc.                                                              Page 48 of 152
                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                                PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                            Use   Type         Len   Field   PRHP Processing Field

2153     PRV      Operating Physician Specialty Information       REQ       PRV01      PROVIDER CODE                                    R     ID     1/3          X

2154     PRV      Operating Physician Specialty Information                            OP, Operating

2155     PRV      Operating Physician Specialty Information       REQ       PRV02      REFERENCE IDENTIFICATION QUALIFIER               R     ID     2/3          X

2156     PRV      Operating Physician Specialty Information                            ZZ, Mutually Defined (Provider Taxonomy Code)

2157     PRV      Operating Physician Specialty Information       REQ       PRV03      REFERENCE IDENTIFICATION                         R     ID     1/30         E      PRHP Processing Field

2158     PRV      Operating Physician Specialty Information     Not used    PRV04      State or Province Code                                                     X

2159     PRV      Operating Physician Specialty Information     Not used    PRV05      Provider Specialty Information                                             X

2160     PRV      Operating Physician Specialty Information     Not used    PRV06      Provider Organization Code                                                 X

2161
2162              OPERATING PHYSICIAN SECONDARY                 SIT/2310B
                  IDENTIFICATION
2163     REF      Operating Physician Secondary ID                REQ       REF01      REFERENCE IDENTIFICATION QUALIFIER              R      ID     2/3          E      PRHP Processing Field
2164     REF      Operating Physician Secondary ID                                     OB, State License Number
2165     REF      Operating Physician Secondary ID                                     1A, Blue Cross Provider Number
2166     REF      Operating Physician Secondary ID                                     1B, Blue Shield Provider Number
2167     REF      Operating Physician Secondary ID                                     1C, Medicare Provider Number
2168     REF      Operating Physician Secondary ID                                     1D, Medicaid Provider Number
2169     REF      Operating Physician Secondary ID                                     1G, Provider UPIN Number
2170     REF      Operating Physician Secondary ID                                     1H, CHAMPUS Identification Number
2171     REF      Operating Physician Secondary ID                                     EI, Employer's Identification Number
2172     REF      Operating Physician Secondary ID                                     G2, Provider Commercial Number
2173     REF      Operating Physician Secondary ID                                     LU, Location Number
2174     REF      Operating Physician Secondary ID                                     N5, Provider Plan Network Identification Number

2175     REF      Operating Physician Secondary ID                                     SY, SSN
2176     REF      Operating Physician Secondary ID                                     X5, State Industrical Accident Provider Number

2177     REF      Operating Physician Secondary ID                REQ       REF02      Reference Identifier                             R     AN     1/80         E      PRHP Processing Field

2178     REF      Operating Physician Secondary ID              Not used    REF03      Description                                                                X
2179     REF      Operating Physician Secondary ID              Not used    REF04      Reference Identifier                                                       X
2180
2181              Other Provider Name                           SIT/2310C
2182     NM1      Other Provider Name                              REQ      NM101      Entity Identifier Code                           R     ID     2/3          X
2183     NM1      Other Provider Name                                                  73      Other Physician
2184     NM1      Other Provider Name                             REQ       NM102      Entity Type Qualifier                            R     ID     1/1          E      PRHP Processing Field
2185     NM1      Other Provider Name                                                  1        Person
2186     NM1      Other Provider Name                                                  2        Non-Person Entity
2187     NM1      Other Provider Name                             REQ       NM103      Name Last or Organization Name                   R     AN     1/35         P      PRHP Processing Field
2188     NM1      Other Provider Name                             SIT       NM104      Name First                                       S     AN     1/25         P      PRHP Processing Field
2189     NM1      Other Provider Name                             SIT       NM105      Name Middle                                      S     AN     1/25         P      PRHP Processing Field
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                                                                                                          Detail Data Definition-837 Institutional

  1                                                             HIPAA - 837 Institutional Claim                                                                                                PRHP Processing Field
  2                                                         REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                    Req/Loop Ref Desc Description                                            Use   Type         Len   Field   PRHP Processing Field

2190     NM1      Other Provider Name                         Not used    NM106      Name Prefix                                                                X
2191     NM1      Other Provider Name                           SIT       NM107      Name Suffix                                      S     AN     1/10         P      PRHP Processing Field
2192     NM1      Other Provider Name                          REQ        NM108      Identification Code Qualifier                    R     ID     1/2          E      PRHP Processing Field
2193     NM1      Other Provider Name                                                24      Employer
2194     NM1      Other Provider Name                                                34      Social Security Number
2195     NM1      Other Provider Name                                                XX       Health Care Fin. Adm. Nat. Prov. Id
2196     NM1      Other Provider Name                          REQ        NM109      Identification Code                              R     AN     2/80         P      PRHP Processing Field
2197     NM1      Other Provider Name                         Not used    NM110      Entity Relationship Code                                                   X
2198     NM1      Other Provider Name                         Not used    NM111      Entity Identifier Code                                                     X
2199
2200              Other Provider Specialty Information       REQ/2310C
2201     PRV      Other Provider Specialty Information         REQ     PRV01         Provider Code                                    R     ID     1/3          E      PRHP Processing Field
2202     PRV      Other Provider Specialty Information                               OT, Other Physician
2203     PRV      Other Provider Specialty Information                               PE, Performing
2204     PRV      Other Provider Specialty Information          REQ       PRV02      Reference Identification Qualifier               R     ID     2/3          X
2205     PRV      Other Provider Specialty Information                               ZZ, Mutually Defined ( Provider Taxonomy
                                                                                     Code)
2206     PRV      Other Provider Specialty Information         REQ        PRV03      Reference Identification                         R     AN     1/30         E      PRHP Processing Field
2207     PRV      Other Provider Specialty Information        Not used    PRV04      State or Province Code                                                     X
2208     PRV      Other Provider Specialty Information        Not used    PRV05      Provider Specialty Information                                             X
2209     PRV      Other Provider Specialty Information        Not used    PRV06      Provider Organization Code                                                 X
2210
2211              Other Provider Secondary Identification     SIT/2310C

2212     REF      Other Provider Secondary ID                   REQ       REF01      Reference Identification Qualifier              R      ID     2/3          E      PRHP Processing Field
2213     REF      Other Provider Secondary ID                                        OB, State License Number
2214     REF      Other Provider Secondary ID                                        1A, Blue Cross Provider Number
2215     REF      Other Provider Secondary ID                                        1B, Blue Shield Provider Number
2216     REF      Other Provider Secondary ID                                        1C, Medicare Provider Number
2217     REF      Other Provider Secondary ID                                        1D, Medicaid Provider Number
2218     REF      Other Provider Secondary ID                                        1G, Provider UPIN Number
2219     REF      Other Provider Secondary ID                                        1H, CHAMPUS Identification Number
2220     REF      Other Provider Secondary ID                                        EI, Employer's Identification Number
2221     REF      Other Provider Secondary ID                                        G2, Provider Commercial Number
2222     REF      Other Provider Secondary ID                                        LU, Location Number
2223     REF      Other Provider Secondary ID                                        N5, Provider Plan Network Identification Number

2224     REF      Other Provider Secondary ID                                        SY, SSN
2225     REF      Other Provider Secondary ID                                        X5, State Industrical Accident Provider Number

2226     REF      Other Provider Secondary ID                   REQ       REF02      Reference Identification                         R     AN     1/30         E      PRHP Processing Field

2227     REF      Other Provider Secondary ID                 Not used    REF03      Description                                                                X
2228     REF      Other Provider Secondary ID                 Not used    REF04      Reference Identifier                                                       X
2229
2230              Referring Provider Name                     SIT/2310D
2231     NM1      Referring Provider Name                        REQ      NM01       Entity Identifier Code                           R     ID     2/3          X
2232     NM1      Referring Provider Name                                            DN       Referring Provider
2233     NM1      Referring Provider Name                                            P3       Primary Care Provider

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                                                                                                           Detail Data Definition-837 Institutional

  1                                                              HIPAA - 837 Institutional Claim                                                                                                PRHP Processing Field
  2                                                          REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                     Req/Loop Ref Desc Description                                            Use   Type         Len   Field   PRHP Processing Field

2234     NM1      Referring Provider Name                        REQ       NM102      Entity Type Qualifier                            R     ID     1/1          E      PRHP Processing Field
2235     NM1      Referring Provider Name                                             1          Person
2236     NM1      Referring Provider Name                                             2         Non-Person Entity
2237     NM1      Referring Provider Name                       REQ        NM103      Name Last or Organization Name                   R     AN     1/35         P      PRHP Processing Field
2238     NM1      Referring Provider Name                        SIT       NM104      Name First                                       S     AN     1/25         P      PRHP Processing Field
2239     NM1      Referring Provider Name                        SIT       NM105      Name Middle                                      S     AN     1/25         P      PRHP Processing Field
2240     NM1      Referring Provider Name                      Not used    NM106      Name Prefix                                                                X
2241     NM1      Referring Provider Name                        SIT       NM107      Name Suffix                                      S     AN     1/10         P      PRHP Processing Field
2242     NM1      Referring Provider Name                        SIT       NM108      Identification Code Qualifier                    S     ID     1/2          E      PRHP Processing Field
2243     NM1      Referring Provider Name                                             24, Employer's Identification Number
2244     NM1      Referring Provider Name                                             34, SSN
2245     NM1      Referring Provider Name                                             XX, HCFA NPI
2246     NM1      Referring Provider Name                        SIT       NM109      Identification Code                              S     AN     2/80         P      PRHP Processing Field
2247     NM1      Referring Provider Name                      Not used    NM110      Entity Relationship Code                                                   X
2248     NM1      Referring Provider Name                      Not used    NM111      Entity Identifier Code                                                     X
2249
2250              Referring Provider Specialty Information     SIT/2310D

2251     PRV      Referring Provider Specialty Information       REQ       PRV01      Provider Code                                    R     ID     1/3          X
2252     PRV      Referring Provider Specialty Information                            RF        Referring
2253     PRV      Referring Provider Specialty Information       REQ       PRV02      Reference Identification Qualifier               R     ID     2/3          X
2254     PRV      Referring Provider Specialty Information                            ZZ, Mutually Defined ( Provider Taxonomy
                                                                                      Code)
2255     PRV      Referring Provider Specialty Information      REQ        PRV03      Reference Identification                         R     AN     1/30         E      PRHP Processing Field
2256     PRV      Referring Provider Specialty Information     Not used    PRV04      State or Province Code                                                     X
2257     PRV      Referring Provider Specialty Information     Not used    PRV05      Provider Specialty Information                                             X
2258     PRV      Referring Provider Specialty Information     Not used    PRV06      Provider Organization Code                                                 X
2259
2260              Referring Provider Secondary                 SIT/2310D
                  Identification
2261     REF      Reference Identification                     OPT/2310    REF01      Reference Identification Qualifier              R      ID     2/3          E      PRHP Processing Field
2262     REF      Reference Identification                                            OB, State License Number
2263     REF      Reference Identification                                            1A, Blue Cross Provider Number
2264     REF      Reference Identification                                            1B, Blue Shield Provider Number
2265     REF      Reference Identification                                            1C, Medicare Provider Number
2266     REF      Reference Identification                                            1D, Medicaid Provider Number
2267     REF      Reference Identification                                            1G, Provider UPIN Number
2268     REF      Reference Identification                                            1H, CHAMPUS Identification Number
2269     REF      Reference Identification                                            EI, Employer's Identification Number
2270     REF      Reference Identification                                            G2, Provider Commercial Number
2271     REF      Reference Identification                                            LU, Location Number
2272     REF      Reference Identification                                            N5, Provider Plan Network Identification Number

2273     REF      Reference Identification                                            SY, SSN
2274     REF      Reference Identification                                            X5, State Industrical Accident Provider Number

2275     REF      Reference Identification                                 REF02      Reference Identification                         R     AN     1/30         E      PRHP Processing Field

2276     REF      Reference Identification                   Not used      REF03      Description                                                                X
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                                                                                                         Detail Data Definition-837 Institutional

  1                                                            HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                        REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                   Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2277     REF      Reference Identification                 Not used      REF04      Reference Identifier                                                     X
2278
2279              Service Facility Name                      SIT/2310E
2280     NM1      Service Facility Name                         REQ      NM101      Entity Identifier Code                        R      ID     2/3          X
2281     NM1      Service Facility Name                                             FA, Facility
2282     NM1      Service Facility Name                        REQ       NM102      Entity Type Qualifier                         R      ID     1/1          X
2283     NM1      Service Facility Name                                             2, Non-Person Entity
2284     NM1      Service Facility Name                       REQ        NM103      Name Last or Organization Name                R      AN     1/35         E      PRHP Processing Field
2285     NM1      Service Facility Name                      Not used    NM104      Name First                                                               X
2286     NM1      Service Facility Name                      Not used    NM105      Name Middle                                                              X
2287     NM1      Service Facility Name                      Not used    NM106      Name Prefix                                                              X
2288     NM1      Service Facility Name                      Not used    NM107      Name Suffix                                                              X
2289     NM1      Service Facility Name                        SIT       NM108      Identification Code Qualifier                 S      ID     1/2          X
2290     NM1      Service Facility Name                                             24, Employer's Identification Number
2291     NM1      Service Facility Name                                             34, SSN
2292     NM1      Service Facility Name                                             XX, HCFA NPI
2293     NM1      Service Facility Name                        SIT       NM109      Identification Code                           S      AN     2/80         P      PRHP Processing Field
2294     NM1      Service Facility Name                      Not used    NM110      Entity Relationship Code                                                 X
2295     NM1      Service Facility Name                      Not used    NM111      Entity Identifier Code                                                   X
2296
2297              Service Facility Specialty Information     SIT/2310E
2298     PRV      Service Facility Specialty Information        REQ      PRV01      Provider Code                                 R      ID     1/3          E      PRHP Processing Field
2299              Service Facility Specialty Information                            RP, Reporting Provider
2300     PRV      Service Facility Specialty Information       REQ       PRV02      Reference Identification Qualifier            R      ID     2/3          X
2301     PRV      Service Facility Specialty Information                            ZZ, Mutually Defined ( Provider Taxonomy
                                                                                    Code)
2302     PRV      Service Facility Specialty Information      REQ        PRV03      Reference Identification                      R      AN     1/30         E      PRHP Processing Field
2303     PRV      Service Facility Specialty Information     Not used    PRV04      State or Province Code                                                   X
2304     PRV      Service Facility Specialty Information     Not used    PRV05      Provider Specialty Information                                           X
2305     PRV      Service Facility Specialty Information     Not used    PRV06      Provider Organization Code                                               X
2306
2307              SERVICE FACILITY ADDRESS                  REQ/2310E
2308      N3      Service Facility Address                    REQ     N301          ADDRESS INFORMATION                           R      AN     1/55         E      PRHP Processing Field
2309      N3      Service Facility Address                     SIT    N302          ADDRESS INFORMATION                           S      AN     1/55         E      PRHP Processing Field
2310
2311              SERVICE FACILITY CITY/STATE/ZIP           REQ/2310E
                  CODE
2312      N4      Service Facility City/State/Zip Code        REQ        N401       CITY NAME                                     R      AN     2/30         E      PRHP Processing Field
2313      N4      Service Facility City/State/Zip Code        REQ        N402       STATE OR PROVINCE CODE                        R      ID     2/2          E      PRHP Processing Field
2314      N4      Service Facility City/State/Zip Code        REQ        N403       POSTAL CODE                                   R      ID     3/15         E      PRHP Processing Field
2315      N4      Service Facility City/State/Zip Code         SIT       N404       COUNTRY CODE                                  S      ID     2/3          E      PRHP Processing Field
2316      N4      Service Facility City/State/Zip Code       Not used    N405       Location Qualifier                                                       X
2317      N4      Service Facility City/State/Zip Code       Not used    N406       Location Identifier                                                      X
2318
2319              SERVICE FACILITY SECONDARY                 SIT/2310E
                  IDENTIFICATION
2320     REF      Service Facility Secondary ID                REQ       REF01      REFERENCE IDENTIFICATION QUAL                 R      ID     2/3          E      PRHP Processing Field
2321     REF      Service Facility Secondary ID                                     OB, State License Number
2322     REF      Service Facility Secondary ID                                     1A, Blue Cross Provider Number

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                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                                 PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                             Use   Type         Len   Field   PRHP Processing Field

2323     REF      Service Facility Secondary ID                            1B, Blue Shield Provider Number
2324     REF      Service Facility Secondary ID                            1C, Medicare Provider Number
2325     REF      Service Facility Secondary ID                            1D, Medicaid Provider Number
2326     REF      Service Facility Secondary ID                            1G, Provider UPIN Number
2327     REF      Service Facility Secondary ID                            1H, CHAMPUS Identification Number
2328     REF      Service Facility Secondary ID                            EI, Employer's Identification Number
2329     REF      Service Facility Secondary ID                            G2, Provider Commercial Number
2330     REF      Service Facility Secondary ID                            LU, Location Number
2331     REF      Service Facility Secondary ID                            N5, Provider Plan Network Identification Number

2332     REF      Service Facility Secondary ID                            SY, SSN
2333     REF      Service Facility Secondary ID                            X5, State Industrical Accident Provider Number

2334     REF      Service Facility Secondary ID       REQ       REF02      REFERENCE IDENTIFICATION                          R     AN     1/30         E      PRHP Processing Field

2335     REF      Service Facility Secondary ID     Not used    REF 03     Description                                                                 X
2336     REF      Service Facility Secondary ID     Not used    REF04      Reference Identifier                                                        X
2337
2338              OTHER SUBSCRIBER INFORMATION      SIT/2320
2339     SBR      Other Subscriber Information        REQ       SBR01      Payer Responsibility Sequence Number Code         R     ID     1/1          P      PRHP Processing Field
2340     SBR      Other Subscriber Information                             P, Primary
2341     SBR      Other Subscriber Information                             S, Secondary
2342     SBR      Other Subscriber Information                             T, Tertiary
2343     SBR      Other Subscriber Information        REQ       SBR02      Individual Relationship Code                      R     ID     2/2          E      PRHP Processing Field
2344     SBR      Other Subscriber Information                             01, Spouse
2345     SBR      Other Subscriber Information                             04, Grandfather or Grandmother
2346     SBR      Other Subscriber Information                             05, Grandson or Granddaughter
2347     SBR      Other Subscriber Information                             07, Nephew or Niece
2348     SBR      Other Subscriber Information                             10, Foster Child
2349     SBR      Other Subscriber Information                             15, Ward
2350     SBR      Other Subscriber Information                             17, Stepson or Stepdaughter
2351     SBR      Other Subscriber Information                             18, Self
2352     SBR      Other Subscriber Information                             19, Child
2353     SBR      Other Subscriber Information                             20, Employee
2354     SBR      Other Subscriber Information                             21, Unknown
2355     SBR      Other Subscriber Information                             22, Handicapped Dependent
2356     SBR      Other Subscriber Information                             23, Sponsored Dependent
2357     SBR      Other Subscriber Information                             24, Dependent of a Minor Dependent
2358     SBR      Other Subscriber Information                             29, Significant Other
2359     SBR      Other Subscriber Information                             32, Mother
2360     SBR      Other Subscriber Information                             33, Father
2361     SBR      Other Subscriber Information                             36, Emancipated Minor
2362     SBR      Other Subscriber Information                             39, Organ Donor
2363     SBR      Other Subscriber Information                             40, Cadaver Donor
2364     SBR      Other Subscriber Information                             41, Injured Plaintiff
2365     SBR      Other Subscriber Information                             43, Child where insured has no financial
                                                                           responsibility
2366     SBR      Other Subscriber Information                             53, Life Partner
2367     SBR      Other Subscriber Information                             G8, Other Relationship

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                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2368     SBR      Other Subscriber Information        SIT       SBR03      REFERENCE IDENTIFICATION                      S      AN     1/30         P      PRHP Processing Field
2369     SBR      Other Subscriber Information        SIT       SBR04      NAME                                          S      AN     1/60         E      PRHP Processing Field
2370     SBR      Other Subscriber Information      Not used    SBR05      Insurance Type Code                                                      X
2371     SBR      Other Subscriber Information      Not used    SBR06      COB Code                                                                 X
2372     SBR      Other Subscriber Information      Not used    SBR07      Yes/No Condition or Response Code                                        X
2373     SBR      Other Subscriber Information      Not used    SBR08      Employment Status Code                                                   X
2374     SBR      Other Subscriber Information        SIT       SBR09      Claim Filing Indicator Code                   S      ID     1/2          E      PRHP Processing Field
2375     SBR      Other Subscriber Information                             09, Self-pay
2376     SBR      Other Subscriber Information                             10, Central Certification
2377     SBR      Other Subscriber Information                             11, Other Non-Federal Programs
2378     SBR      Other Subscriber Information                             12, PPO
2379     SBR      Other Subscriber Information                             13, POS
2380     SBR      Other Subscriber Information                             14, Exclusive Provider Organization
2381     SBR      Other Subscriber Information                             15, Indemnity Insurance
2382     SBR      Other Subscriber Information                             16, HMO Medicare Risk
2383     SBR      Other Subscriber Information                             AM, Automobile Medical
2384     SBR      Other Subscriber Information                             BL, Blue Cross/Blue Shield
2385     SBR      Other Subscriber Information                             CH, CHAMPUS
2386     SBR      Other Subscriber Information                             CI, Commercial Insurance Co.
2387     SBR      Other Subscriber Information                             DS, Disability
2388     SBR      Other Subscriber Information                             HM, HMO
2389     SBR      Other Subscriber Information                             LI, Liability
2390     SBR      Other Subscriber Information                             LM, Liability Medical
2391     SBR      Other Subscriber Information                             MA, Medicare Part A
2392     SBR      Other Subscriber Information                             MB, Medicare Part B
2393     SBR      Other Subscriber Information                             MC, Medicaid
2394     SBR      Other Subscriber Information                             OF, Other Federal Program
2395     SBR      Other Subscriber Information                             TV, Title V
2396     SBR      Other Subscriber Information                             VA, Veterans Administration Plan
2397     SBR      Other Subscriber Information                             WC, Workers' Compensation Health Claim
2398     SBR      Other Subscriber Information                             ZZ, Mutually Defined
2399
2400              CLAIM LEVEL ADJUSTMENT            SIT/2320
2401     CAS      CLAIM LEVEL ADJUSTMENT              REQ       CAS01      CLAIM ADJUSTMENT GROUP CODE                   R      ID     1/2          E      PRHP Processing Field
2402     CAS      CLAIM LEVEL ADJUSTMENT                                   CO, Contractual Obligations
2403     CAS      CLAIM LEVEL ADJUSTMENT                                   CR, Correction and Reversals
2404     CAS      CLAIM LEVEL ADJUSTMENT                                   OA, Other Adjustments
2405     CAS      CLAIM LEVEL ADJUSTMENT                                   PI, Payor Initiated Reductions
2406     CAS      CLAIM LEVEL ADJUSTMENT                                   PR, Patient Responsibility
2407     CAS      CLAIM LEVEL ADJUSTMENT              REQ       CAS02      CLAIM ADJUSTMENT GROUP CODE                   R      ID     1/5          E      PRHP Processing Field
2408     CAS      CLAIM LEVEL ADJUSTMENT              REQ       CAS03      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2409     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS04      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
2410     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS05      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
2411     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS06      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
2412     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS07      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
2413     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS08      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
2414     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS09      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
2415     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS10      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
2416     CAS      CLAIM LEVEL ADJUSTMENT              SIT       CAS11      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field

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                                                                                                 Detail Data Definition-837 Institutional

  1                                                    HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                           Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2417     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS12      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
2418     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS13      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
2419     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS14      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
2420     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS15      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
2421     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS16      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
2422     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS17      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
2423     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS18      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
2424     CAS      CLAIM LEVEL ADJUSTMENT                SIT      CAS19      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
2425
2426     AMT      Payor Prior Payment                SIT/2320
2427     AMT      Payor Prior Payment                  REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2428                                                                        C4, Prior Payment-Actual
2429     AMT      Payor Prior Payment                 REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2430     AMT      Payor Prior Payment                Not used    AMT03      Credit/Debit Flag Code                                                   X
2431
2432     AMT      COB, Total Allowed Amount          SIT/2320
2433     AMT      COB, Total Allowed Amount            REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2434     AMT      COB, Total Allowed Amount                                 B6, Allowed-Actual
2435     AMT      COB, Total Allowed Amount           REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2436     AMT      COB, Total Allowed Amount          Not used    AMT03      Credit/Debit Flag code                                                   X
2437
2438     AMT      COB, Total Submitted Charges       SIT/2320
2439     AMT      COB, Total Submitted Charges         REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2440     AMT      COB, Total Submitted Charges                              T3, Total Submitted Charges
2441     AMT      COB, Total Submitted Charges        REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2442     AMT      COB, Total Submitted Charges       Not used    AMT03      Credit/Debit Flag Code                                                   X
2443
2444     AMT      DRG Outlier Amount                 SIT/2320
2445     AMT      DRG Outlier Amount                   REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2446     AMT      DRG Outlier Amount                                        ZZ, Mutually Defined
2447     AMT      DRG Outlier Amount                  REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2448     AMT      DRG Outlier Amount                 Not used    AMT03      Credit/Debit Flag Code                                                   X
2449
2450     AMT      COB Total Medicare Paid Amount     SIT/2320
2451     AMT      COB Total Medicare Paid Amount       REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2452     AMT      COB Total Medicare Paid Amount                            N1, Net Worth
2453     AMT      COB Total Medicare Paid Amount      REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2454     AMT      COB Total Medicare Paid Amount     Not used    AMT03      Credit/Debit Flag code                                                   X
2455
2456     AMT      Medicare Paid Amount 100%          SIT/2320
2457     AMT      Medicare Paid Amount 100%            REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2458     AMT      Medicare Paid Amount 100%                                 KF, Net Paid Amount
2459     AMT      Medicare Paid Amount 100%           REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2460     AMT      Medicare Paid Amount 100%          Not used    AMT03      Credit Debit Flag Code                                                   X
2461
2462     AMT      Medicare Paid Amount 80%           SIT/2320
2463     AMT      Medicare Paid Amount 80%             REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2464     AMT      Medicare Paid Amount 80%                                  PG, Net Paid Amount
2465     AMT      Medicare Paid Amount 80%             REQ       AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field

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       1/22/2011, 6:51 AM                                                                                      Puerto Rico Health Plan, Inc.                                                            Page 55 of 152
                                                                                                           Detail Data Definition-837 Institutional

  1                                                              HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                          REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                     Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2466     AMT      Medicare Paid Amount 80%                     Not used    AMT03      Credit Debit Flag Code                                                   X
2467
2468     AMT      COB Medicare A Trust Fund Paid               SIT/2320
                  Amount
2469     AMT      COB Medicare A Trust Fund Paid Amount          REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X

2470     AMT      COB Medicare A Trust Fund Paid Amount                               AA, Allocated

2471     AMT      COB Medicare A Trust Fund Paid Amount          REQ       AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field

2472     AMT      COB Medicare A Trust Fund Paid Amount        Not used    AMT03      Credit Debit Flag Code                                                   X

2473
2474     AMT      COB Medicare B Trust Fund Paid               SIT/2320
                  Amount
2475     AMT      COB Medicare B Trust Fund Paid Amount          REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X

2476     AMT      COB Medicare B Trust Fund Paid Amount                               B1 Benefit Amount                             R      R      1/18

2477     AMT      COB Medicare B Trust Fund Paid Amount          REQ       AMT02      MONETARY AMOUNT                                                          E      PRHP Processing Field

2478     AMT      COB Medicare B Trust Fund Paid Amount        Not used    AMT03      Credit Debit Flag Code

2479
2480     AMT      COB Total Non-Covered Amount                 SIT/2320
2481     AMT      COB Total Non-Covered Amount                   REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2482     AMT      COB Total Non-Covered Amount                                        A8, Noncovered Charges-Actual                 R      R      1/18
2483     AMT      COB Total Non-Covered Amount                  REQ        AMT02      MONETARY AMOUNT                                                          E      PRHP Processing Field
2484     AMT      COB Total Non-Covered Amount                 Not used    AMT03      Credit Debit Flag Code
2485
2486     AMT      COB Total Denied Amount                      SIT/2320
2487     AMT      COB Total Denied Amount                        REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2488     AMT      COB Total Denied Amount                                             YT, Denied                                    R      R      1/18
2489     AMT      COB Total Denied Amount                       REQ        AMT02      MONETARY AMOUNT                                                          E      PRHP Processing Field
2490     AMT      COB Total Denied Amount                      Not used    AMT03      Credit Debit Flag Code
2491
2492     DMG      OTHER SUBSCRIBER DEMOGRAPHIC                 SIT/2320
                  INFORMATION
2493     DMG      Other Subscriber Demographic Information       REQ       DMG01      DATE TIME PERIOD FORMAT QUALIFIER             R      ID     2/3          X

2494     DMG      Other Subscriber Demographic Information                            D8, Date Expressed in Format CCYYMMDD

2495     DMG      Other Subscriber Demographic Information       REQ       DMG02      DATE TIME PERIOD                              R      AN     1/35         P      PRHP Processing Field

2496     DMG      Other Subscriber Demographic Information       REQ       DMG03      GENDER CODE                                   R      ID     1/1          P      PRHP Processing Field

2497     DMG      Other Subscriber Demographic Information                            F, Female



       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                         Puerto Rico Health Plan, Inc.                                                                 Page 56 of 152
                                                                                                              Detail Data Definition-837 Institutional

  1                                                                 HIPAA - 837 Institutional Claim                                                                                                   PRHP Processing Field
  2                                                             REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                        Req/Loop Ref Desc Description                                               Use   Type         Len   Field   PRHP Processing Field

2498     DMG      Other Subscriber Demographic Information                               M, Male

2499     DMG      Other Subscriber Demographic Information                               U, Unknown

2500     DMG      Other Subscriber Demographic Information        Not used    DMG04      Marital Status Code                                                           X

2501     DMG      Other Subscriber Demographic Information        Not used    DMG05      Race or Ethnicity Code                                                        X

2502     DMG      Other Subscriber Demographic Information        Not used    DMG06      Citizenship Status Code                                                       X

2503     DMG      Other Subscriber Demographic Information        Not used    DMG07      Country Code                                                                  X

2504     DMG      Other Subscriber Demographic Information        Not used    DMG08      Basis of Verification Code                                                    X

2505     DMG      Other Subscriber Demographic Information        Not used    DMG09      Quantity                                                                      X

2506
2507      OI      Other Insurance Coverage Information            REQ/2320

2508      OI      Other Insurance Coverage Information            Not used    OI01       Claim Filing Indicator Code                                                   X
2509      OI      Other Insurance Coverage Information            Not used    OI02       Claim Submission Reason Code                                                  X
2510      OI      Other Insurance Coverage Information             REQ        OI03       YES/NO CONDITION OR RESPONSE                         R    ID     1/1          E      PRHP Processing Field
2511      OI      Other Insurance Coverage Information                                   N, No
2512      OI      Other Insurance Coverage Information            Not used    OI04       Patient Signature Source Code                                                 X
2513      OI      Other Insurance Coverage Information            Not used    OI05       Provider Agreement Code                                                       X
2514      OI      Other Insurance Coverage Information            Not used    OI06       Release of Information Code                          R    ID     1/1          X
2515      OI      Other Insurance Coverage Information                                   A, Appropriate Release of Information on File at
                                                                                         Health Care Sservice Provider or at URO
2516      OI      Other Insurance Coverage Information                                   I, Informed Consenst to release medical
                                                                                         information for conditions or diagnoses regulated
                                                                                         by federal statutes
2517      OI      Other Insurance Coverage Information                                   M, The provider has limited or restricted ability to
                                                                                         release data related to a claim
2518      OI      Other Insurance Coverage Information                                   N, No, Provider is not allowed to release data
2519      OI      Other Insurance Coverage Information                                   O, On file at payor or at plan sponsor
2520      OI      Other Insurance Coverage Information                                   Y, Yes, Provider has a signed statement
                                                                                         permitting release of medical billing data related
                                                                                         to a claim
2521
2522     MIA      MEDICARE INPATIENT ADJUDICATION                 SIT/2320
                  INFORMATION




2523     MIA      Medicare Inpatient Adjudication Information       REQ       MIA01      QUANTITY                                            R     R      1/15         E      PRHP Processing Field

2524     MIA      Medicare Inpatient Adjudication Information        SIT      MIA02      QUANTITY                                            S     R      1/15         E      PRHP Processing Field


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                                                                                                              Detail Data Definition-837 Institutional

  1                                                                 HIPAA - 837 Institutional Claim                                                                                            PRHP Processing Field
  2                                                             REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                        Req/Loop Ref Desc Description                                          Use   Type       Len   Field   PRHP Processing Field

2525     MIA      Medicare Inpatient Adjudication Information        SIT      MIA03      QUANTITY                                      S      R      1/15       E      PRHP Processing Field

2526     MIA      Medicare Inpatient Adjudication Information        SIT      MIA04      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2527     MIA      Medicare Inpatient Adjudication Information        SIT      MIA05      REFERENCE IDENTIFICATION                      S      AN     1/30       E      PRHP Processing Field

2528     MIA      Medicare Inpatient Adjudication Information        SIT      MIA06      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2529     MIA      Medicare Inpatient Adjudication Information        SIT      MIA07      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2530     MIA      Medicare Inpatient Adjudication Information        SIT      MIA08      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2531     MIA      Medicare Inpatient Adjudication Information        SIT      MIA09      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2532     MIA      Medicare Inpatient Adjudication Information        SIT      MIA10      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2533     MIA      Medicare Inpatient Adjudication Information        SIT      MIA11      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2534     MIA      Medicare Inpatient Adjudication Information        SIT      MIA12      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2535     MIA      Medicare Inpatient Adjudication Information        SIT      MIA13      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2536     MIA      Medicare Inpatient Adjudication Information        SIT      MIA14      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2537     MIA      Medicare Inpatient Adjudication Information        SIT      MIA15      QUANTITY                                      S      R      1/15       E      PRHP Processing Field

2538     MIA      Medicare Inpatient Adjudication Information        SIT      MIA16      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2539     MIA      Medicare Inpatient Adjudication Information        SIT      MIA17      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2540     MIA      Medicare Inpatient Adjudication Information        SIT      MIA18      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2541     MIA      Medicare Inpatient Adjudication Information        SIT      MIA19      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2542     MIA      Medicare Inpatient Adjudication Information        SIT      MIA20      REFERENCE IDENTIFICATION                      S      AN     1/30       E      PRHP Processing Field

2543     MIA      Medicare Inpatient Adjudication Information        SIT      MIA21      REFERENCE IDENTIFICATION                      S      AN     1/30       E      PRHP Processing Field

2544     MIA      Medicare Inpatient Adjudication Information        SIT      MIA22      REFERENCE IDENTIFICATION                      S      AN     1/30       E      PRHP Processing Field

2545     MIA      Medicare Inpatient Adjudication Information        SIT      MIA23      REFERENCE IDENTIFICATION                      S      AN     1/30       E      PRHP Processing Field

2546     MIA      Medicare Inpatient Adjudication Information        SIT      MIA24      MONETARY AMOUNT                               S      R      1/18       E      PRHP Processing Field

2547




       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                              Puerto Rico Health Plan, Inc.                                                            Page 58 of 152
                                                                                                   Detail Data Definition-837 Institutional

  1                                                      HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                  REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                             Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2548     MOA      MEDICARE OUTPATIENT                  SIT/2320
                  ADJUDICATION INFORMATION




2549     MOA      Medicare Outpatient Adjudication
                  Information
2550     MOA      Medicare Outpatient Adjudication        SIT      MOA01      PERCENT                                       S      R      1/10         E      PRHP Processing Field
                  Information
2551     MOA      Medicare Outpatient Adjudication        SIT      MOA02      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
                  Information
2552     MOA      Medicare Outpatient Adjudication        SIT      MOA03      REFERENCE IDENTIFICATION                      S      AN     1/30         E      PRHP Processing Field
                  Information
2553     MOA      Medicare Outpatient Adjudication        SIT      MOA04      REFERENCE IDENTIFICATION                      S      AN     1/30         E      PRHP Processing Field
                  Information
2554     MOA      Medicare Outpatient Adjudication        SIT      MOA05      REFERENCE IDENTIFICATION                      S      AN     1/30         E      PRHP Processing Field
                  Information
2555     MOA      Medicare Outpatient Adjudication        SIT      MOA06      REFERENCE IDENTIFICATION                      S      AN     1/30         E      PRHP Processing Field
                  Information
2556     MOA      Medicare Outpatient Adjudication        SIT      MOA07      REFERENCE IDENTIFICATION                      S      AN     1/30         E      PRHP Processing Field
                  Information
2557     MOA      Medicare Outpatient Adjudication        SIT      MOA08      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
                  Information
2558     MOA      Medicare Outpatient Adjudication        SIT      MOA09      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
                  Information
2559
2560     NM1      OTHER SUBSCRIBER NAME               REQ/2330A
2561     NM1      Other Subscriber Name                 REQ     NM101         ENTITY IDENTIFIER CODE                        R      ID     2/3          X
2562     NM1      Other Subscriber Name                                       IL, Insured or Subscriber
2563     NM1      Other Subscriber Name                  REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          E      PRHP Processing Field
2564     NM1      Other Subscriber Name                                       1, Person
2565     NM1      Other Subscriber Name                                       2, Non-person Entity
2566     NM1      Other Subscriber Name                 REQ        NM103      NAME LAST OR ORG NAME                         R      AN     1/35         P      PRHP Processing Field
2567     NM1      Other Subscriber Name                  SIT       NM104      NAME FIRST                                    S      AN     1/25         P      PRHP Processing Field
2568     NM1      Other Subscriber Name                  SIT       NM105      NAME MIDDLE                                   S      AN     1/25         P      PRHP Processing Field
2569     NM1      Other Subscriber Name                Not used    NM106      Name Prefix                                                              X
2570     NM1      Other Subscriber Name                  SIT       NM107      NAME SUFFIX                                   S      AN     1/10         P      PRHP Processing Field
2571     NM1      Other Subscriber Name                 REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
2572     NM1      Other Subscriber Name                                       MI, Member Identification Number
2573     NM1      Other Subscriber Name                                       ZZ, Mutually Defined
2574     NM1      Other Subscriber Name                 REQ        NM109      IDENTIFICATION CODE                           R      AN     2/80         E      PRHP Processing Field
2575     NM1      Other Subscriber Name                Not used    NM110      Entity Relationship Code                                                 X
2576     NM1      Other Subscriber Name                Not used    NM111      Entity Identifier Code                                                   X
2577
2578      N3      OTHER SUBSCRIBER ADDRESS             SIT/2330A
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                                                                                                         Detail Data Definition-837 Institutional

  1                                                            HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                        REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                   Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2579      N3      Other Subscriber Address                     REQ       N301       ADDRESS INFORMATION                           R      AN     1/55         E      PRHP Processing Field
2580      N3      Other Subscriber Address                     SIT       N302       ADDRESS INFORMATION                           S      AN     1/55         E      PRHP Processing Field
2581
2582      N4      OTHER SUBSCRIBER CITY/STATE/ZIP            SIT/2330A
                  CODE
2583      N4      Other Subscriber City/State/Zip Code        REQ        N401       CITY NAME                                     R      AN     2/30         E      PRHP Processing Field
2584      N4      Other Subscriber City/State/Zip Code        REQ        N402       STATE OR PROVIDENCE CODE                      R      ID     2/2          E      PRHP Processing Field
2585      N4      Other Subscriber City/State/Zip Code        REQ        N403       POSTAL CODE                                   R      ID     3/15         E      PRHP Processing Field
2586      N4      Other Subscriber City/State/Zip Code         SIT       N404       COUNTRY CODE                                  S      ID     2/3          E      PRHP Processing Field
2587      N4      Other Subscriber City/State/Zip Code       Not used    N405       Location Qualifier                                                       X
2588      N4      Other Subscriber City/State/Zip Code       Not used    N406       Location Identifier                                                      X
2589
2590     REF      OTHER SUBSCRIBER SECONDARY                 SIT/2330A
                  INFORMATION
2591     REF      Other Subscriber Secondary Information       REQ       REF01      Reference Identification Qualifier            R      ID     2/3          E      PRHP Processing Field
2592     REF      Other Subscriber Secondary Information                            1W, Member Identification Number
2593     REF      Other Subscriber Secondary Information                            23, Client Number
2594     REF      Other Subscriber Secondary Information                            IG, Insurance Policy Number
2595     REF      Other Subscriber Secondary Information                            SY, SSN
2596     REF      Other Subscriber Secondary Information      REQ        REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
2597     REF      Other Subscriber Secondary Information     Not used    REF03      Description                                                              X
2598     REF      Other Subscriber Secondary Information     Not used    REF04      Reference Identifier                                                     X
2599
2600     NM1      OTHER PAYER NAME                          REQ/2330B
2601     NM1      Other Payer Name                            REQ     NM101         ENTITY IDENTIFIER CODE                        R      ID     2/3          X
2602     NM1      Other Payer Name                                                  PR, Payer
2603     NM1      Other Payer Name                             REQ       NM102      ENTITY IDENTIFIER QUALIFIER                   R      ID     1/1          X
2604     NM1      Other Payer Name                                                  2, Non-person Entity
2605     NM1      Other Payer Name                            REQ        NM103      NAME LAST OR ORGANIZATION NAME                R      AN     1/35         E      PRHP Processing Field
2606     NM1      Other Payer Name                           Not used    NM104      Name First                                                               X
2607     NM1      Other Payer Name                           Not used    NM105      Name Middle                                                              X
2608     NM1      Other Payer Name                           Not used    NM106      Name Prefix                                                              X
2609     NM1      Other Payer Name                           Not used    NM107      Name Suffix                                                              X
2610     NM1      Other Payer Name                            REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
2611     NM1      Other Payer Name                                                  PI, Payor Identification
2612     NM1      Other Payer Name                                                  SV, HCFA NPI
2613     NM1      Other Payer Name                            REQ        NM109      IDENTIFICATION CODE                           R      AN     2/80         P      PRHP Processing Field
2614     NM1      Other Payer Name                           Not used    NM110      Entity Relationship Code                                                 X
2615     NM1      Other Payer Name                           Not used    NM111      Entity Identifier Code                                                   X
2616
2617      N3      OTHER PAYER ADDRESS                        SIT/2330B
2618      N3      Other Payer Address                           REQ      N301       ADDRESS INFORMATION                           R      AN     1/55         E      PRHP Processing Field
2619      N3      Other Payer Address                           SIT      N302       ADDRESS INFORMATION                           S      AN     1/55         E      PRHP Processing Field
2620
2621      N4      OTHER PAYER CITY/STATE/ZIP CODE            SIT/2330B
2622      N4      Other Payer City/State/Zip Code               REQ      N401       CITY NAME                                     R      AN     2/30         E      PRHP Processing Field
2623      N4      Other Payer City/State/Zip Code               REQ      N402       STATEOR PROVINCE CODE                         R      ID     2/2          E      PRHP Processing Field
2624      N4      Other Payer City/State/Zip Code               REQ      N403       POSTAL CODE                                   R      ID     3/15         E      PRHP Processing Field
2625      N4      Other Payer City/State/Zip Code               SIT      N404       COUNTRY CODE                                  S      ID     2/3          E      PRHP Processing Field

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       1/22/2011, 6:51 AM                                                                                        Puerto Rico Health Plan, Inc.                                                            Page 60 of 152
                                                                                                             Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                               PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                           Use   Type         Len   Field   PRHP Processing Field

2626      N4      Other Payer City/State/Zip Code               Not used    N405       Location Qualifier                                                        X
2627      N4      Other Payer City/State/Zip Code               Not used    N406       Location Identifier                                                       X
2628
2629     DTP      CLAIM ADJUDICATION DATE                       SIT/2330B
2630     DTP      Claim Adjudication Date                          REQ      DTP01      DATE/TIME QUALIFIER                            R      ID     3/3          X
2631     DTP      Claim Adjudication Date                                              573, Date Claim Paid
2632     DTP      Claim Adjudication Date                         REQ       DTP02      DATE TIME PERIOD FORMAT QUALIFIER              R      ID     2/3          X
2633     DTP      Claim Adjudication Date                                              D8, Date Expressed in Format CCYYMMDD
2634     DTP      Claim Adjudication Date                         REQ       DTP03      DATE TIME PERIOD                               R      AN     1/35         E      PRHP Processing Field
2635
2636     REF      OTHER PAYER SECONDARY                         SIT/2330B
                  IDENTIFICATION & REFERENCE
                  NUMBER
2637     REF      Other Payer Secondary Identification &          REQ       REF01      REFERENCE IDENTIFICATION QUALIFIER             R      ID     2/3          E      PRHP Processing Field
                  Reference Number
2638     REF      Other Payer Secondary Identification &                               2U, Payer Identification Number
                  Reference Number
2639     REF      Other Payer Secondary Identification &                               F8, Original Reference Number
                  Reference Number
2640     REF      Other Payer Secondary Identification &                               FY, Claim Office Number
                  Reference Number
2641     REF      Other Payer Secondary Identification &                               NF, NAIC Code
                  Reference Number
2642     REF      Other Payer Secondary Identification &                               TJ, Federal Taxpayer's Identification Number
                  Reference Number
2643     REF      Other Payer Secondary Identification &          REQ       REF02      REFERENCE IDENTIFICATION                       R      AN     1/30         E      PRHP Processing Field
                  Reference Number
2644     REF      Other Payer Secondary Identification &        Not used    REF03      Description                                                               X
                  Reference Number
2645     REF      Other Payer Secondary Identification &        Not used    REF04      Reference Identifier                                                      X
                  Reference Number
2646
2647     REF      OTHER PAYER PRIOR                             SIT/2330B
                  AUTHORAIZATION OR REFERRAL
                  NUMBER
2648     REF      Other Payer Prior Auth or Referral Number       REQ       REF01      REFERENCE IDENTIFICATION QUALIFIER             R      ID     2/3          X

2649     REF      Other Payer Prior Auth or Referral Number                            9F, Referral Number

2650     REF      Other Payer Prior Auth or Referral Number                            G1, Prior Authorization Number

2651     REF      Other Payer Prior Auth or Referral Number       REQ       REF02      REFERENCE IDENTIFICATION                       R      AN     1/30         E      PRHP Processing Field

2652     REF      Other Payer Prior Auth or Referral Number     Not used    REF03      Description                                                               X

2653     REF      Other Payer Prior Auth or Referral Number     Not used    REF04      Reference Identifier                                                      X

2654


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       1/22/2011, 6:51 AM                                                                                       Puerto Rico Health Plan, Inc.                                                            Page 61 of 152
                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2655     NM1      OTHER PAYER PATIENT INFORMATION               SIT/2330C

2656     NM1      Other Payer Patient Information                 REQ       NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
2657                                                                                   QC, Patient
2658     NM1      Other Payer Patient Information                 REQ       NM102      ENTITY IDENTIFIER QUALIFIER                   R      ID     1/1          X
2659                                                                                   1, Person
2660     NM1      Other Payer Patient Information               Not used    NM103      Name Last or Organization Name                                           X
2661     NM1      Other Payer Patient Information               Not used    NM104      Name First                                                               X
2662     NM1      Other Payer Patient Information               Not used    NM105      Name Middle                                                              X
2663     NM1      Other Payer Patient Information               Not used    NM106      Name Prefix                                                              X
2664     NM1      Other Payer Patient Information               Not used    NM107      Name Suffix                                                              X
2665     NM1      Other Payer Patient Information                REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
2666     NM1      Other Payer Patient Information                                      EI, Employee Identification Code
2667     NM1      Other Payer Patient Information                                      MI, Member Identification Code
2668     NM1      Other Payer Patient Information                REQ        NM109      IDENTIFICATION CODE                           R      AN     2/80         E      PRHP Processing Field
2669     NM1      Other Payer Patient Information               Not used    NM110      Entity Relationship Code                                                 X
2670     NM1      Other Payer Patient Information               Not used    NM111      Entity Identifier Code                                                   X
2671
2672     REF      OTHER PAYER PATIENT                           SIT/2330C
                  IDENTIFICATION NUMBER
2673     REF      Other Payer Patient Identification Number       REQ       REF01      REFERENCE IDENTIFICATION QUALIFIER            R      ID     2/3          E      PRHP Processing Field

2674     REF      Other Payer Patient Identification Number                            1W, Member Identification Number

2675     REF      Other Payer Patient Identification Number                            IG, Insurance Policy Number

2676     REF      Other Payer Patient Identification Number                            SY, SSN

2677     REF      Other Payer Patient Identification Number       REQ       REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field

2678     REF      Other Payer Patient Identification Number     Not used    REF03      Description                                                              X

2679     REF      Other Payer Patient Identification Number     Not used    REF04      Reference Identification                                                 X

2680
2681     NM1      OTHER PAYER ATTENDING PROVIDER                SIT/2330D

2682     NM1      Other Payer Attending Provider                  REQ       NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
2683     NM1      Other Payer Attending Provider                                       71, Attending Physician
2684     NM1      Other Payer Attending Provider                  REQ       NM102      ENTITY TYPE CODE                              R      ID     1/1          E      PRHP Processing Field
2685     NM1      Other Payer Attending Provider                                       1, Person
2686     NM1      Other Payer Attending Provider                                       2, Non-person Entity
2687     NM1      Other Payer Attending Provider                Not used    NM103      Name Last or Organization Name                                           X
2688     NM1      Other Payer Attending Provider                Not used    NM104      Name First                                                               X
2689     NM1      Other Payer Attending Provider                Not used    NM105      Name Middle                                                              X
2690     NM1      Other Payer Attending Provider                Not used    NM106      Name Prefix                                                              X
2691     NM1      Other Payer Attending Provider                Not used    NM107      Name Suffix                                                              X
2692     NM1      Other Payer Attending Provider                Not used    NM108      Identification Code Qualifier                                            X
2693     NM1      Other Payer Attending Provider                Not used    NM109      Identification Code                                                      X
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       1/22/2011, 6:51 AM                                                                            Puerto Rico Health Plan, Inc.                                                            Page 62 of 152
                                                                                                 Detail Data Definition-837 Institutional

  1                                                    HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                           Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2694     NM1      Other Payer Attending Provider     Not used    NM110      Entity Relationship Code                                                 X
2695     NM1      Other Payer Attending Provider     Not used    NM111      Entity Identifier Code                                                   X
2696
2697              OTHER PAYER ATTENDING PROVIDER    REQ/2330D
                  IDENTIFICATION
2698     REF      Other Payer Attending Provider       REQ       REF01      REFERENCE IDENT. QUALIFIER                    R      ID     2/3          E      PRHP Processing Field
                  Identification
2699     REF      Other Payer Attending Provider                            1A   BLUE CROSS PROVIDER NUMBER
                  Identification
2700     REF      Other Payer Attending Provider                            1B   BLUE SHIELD PROVIDER NUMBER
                  Identification
2701     REF      Other Payer Attending Provider                            1C    MEDICARE PROVIDER NUMBER
                  Identification
2702     REF      Other Payer Attending Provider                            1D    MEDICAID PROVIDER NUMBER
                  Identification
2703     REF      Other Payer Attending Provider                            1G    PROVIDER UPIN NUMBER
                  Identification
2704     REF      Other Payer Attending Provider                            1H    CHAMPUS IDENTIFICATION #
                  Identification
2705     REF      Other Payer Attending Provider                            EI   EMPLOYER'S IDENTIFICATION #
                  Identification
2706     REF      Other Payer Attending Provider                            G2 PROVIDER COMMERCIAL NUMBER
                  Identification
2707     REF      Other Payer Attending Provider                            LU    LOCATION NUMBER
                  Identification
2708     REF      Other Payer Attending Provider                            N5    PROVIDER PLAN NETWORK ID #
                  Identification
2709     REF      Other Payer Attending Provider       REQ       REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
                  Identification
2710     REF      Other Payer Attending Provider     Not used    REF03      Description                                                              X
                  Identification
2711     REF      Other Payer Attending Provider     Not used    REF04      Reference Identifier                                                     X
                  Identification
2712
2713     NM1      OTHER PAYER OPERATING PROVIDER     SIT/2330E

2714     NM1      Other Payer Operating Provider       REQ       NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
2715     NM1      Other Payer Operating Provider                            72 OPERATING PHYSICIAN
2716     NM1      Other Payer Operating Provider       REQ       NM102      ENTITY TYPE                                   R      ID     1/1          X
2717     NM1      Other Payer Operating Provider                            1 PERSON
2718     NM1      Other Payer Operating Provider     Not used    NM103      Name Last or Organization Name                                           X
2719     NM1      Other Payer Operating Provider     Not used    NM104      Name First                                                               X
2720     NM1      Other Payer Operating Provider     Not used    NM105      Name Middle                                                              X
2721     NM1      Other Payer Operating Provider     Not used    NM106      Name Prefix                                                              X
2722     NM1      Other Payer Operating Provider     Not used    NM107      Name Suffix                                                              X
2723     NM1      Other Payer Operating Provider     Not used    NM108      Identification Code Qualifier                                            X
2724     NM1      Other Payer Operating Provider     Not used    NM109      Identification Code                                                      X
2725     NM1      Other Payer Operating Provider     Not used    NM110      Entity Relationship Code                                                 X
2726     NM1      Other Payer Operating Provider     Not used    NM111      Entity Identifier Code                                                   X
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       1/22/2011, 6:51 AM                                                                            Puerto Rico Health Plan, Inc.                                                            Page 63 of 152
                                                                                                 Detail Data Definition-837 Institutional

  1                                                    HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                           Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2727
2728              OTHER PAYER OPERATING PROVIDER    REQ/2330E
                  IDENTIFICATION
2729     REF      Other Payer Operating Provider       REQ       REF01      REFERENCE IDENTIFICATION                      R      ID     2/3          E      PRHP Processing Field
                  Identification
2730     REF      Other Payer Operating Provider                            1A   BLUE CROSS PROVIDER #
                  Identification
2731     REF      Other Payer Operating Provider                            1B   BLUE SHIELD PROVIDER #
                  Identification
2732     REF      Other Payer Operating Provider                            1C    MEDICARE PROVIDER #
                  Identification
2733     REF      Other Payer Operating Provider                            1D    MEDICAID PROVIDER #
                  Identification
2734     REF      Other Payer Operating Provider                            1G    PROVIDER UPIN #
                  Identification
2735     REF      Other Payer Operating Provider                            1H    CHAMPUS IDENT. #
                  Identification
2736     REF      Other Payer Operating Provider                            E1    EMLOYER'S IDENT. #
                  Identification
2737     REF      Other Payer Operating Provider                            G2    PROVIDER COMMERCIAL #
                  Identification
2738     REF      Other Payer Operating Provider                            LU    LOCATION #
                  Identification
2739     REF      Other Payer Operating Provider                            N5    PROVIDER PLAB NETWORK IDENT. #
                  Identification
2740     REF      Other Payer Operating Provider       REQ       REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
                  Identification
2741     REF      Other Payer Operating Provider     Not used    REF03      Description                                                              X
                  Identification
2742     REF      Other Payer Operating Provider     Not used    REF04      Reference Identifier                                                     X
                  Identification
2743
2744     NM1      OTHER PAYER OTHER PROVIDER         SIT/2330F
2745     NM1      Other Payer Other Provider           REQ       NM101      ENTITY CODE                                   R      ID     2/3          X
2746     NM1      Other Payer Other Provider                                73 OTHER PHYSICIAN
2747     NM1      Other Payer Other Provider           REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          E      PRHP Processing Field
2748     NM1      Other Payer Other Provider                                1 PERSON
2749     NM1      Other Payer Other Provider                                2 NON-PERSON
2750     NM1      Other Payer Other Provider         Not used    NM103      Name Last or Organization Name                                           X
2751     NM1      Other Payer Other Provider         Not used    NM104      Name First                                                               X
2752     NM1      Other Payer Other Provider         Not used    NM105      Name Middle                                                              X
2753     NM1      Other Payer Other Provider         Not used    NM106      Name Prefix                                                              X
2754     NM1      Other Payer Other Provider         Not used    NM107      Name Suffix                                                              X
2755     NM1      Other Payer Other Provider         Not used    NM108      Identification Code Qualifier                                            X
2756     NM1      Other Payer Other Provider         Not used    NM109      Identification Code                                                      X
2757     NM1      Other Payer Other Provider         Not used    NM110      Entity Relationship Code                                                 X
2758     NM1      Other Payer Other Provider         Not used    NM111      Entity Identifier Code                                                   X
2759


       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
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                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2760              OTHER PAYER OTHER PROVIDER                   REQ/2330F
                  IDENTIFICATION
2761     REF      Other Payer Other Provider Identification       REQ       REF01      REFERENCE IDENT. QUALIFIER                    R      ID     2/3          E      PRHP Processing Field
2762     REF      Other Payer Other Provider Identification                            1A BLUE CROSS PROVIDER #
2763     REF      Other Payer Other Provider Identification                            1B BLUE SHIELD PROVIDER #
2764     REF      Other Payer Other Provider Identification                            1C MEDICARE PROVIDER #
2765     REF      Other Payer Other Provider Identification                            1D MEDICAID PROVIDER #
2766     REF      Other Payer Other Provider Identification                            1G PROVIDER UPIN #
2767     REF      Other Payer Other Provider Identification                            1H CHAMPUS IDENT. #
2768     REF      Other Payer Other Provider Identification                            E1 EMLOYER'S IDENT. #
2769     REF      Other Payer Other Provider Identification                            G2 PROVIDER COMMERCIAL #
2770     REF      Other Payer Other Provider Identification                            LU LOCATION #
2771     REF      Other Payer Other Provider Identification                            N5 PROVIDER PLAB NETWORK IDENT. #
2772     REF      Other Payer Other Provider Identification                            SY SOCIAL SECURITY #
2773     REF      Other Payer Other Provider Identification      REQ        REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
2774     REF      Other Payer Other Provider Identification     Not used    REF03      Description                                                              X
2775     REF      Other Payer Other Provider Identification     Not used    REF04      Reference Identifier                                                     X
2776
2777              OTHER PAYER REFERRING PROVIDER               SIT/2330G

2778     NM1      Other Payer Referring Provider                  REQ       NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
2779     NM1      Other Payer Referring Provider                                       DN REFERRING PROVIDER
2780     NM1      Other Payer Referring Provider                                       P3 PRIMARY CARE PROVIDER
2781     NM1      Other Payer Referring Provider                  REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          E      PRHP Processing Field
2782     NM1      Other Payer Referring Provider                                       1 PERSON
2783     NM1      Other Payer Referring Provider                                       2 NON-PERSON
2784     NM1      Other Payer Referring Provider                Not used    NM103      Name Last or Organization Name                                           X
2785     NM1      Other Payer Referring Provider                Not used    NM104      Name First                                                               X
2786     NM1      Other Payer Referring Provider                Not used    NM105      Name Middle                                                              X
2787     NM1      Other Payer Referring Provider                Not used    NM106      Name Prefix                                                              X
2788     NM1      Other Payer Referring Provider                Not used    NM107      Name Suffix                                                              X
2789     NM1      Other Payer Referring Provider                Not used    NM108      Identification Code Qualifier                                            X
2790     NM1      Other Payer Referring Provider                Not used    NM109      Identification Code                                                      X
2791     NM1      Other Payer Referring Provider                Not used    NM110      Entity Relationship Code                                                 X
2792     NM1      Other Payer Referring Provider                Not used    NM111      Entity Identifier Code                                                   X
2793
2794              OTHER PAYER REFERRING PROVIDER               REQ/2330G
                  IDENTIFICATION
2795     REF      Other Payer Referring Provider                  REQ       REF01      REFERENCE IDENTIFICATION                      R      ID     2/3          E      PRHP Processing Field
                  Identification
2796     REF      Other Payer Referring Provider                                       1A   BLUE CROSS PROVIDER #
                  Identification
2797     REF      Other Payer Referring Provider                                       1B   BLUE SHIELD PROVIDER #
                  Identification
2798     REF      Other Payer Referring Provider                                       1C    MEDICARE PROVIDER #
                  Identification
2799     REF      Other Payer Referring Provider                                       1D    MEDICAID PROVIDER #
                  Identification


       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                      Puerto Rico Health Plan, Inc.                                                            Page 65 of 152
                                                                                                           Detail Data Definition-837 Institutional

  1                                                              HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                          REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                     Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2800     REF      Other Payer Referring Provider                                      1G    PROVIDER UPIN #
                  Identification
2801     REF      Other Payer Referring Provider                                      B3 PREFERRED PROVIDER ORG. #
                  Identification
2802     REF      Other Payer Referring Provider                                      BQ    HEALTH MAINTENANCE ORG. CODE #
                  Identification
2803     REF      Other Payer Referring Provider                                      E1    EMLOYER'S IDENT. #
                  Identification
2804     REF      Other Payer Referring Provider                                      G2    PROVIDER COMMERCIAL #
                  Identification
2805     REF      Other Payer Referring Provider                                      LU    LOCATION #
                  Identification
2806     REF      Other Payer Referring Provider                                      N5    PROVIDER PLAN NETWORK IDENT. #
                  Identification
2807     REF      Other Payer Referring Provider                                      SY    SOCIAL SECURITY #
                  Identification
2808     REF      Other Payer Referring Provider                                      X5 STATE INDUSTRIAL ACCIDENT
                  Identification                                                      PROVIDER NUMBER
2809     REF      Other Payer Referring Provider                 REQ       REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
                  Identification
2810     REF      Other Payer Referring Provider               Not used    REF03      Description                                                              X
                  Identification
2811     REF      Other Payer Referring Provider               Not used    REF04      Reference Identifier                                                     X
                  Identification
2812
2813              OTHER PAYER SERVICE FACILITY                 SIT/2330H
                  PROVIDER
2814     NM1      Other Payer Service Facility Provider          REQ       NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          E      PRHP Processing Field
2815     NM1      Other Payer Service Facility Provider                               FA, FACILITY
2816     NM1      Other Payer Service Facility Provider          REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          X
2817     NM1      Other Payer Service Facility Provider                               2, NON-PERSON
2818     NM1      Other Payer Service Facility Provider        Not used    NM103      Name Last or Organization Name                                           X
2819     NM1      Other Payer Service Facility Provider        Not used    NM104      Name First                                                               X
2820     NM1      Other Payer Service Facility Provider        Not used    NM105      Name Middle                                                              X
2821     NM1      Other Payer Service Facility Provider        Not used    NM106      Name Prefix                                                              X
2822     NM1      Other Payer Service Facility Provider        Not used    NM107      Name Suffix                                                              X
2823     NM1      Other Payer Service Facility Provider        Not used    NM108      Identification Code Qualifier                                            X
2824     NM1      Other Payer Service Facility Provider        Not used    NM109      Identification Code                                                      X
2825     NM1      Other Payer Service Facility Provider        Not used    NM110      Entity Relationship Code                                                 X
2826     NM1      Other Payer Service Facility Provider        Not used    NM111      Entity Identifier Code                                                   X
2827
2828              OTHER PAYER SERVICE FACILITY                REQ/2330H
                  PROVIDER IDENTIFICATION
2829     REF      Other Payer Service Facility Provider ID       REQ       REF01      REFERENCE IDENT. QUALIFIER                    R      ID     2/3          E      PRHP Processing Field
2830     REF      Other Payer Service Facility Provider ID                            1B BLUE SHIELD PROVIDER #
2831     REF      Other Payer Service Facility Provider ID                            1C MEDICARE PROVIDER #
2832     REF      Other Payer Service Facility Provider ID                            1D MEDICAID PROVIDER #
2833     REF      Other Payer Service Facility Provider ID                            E1 EMLOYER'S IDENT. #
2834     REF      Other Payer Service Facility Provider ID                            G2 PROVIDER COMMERCIAL #
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       1/22/2011, 6:51 AM                                                                                      Puerto Rico Health Plan, Inc.                                                             Page 66 of 152
                                                                                                           Detail Data Definition-837 Institutional

  1                                                              HIPAA - 837 Institutional Claim                                                                                               PRHP Processing Field
  2                                                          REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                     Req/Loop Ref Desc Description                                          Use    Type         Len   Field   PRHP Processing Field

2835     REF      Other Payer Service Facility Provider ID                            LU LOCATION #
2836     REF      Other Payer Service Facility Provider ID                            N5 PROVIDER PLAN NETWORK IDENT. #
2837     REF      Other Payer Service Facility Provider ID      REQ        REF02      REFERENCE IDENTIFIER                          R      AN      1/30         E      PRHP Processing Field
2838     REF      Other Payer Service Facility Provider ID     Not used    REF03      Description                                                               X
2839     REF      Other Payer Service Facility Provider ID     Not used    REF04      Reference Identifier                                                      X
2840
2841              SERVICE LINE NUMBER                          REQ/2400
2842      LX      Service Line Number                            REQ       LX01       ASSIGNED NUMBER                               R      NO      1/6          P      PRHP Processing Field
2843
2844              INSTITUTIONAL SERVICE LINE                   REQ/2400
2845     SV2      Institutional Service Line                     REQ       SV201      PRODUCT/SERVICE ID                            R      AN      1/48         P      PRHP Processing Field
2846     SV2      Institutional Service Line                                          42 REVENUE CODES
2847     SV2      Institutional Service Line                      SIT      SV202      COMPOSITE MEDICAL PROCE.                      S      --
2848     SV2      Institutional Service Line                                          44 HCPCS
2849     SV2      Institutional Service Line                     REQ       SV202-1    PRODUCE/SERVICE ID QUALIFIER                  R      ID      2/2          E      PRHP Processing Field
2850     SV2      Institutional Service Line                                          HC, HCPCS
2851     SV2      Institutional Service Line                                          IV, HIEC
2852     SV2      Institutional Service Line                                          N1, NDC IN 4-4-2 Format
2853     SV2      Institutional Service Line                                          N2, NDC in 5-3-2 Format
2854     SV2      Institutional Service Line                                          N3, NDC in 5-4-1 Format
2855     SV2      Institutional Service Line                                          N4, NDC in 5-4-2 Format
2856     SV2      Institutional Service Line                                          ZZ MUTUALLY DEFINED
2857     SV2      Institutional Service Line                    REQ        SV202-2    PRODUCE/SERVICE ID                            R      AN      1/48         P      PRHP Processing Field
2858     SV2      Institutional Service Line                     SIT       SV202-3    PROCEDURE MODIFIER                            S      AN      2/2          P      PRHP Processing Field
2859     SV2      Institutional Service Line                     SIT       SV202-4    PROCEDURE MODIFIER                            S      AN      2/2          P      PRHP Processing Field
2860     SV2      Institutional Service Line                     SIT       SV202-5    PROCEDURE MODIFIER                            S      AN      2/2          P      PRHP Processing Field
2861     SV2      Institutional Service Line                     SIT       SV202-6    PROCEDURE MODIFIER                            S      AN      2/2          P      PRHP Processing Field
2862     SV2      Institutional Service Line                   Not used    SV202-7    Description
2863     SV2      Institutional Service Line                    REQ        SV203      MONETARY AMOUNT                               R      R       1/18         P      PRHP Processing Field
2864     SV2      Institutional Service Line                    REQ        SV204      Unit or Basis for Measurement Code                                        X
2865     SV2      Institutional Service Line                                          DA, DAYS
2866     SV2      Institutional Service Line                                          F2, INTERNATIONAL UNIT
2867     SV2      Institutional Service Line                                          UN, UNIT
2868     SV2      Institutional Service Line                    REQ        SV205      QUANTITY                                      R      R       1/15         P      PRHP Processing Field
2869     SV2      Institutional Service Line                     SIT       SV206      UNIT RATE                                     S      R       1/10         E      PRHP Processing Field
2870     SV2      Institutional Service Line                     SIT       SV207      MONETARY AMOUNT                               S      R       1/18         E      PRHP Processing Field
2871     SV2      Institutional Service Line                   Not used    SV208      Yes/No Condition or response code                                         X
2872     SV2      Institutional Service Line                   Not used    SV209      Nursing Home Residential Status Code                                      X
2873     SV2      Institutional Service Line                   Not used    SV210      Level of Care Code                                                        X
2874
2875              PRESCRIPTION NUMBER                          SIT/2400
2876     SV4      Prescription Number                            REQ       SV401      REFERENCE Identification                      R      AN      1/30         E      PRHP Processing Field
2877     SV4      Prescription Number                          Not used    SV402      Composite Medical Procedure Identifier                                    X
2878     SV4      Prescription Number                          Not used    SV403      Reference Identification                                                  X
2879     SV4      Prescription Number                          Not used    SV404      Yes/No Condition or response code                                         X
2880     SV4      Prescription Number                          Not used    SV405      Dispense as Written Code                                                  X
2881     SV4      Prescription Number                          Not used    SV406      Level of Service Code                                                     X
2882     SV4      Prescription Number                          Not used    SV407      Prescription OriginCode                                                   X
2883     SV4      Prescription Number                          Not used    SV408      Description                                                               X

       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 67 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2884     SV4      Prescription Number               Not used    SV409      Yes/No Condition or response code                                        X
2885     SV4      Prescription Number               Not used    SV410      Yes/No Condition or response code                                        X
2886     SV4      Prescription Number               Not used    SV411      Unit Dose Code                                                           X
2887     SV4      Prescription Number               Not used    SV412      Basis of Cost Determination Code                                         X
2888     SV4      Prescription Number               Not used    SV413      Basis of Days Supply Determination Coded                                 X
2889     SV4      Prescription Number               Not used    SV414      Dosage Form Code                                                         X
2890     SV4      Prescription Number               Not used    SV415      Copay Status Code                                                        X
2891     SV4      Prescription Number               Not used    SV416      Patient Location Code                                                    X
2892     SV4      Prescription Number               Not used    SV417      Level of Care Code                                                       X
2893     SV4      Prescription Number               Not used    SV418      Prior Authorization Type Code                                            X
2894
2895              LINE SUPPLEMENTAL INFORMATION     SIT/2400
2896     PWK      Line Supplemental Information       REQ       PWK01      REPORT TYPE CODE                     R               ID     2/2          E      PRHP Processing Field
2897     PWK      Line Supplemental Information                            AS, ADMISSION SUMMARY
2898     PWK      Line Supplemental Information                            B2, PRESCRIPTION
2899     PWK      Line Supplemental Information                            B3, PHYSICIAN ORDER
2900     PWK      Line Supplemental Information                            B4, REFERRAL FORM
2901     PWK      Line Supplemental Information                            CT, CERTIFICATION
2902     PWK      Line Supplemental Information                            DA, DENTAL MODELS
2903     PWK      Line Supplemental Information                            DG, DIAGNOSTIC REPORT
2904     PWK      Line Supplemental Information                            DS, DISCHARGE SUMMARY
2905     PWK      Line Supplemental Information                            EB, EXPLANATION OF BENEFITS
2906     PWK      Line Supplemental Information                            MT, MODELS
2907     PWK      Line Supplemental Information                            NM, NURSING NOTES
2908     PWK      Line Supplemental Information                            OB, OPERATIVE NOTE
2909     PWK      Line Supplemental Information                            OZ, SUPPORT DATA FOR CLAIM
2910     PWK      Line Supplemental Information                            PN, PHYSICAL THERAPY NOTES
2911     PWK      Line Supplemental Information                            PO, PROSTHETICS OR ORTHOTIC
                                                                           CERTIFICATION.
2912     PWK      Line Supplemental Information                            PZ, PHYSICAL THERAPY CERTIFICATION
2913     PWK      Line Supplemental Information                            RB, RADIOLOGY FILMS
2914     PWK      Line Supplemental Information                            RR, RADIOLOGY REPORTS
2915     PWK      Line Supplemental Information                            RT, REPORT OF TESTS AND ANALYSIS
                                                                           REPORT
2916     PWK      Line Supplemental Information       REQ       PWK02      REPORT TRANSMISSION CODE             R               ID     1/2          E      PRHP Processing Field
2917     PWK      Line Supplemental Information                            AA, AVAILABLE ON REQUEST AT PROVIDER
                                                                           SITE
2918     PWK      Line Supplemental Information                            AB, PREVIOUSLY SUBMITTED TO PAYER
2919     PWK      Line Supplemental Information                            AD, CERTIFICATION INCLUDED IN THIS
                                                                           CLAIM
2920     PWK      Line Supplemental Information                            AF, NARRATIVE SEGMENT INCLUDED IN
                                                                           THIS CLAIM
2921     PWK      Line Supplemental Information                            AG, NO DOCUMENTATION IS REQUIRED
2922     PWK      Line Supplemental Information                            BM, BY MAIL
2923     PWK      Line Supplemental Information                            EL, ELECTRONICALLY ONLY
2924     PWK      Line Supplemental Information                            EM, E-MAIL
2925     PWK      Line Supplemental Information                            FX, BY FAX
2926     PWK      Line Supplemental Information     Not used    PWK03      Report Copies Needed                                                     X
2927     PWK      Line Supplemental Information     Not used    PWK04      Entity Identifier Code                                                   X
       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                           Puerto Rico Health Plan, Inc.                                                            Page 68 of 152
                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2928     PWK      Line Supplemental Information        SIT      PWK05      IDENTIFICATION CODE QUALIFIER                 S      ID     1/2          X
2929     PWK      Line Supplemental Information                            AC, ATTACHMENT CONTROL NUMBER
2930     PWK      Line Supplemental Information       SIT       PWK06      IDENTIFICATION CODE                           S      AN     2/280        E      PRHP Processing Field
2931     PWK      Line Supplemental Information     Not used    PWK07      Description                                                              X
2932     PWK      Line Supplemental Information     Not used    PWK08      Actions Indicated                                                        X
2933     PWK      Line Supplemental Information     Not used    PWK09      Request Category Code                                                    X
2934
2935     DTP      Service Line Date                 SIT/2400                                                             S
2936     DTP      Service Line Date                   REQ       DTP01      Date Time Qualifier                           R      ID     3/3          X
2937     DTP      Service Line Date                                        472, SERVICE
2938     DTP      Service Line Date                   REQ       DTP02      Date Time Format                              R      ID     2/3          X
2939     DTP      Service Line Date                                        D8, Date Expressed in Format CCYYMMDD
2940     DTP      Service Line Date                                        RD8, Range of Dates Expressed in Format
                                                                           CCYYMMDD-CCYYMMDD
2941     DTP      Service Line Date                   REQ       DTP03      Date Time Period                              R      AN     1/35         P      PRHP Processing Field
2942
2943     DTP      ASSESSMENT DATE                   SIT/2400                                                             S
2944     DTP      Assessment Date                     REQ       DTP01      Date Time Qualifier                           R      ID     3/3          X
2945     DTP      Assessment Date                                          866, EXAMINATION
2946     DTP      Assessment Date                     REQ       DTP02      Date Time Format                              R      ID     2/3          X
2947     DTP      Assessment Date                                          D8, Date Expressed in Format CCYYMMDD
2948     DTP      Assessment Date                     REQ       DTP03      Date Time Period                              R      AN     1/35         E      PRHP Processing Field
2949
2950              Service Tax Amount                SIT/2400
2951     AMT      Service Tax Amount                  REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2952     AMT      Service Tax Amount                                       GT, GOODS AND SERVICE TAX
2953     AMT      Service Tax Amount                 REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2954     AMT      Service Tax Amount                Not used    AMT03      Credit/Debit Flag Code                                                   X
2955
2956              Facility Tax Amount               SIT/2400
2957     AMT      Facility Tax Amount                 REQ       AMT01      AMOUNT QUALIFIER CODE                         R      ID     1/3          X
2958     AMT      Facility Tax Amount                                      N8, MISCELLANEOUS TAXES
2959     AMT      Facility Tax Amount                REQ        AMT02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
2960     AMT      Facility Tax Amount               Not used    AMT03      Credit/Debit Flag Code                                                   X
2961
2962              File Information                    2400                                                               S
2963      K3      File Information                              K301       Fixed Format Information                      R      AN     1/80         X
2964      K3      File Information                              K302       Not used                                                                 X
2965      K3      File Information                              K303       Not used                                                                 X
2966
2967              Attending Physician Name          SIT/2420A
2968     NM1      Attending Physician Name             REQ      NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
2969     NM1      Attending Physician Name                                 71, ATTENDING PHYSICIAN
2970     NM1      Attending Physician Name            REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          E      PRHP Processing Field
2971     NM1      Attending Physician Name                                 1, PERSON
2972     NM1      Attending Physician Name                                 2, NON-PERSON ENTITY
2973     NM1      Attending Physician Name            REQ       NM103      NAME LAST OR ORGANI. NAME                     R      AN     1/35         E      PRHP Processing Field
2974     NM1      Attending Physician Name            SIT       NM104      NAME FIRST                                    S      AN     1/25         E      PRHP Processing Field
2975     NM1      Attending Physician Name            SIT       NM105      NAME MIDDLE                                   S      AN     1/25         E      PRHP Processing Field

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       1/22/2011, 6:51 AM                                                                                       Puerto Rico Health Plan, Inc.                                                            Page 69 of 152
                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

2976     NM1      Attending Physician Name                      Not used    NM106      Name Prefix                                                              X
2977     NM1      Attending Physician Name                        SIT       NM107      NAME SUFFIX                                   S      AN     1/10         E      PRHP Processing Field
2978     NM1      Attending Physician Name                       REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
2979     NM1      Attending Physician Name                                             24, EMPLOYER'S IDENTIFICATION NUMBER

2980     NM1      Attending Physician Name                                             34, SOCIAL SECURITY NUMBER
2981     NM1      Attending Physician Name                                             XX, NATIONAL PROVIDER NUMBER
2982     NM1      Attending Physician Name                       REQ        NM109      IDENTIFICATION CODE                           R      AN     2/80         E      PRHP Processing Field
2983     NM1      Attending Physician Name                      Not used    NM110      Entity Relationship Code                                                 X
2984     NM1      Attending Physician Name                      Not used    NM111      Entity Identifier Code                                                   X
2985
2986              Attending Physiican Specialty                REQ/2420A
                  Information
2987     PRV      Attending Physician Specialty Information       REQ       PRV01      PROVIDER CODE                                 R      ID     1/3          X

2988     PRV      Attending Physician Specialty Information                            AT    ATTENDING

2989     PRV      Attending Physician Specialty Information       REQ       PRV02      REFERENCE IDENTIFICATION                                                 X

2990     PRV      Attending Physician Specialty Information                            QUALIFIER                                     R      ID     2/3

2991     PRV      Attending Physician Specialty Information                            ZZ, MUTUALLY DEFINED (Taxonomy Codes)

2992     PRV      Attending Physician Specialty Information       REQ       PR03       REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field

2993     PRV      Attending Physician Specialty Information     Not used    PR04       State or Province Code                                                   X

2994     PRV      Attending Physician Specialty Information     Not used    PR05       Provider Specialty Information                                           X

2995     PRV      Attending Physician Specialty Information     Not used    PR06       Provider Organization Code                                               X

2996
2997              Attending Physician Secondary                 SIT/2420A
                  Identification
2998     REF      Attending Physician Secondary                 OPT/2420
                  Identification
2999     REF      Attending Physician Secondary                   REQ       REF01      REFERENCE IDENTI. QUALIFIER                   R      ID     2/3          E      PRHP Processing Field
                  Identification
3000     REF      Attending Physician Secondary                                        OB    STATE LICENSE NUMBER
                  Identification
3001     REF      Attending Physician Secondary                                        1A   BLUE CROSS PROVIDER #
                  Identification
3002     REF      Attending Physician Secondary                                        1B   BLUE SHIELD PROVIDER #
                  Identification
3003     REF      Attending Physician Secondary                                        1C    MEDICARE PROVIDER #
                  Identification
3004     REF      Attending Physician Secondary                                        1D    MEDICAID PROVIDER #
                  Identification


       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                       Puerto Rico Health Plan, Inc.                                                            Page 70 of 152
                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

3005     REF      Attending Physician Secondary                                        1G    PROVIDER UPIN #
                  Identification
3006     REF      Attending Physician Secondary                                        1H    CHAMPUS IDENT. #
                  Identification
3007     REF      Attending Physician Secondary                                        E1    EMLOYER'S IDENT. #
                  Identification
3008     REF      Attending Physician Secondary                                        G2    PROVIDER COMMERCIAL #
                  Identification
3009     REF      Attending Physician Secondary                                        LU    LOCATION #
                  Identification
3010     REF      Attending Physician Secondary                                        N5    PROVIDER PLAN NETWORK IDENT. #
                  Identification
3011     REF      Attending Physician Secondary                                        SY    SOCIAL SECURITY #
                  Identification
3012     REF      Attending Physician Secondary                                        X5 STATE INDUSTRIAL ACCIDENT
                  Identification                                                       PROVIDER NUMBER
3013     REF      Attending Physician Secondary                   REQ       REF 02     REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
                  Identification
3014     REF      Attending Physician Secondary                 Not used    REF 03     Description                                                              X
                  Identification
3015     REF      Attending Physician Secondary                 Not used    REF 04     Reference Identifier                                                     X
                  Identification
3016
3017              OPERATING PHYSICIAN NAME                      SIT/2420B
3018     NM1      Operating Physician Name                         REQ      NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
3019     NM1      Operating Physician Name                                             72, OPERATING PHYSICIAN
3020     NM1      Operating Physician Name                        REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          X
3021     NM1      Operating Physician Name                                             1, PERSON
3022     NM1      Operating Physician Name                       REQ        NM103      NAME LAST OR ORGANI. NAME                     R      AN     1/35         E      PRHP Processing Field
3023     NM1      Operating Physician Name                       REQ        NM104      NAME FIRST                                    R      AN     1/25         E      PRHP Processing Field
3024     NM1      Operating Physician Name                        SIT       NM105      NAME MIDDLE                                   S      AN     1/25         E      PRHP Processing Field
3025     NM1      Operating Physician Name                      Not used    NM106      Not used                                                                 X
3026     NM1      Operating Physician Name                        SIT       NM107      NAME SUFFIX                                   S      AN     1/10         E      PRHP Processing Field
3027     NM1      Operating Physician Name                       REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
3028     NM1      Operating Physician Name                                             24 EMPLOYER'S IDENTIFICATION NUMBER

3029     NM1      Operating Physician Name                                             34 SOCIAL SECURITY NUMBER
3030     NM1      Operating Physician Name                                             XX NATIONAL PROVIDER NUMBER
3031     NM1      Operating Physician Name                       REQ        NM109      IDENTIFICATION CODE                           R      AN     2/80         E      PRHP Processing Field
3032     NM1      Operating Physician Name                      Not used    NM110      Entity Relationship Code                                                 X
3033     NM1      Operating Physician Name                      Not used    NM111      Entity Identifier Code                                                   X
3034
3035              OPERATING PHYSICIAN SPECIALTY                 SIT/2420B
                  INFORMATION
3036     PRV      Operating Physician Specialty Information       REQ       PRV01      PROVIDER CODE                                 R      ID     1/3          X

3037     PRV      Operating Physician Specialty Information                            OP, Operating



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       1/22/2011, 6:51 AM                                                                                       Puerto Rico Health Plan, Inc.                                                            Page 71 of 152
                                                                                                            Detail Data Definition-837 Institutional

  1                                                               HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                           REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                      Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

3038     PRV      Operating Physician Specialty Information       REQ       PRV02      REFERENCE IDENTI. QUALIFIER                   R      ID     2/3          X

3039     PRV      Operating Physician Specialty Information                            ZZ   MUTUALLY DEFINED (Taxonomy Codes)

3040     PRV      Operating Physician Specialty Information       REQ       PRV03      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field

3041     PRV      Operating Physician Specialty Information     Not used    PRV 04     State or Province Code                                                   X

3042     PRV      Operating Physician Specialty Information     Not used    PRV 05     Provider Specialty Information                                           X

3043     PRV      Operating Physician Specialty Information     Not used    PRV 06     Provider Organization Code                                               X

3044
3045              OPERATING PHYSICIAN SECONDARY                 SIT/2420B
                  IDENTIFICATION
3046     REF      Operating Physician Secondary                   REQ       REF01      Reference Identification Qualifier            R      ID     2/3          E      PRHP Processing Field
                  Identification
3047     REF      Operating Physician Secondary                                        OB    STATE LICENSE NUMBER
                  Identification
3048     REF      Operating Physician Secondary                                        1A   BLUE CROSS PROVIDER #
                  Identification
3049     REF      Operating Physician Secondary                                        1B   BLUE SHIELD PROVIDER #
                  Identification
3050     REF      Operating Physician Secondary                                        1C    MEDICARE PROVIDER #
                  Identification
3051     REF      Operating Physician Secondary                                        1D    MEDICAID PROVIDER #
                  Identification
3052     REF      Operating Physician Secondary                                        1G    PROVIDER UPIN #
                  Identification
3053     REF      Operating Physician Secondary                                        1H    CHAMPUS IDENT. #
                  Identification
3054     REF      Operating Physician Secondary                                        E1    EMLOYER'S IDENT. #
                  Identification
3055     REF      Operating Physician Secondary                                        G2    PROVIDER COMMERCIAL #
                  Identification
3056     REF      Operating Physician Secondary                                        LU    LOCATION #
                  Identification
3057     REF      Operating Physician Secondary                                        N5    PROVIDER PLAN NETWORK IDENT. #
                  Identification
3058     REF      Operating Physician Secondary                                        SY    SOCIAL SECURITY #
                  Identification
3059     REF      Operating Physician Secondary                                        X5 STATE INDUSTRIAL ACCIDENT
                  Identification                                                       PROVIDER NUMBER
3060     REF      Operating Physician Secondary                   REQ       REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
                  Identification
3061     REF      Operating Physician Secondary                 Not used    REF03      Description                                                              X
                  Identification
3062     REF      Operating Physician Secondary                 Not used    REF04      Reference Identifier                                                     X
                  Identification
       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                     Puerto Rico Health Plan, Inc.                                                            Page 72 of 152
                                                                                                          Detail Data Definition-837 Institutional

  1                                                             HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                         REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                    Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

3063
3064              OTHER PROVIDER NAME                         SIT/2420C
3065     NM1      Other Provider Name                            REQ      NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
3066     NM1      Other Provider Name                                                73 OTHER PHYSICIAN
3067     NM1      Other Provider Name                           REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          E      PRHP Processing Field
3068     NM1      Other Provider Name                                                1 PERSON
3069     NM1      Other Provider Name                                                2 NON-PERSON ENTITY
3070     NM1      Other Provider Name                          REQ        NM103      NAME LAST OR ORGANI. NAME                     R      AN     1/35         E      PRHP Processing Field
3071     NM1      Other Provider Name                           SIT       NM104      NAME FIRST                                    S      AN     1/25         E      PRHP Processing Field
3072     NM1      Other Provider Name                           SIT       NM105      NAME MIDDLE                                   S      AN     1/25         E      PRHP Processing Field
3073     NM1      Other Provider Name                         Not used    NM106      Not used
3074     NM1      Other Provider Name                           SIT       NM107      NAME SUFFIX                                   S      AN     1/10         E      PRHP Processing Field
3075     NM1      Other Provider Name                          REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
3076     NM1      Other Provider Name                                                24 EMPLOYER'S IDENTIFICATION NUMBER

3077     NM1      Other Provider Name                                                34 SOCIAL SECURITY NUMBER
3078     NM1      Other Provider Name                                                XX NATIONAL PROVIDER NUMBER
3079     NM1      Other Provider Name                          REQ        NM109      IDENTIFICATION CODE                           R      AN     2/80         E      PRHP Processing Field
3080     NM1      Other Provider Name                         Not used    NM110      Entity Relationship Code                                                 X
3081     NM1      Other Provider Name                         Not used    NM111      Entity Identifier Code                                                   X
3082
3083              OTHER PROVIDER SPECIALTY                    SIT/2420C
                  INFORMATION
3084     PRV      Provider Information                          REQ       PRV01      PROVIDER CODE                                 R      ID     1/3          E      PRHP Processing Field
3085     PRV      Provider Information                                               OT OTHER PHYSICIAN
3086     PRV      Provider Information                                               PE PERFORMING
3087     PRV      Provider Information                          REQ       PRV02      REFERENCE IDENTI. QUALIFIER                   R      ID     2/3          X
3088     PRV      Provider Information                                               ZZ, Mutually Defined (Taxonomy Code)
3089     PRV      Provider Information                          REQ       PRV03      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
3090     PRV      Provider Information                                               PROVIDER SPECIALTY CODE
3091     PRV      Provider Information                        Not used    PR04       State or Province Code                                                   X
3092     PRV      Provider Information                        Not used    PR05       Provider Specialty Information                                           X
3093     PRV      Provider Information                        Not used    PR06       Provider Organization Code                                               X
3094
3095              OTHER PROVIDER SECONDARY                    SIT/2420C
                  IDENTIFICATION
3096     REF      Other Provider Secondary Identification       REQ       REF01      REFERENCE IDENTI. QUALIFIER                   R      ID     2/3          E      PRHP Processing Field
3097     REF      Other Provider Secondary Identification                            OB STATE LICENSE NUMBER
3098     REF      Other Provider Secondary Identification                            1A BLUE CROSS PROVIDER #
3099     REF      Other Provider Secondary Identification                            1B BLUE SHIELD PROVIDER #
3100     REF      Other Provider Secondary Identification                            1C MEDICARE PROVIDER #
3101     REF      Other Provider Secondary Identification                            1D MEDICAID PROVIDER #
3102     REF      Other Provider Secondary Identification                            1G PROVIDER UPIN #
3103     REF      Other Provider Secondary Identification                            1H CHAMPUS IDENT. #
3104     REF      Other Provider Secondary Identification                            E1 EMLOYER'S IDENT. #
3105     REF      Other Provider Secondary Identification                            G2 PROVIDER COMMERCIAL #
3106     REF      Other Provider Secondary Identification                            LU LOCATION #
3107     REF      Other Provider Secondary Identification                            N5 PROVIDER PLAN NETWORK IDENT. #
3108     REF      Other Provider Secondary Identification                            SY SOCIAL SECURITY #

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       1/22/2011, 6:51 AM                                                                                         Puerto Rico Health Plan, Inc.                                                            Page 73 of 152
                                                                                                              Detail Data Definition-837 Institutional

  1                                                                 HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                             REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                        Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

3109     REF      Other Provider Secondary Identification                                X5 STATE INDUSTRIAL ACCIDENT
                                                                                         PROVIDER NUMBER
3110     REF      Other Provider Secondary Identification           REQ       REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field

3111     REF      Other Provider Secondary Identification         Not used    REF03      Description                                                              X
3112     REF      Other Provider Secondary Identification         Not used    REF04      Reference Identifier                                                     X
3113
3114              REFERRING PROVIDER NAME                         SIT/2420D
3115     NM1      Referring Provider Name                            REQ      NM101      ENTITY IDENTIFIER CODE                        R      ID     2/3          X
3116     NM1      Referring Provider Name                                                DN, Referring Provider
3117     NM1      Referring Provider Name                           REQ       NM102      ENTITY TYPE QUALIFIER                         R      ID     1/1          E      PRHP Processing Field
3118     NM1      Referring Provider Name                                                1 PERSON
3119     NM1      Referring Provider Name                                                2 NON-PERSON ENTITY
3120     NM1      Referring Provider Name                          REQ        NM103      NAME LAST OR ORGANI. NAME                     R      AN     1/35         E      PRHP Processing Field
3121     NM1      Referring Provider Name                           SIT       NM104      NAME FIRST                                    S      AN     1/25         E      PRHP Processing Field
3122     NM1      Referring Provider Name                           SIT       NM105      NAME MIDDLE                                   S      AN     1/25         E      PRHP Processing Field
3123     NM1      Referring Provider Name                         Not used    NM106      Not used                                                                 X
3124     NM1      Referring Provider Name                           SIT       NM107      NAME SUFFIX                                   S      AN     1/10         E      PRHP Processing Field
3125     NM1      Referring Provider Name                          REQ        NM108      IDENTIFICATION CODE QUALIFIER                 R      ID     1/2          E      PRHP Processing Field
3126     NM1      Referring Provider Name                                                24 EMPLOYER'S IDENTIFICATION NUMBER

3127     NM1      Referring Provider Name                                                34 SOCIAL SECURITY NUMBER
3128     NM1      Referring Provider Name                                                XX NATIONAL PROVIDER NUMBER
3129     NM1      Referring Provider Name                           REQ       NM109      IDENTIFICATION CODE                           R      AN     2/80         E      PRHP Processing Field
3130     NM1      Referring Provider Name                                                REFERRING PROVIDER PRIMARY
                                                                                         IDENTIFIER
3131     NM1      Referring Provider Name                         Not used    NM110      Entity Relationship Code                                                 X
3132     NM1      Referring Provider Name                         Not used    NM111      Entity Identifier Code                                                   X
3133
3134              REFERRING PROVIDER SPECIALTY                    SIT/2420D
                  INFORMATION
3135     PRV      Referring Provider Specialty Information          REQ       PRV01      PROVIDER CODE                                 R      ID     1/3          X
3136     PRV      Referring Provider Specialty Information                               RF REFERRING
3137     PRV      Referring Provider Specialty Information          REQ       PRV02      REFERENCE IDENTI. QUALIFIER                   R      ID     2/3          X
3138     PRV      Referring Provider Specialty Information                               PROVIDER ''TAXONOMY''
3139     PRV      Referring Provider Specialty Information                               ZZ MUTUALLY DEFINED
3140     PRV      Referring Provider Specialty Information         REQ        PRV03      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field
3141     PRV      Referring Provider Specialty Information        Not used    PRV04      State or Province Code                                                   X
3142     PRV      Referring Provider Specialty Information        Not used    PRV05      Provider Specialty Information                                           X
3143     PRV      Referring Provider Specialty Information        Not used    PRV06      Provider Organization Code                                               X
3144
3145              REFERRING PROVIDER SECONDARY                    SIT/2420D
                  IDENTIFICATION
3146     REF      Referring Provider Secondary Identification       REQ       REF01      REFERENCE IDENTI. QUALIFIER                   R      ID     2/3          E      PRHP Processing Field

3147     REF      Referring Provider Secondary Identification                            OB    STATE LICENSE NUMBER

3148     REF      Referring Provider Secondary Identification                            1A   BLUE CROSS PROVIDER #


       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                         Puerto Rico Health Plan, Inc.                                                            Page 74 of 152
                                                                                                              Detail Data Definition-837 Institutional

  1                                                                 HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                             REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                        Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

3149     REF      Referring Provider Secondary Identification                            1B   BLUE SHIELD PROVIDER #

3150     REF      Referring Provider Secondary Identification                            1C    MEDICARE PROVIDER #

3151     REF      Referring Provider Secondary Identification                            1D    MEDICAID PROVIDER #

3152     REF      Referring Provider Secondary Identification                            1G    PROVIDER UPIN #

3153     REF      Referring Provider Secondary Identification                            B3 PREFERRED PROVIDER
                                                                                         ORGANIZATION #
3154     REF      Referring Provider Secondary Identification                            BQ HEALTH MAINTENANCE ORG. CODE #

3155     REF      Referring Provider Secondary Identification                            E1    EMLOYER'S IDENT. #

3156     REF      Referring Provider Secondary Identification                            G2    PROVIDER COMMERCIAL #

3157     REF      Referring Provider Secondary Identification                            LU    LOCATION #

3158     REF      Referring Provider Secondary Identification                            N5    PROVIDER PLAN NETWORK IDENT. #

3159     REF      Referring Provider Secondary Identification                            SY    SOCIAL SECURITY #

3160     REF      Referring Provider Secondary Identification                            X5 STATE INDUSTRIAL ACCIDENT
                                                                                         PROVIDER NUMBER
3161     REF      Referring Provider Secondary Identification       REQ       REF02      REFERENCE IDENTIFICATION                      R      AN     1/30         E      PRHP Processing Field

3162     REF      Referring Provider Secondary Identification     Not used    REF03      Description                                                              X

3163     REF      Referring Provider Secondary Identification     Not used    REF04      Reference Identifier                                                     X

3164
3165              SERVICE LINE ADJUDICATION                       SIT/2430
                  INFORMATION
3166     SVD      Service Line Adjudication Information             REQ       SVD01      IDENTIFICATION CODE                           R      AN     2/80         E      PRHP Processing Field
3167     SVD      Service Line Adjudication Information             REQ       SVD02      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
3168     SVD      Service Line Adjudication Information             SIT       SVD03      COMPOSITE MEDICAL PROCEDIRE                   S      *      *
                                                                                         IDENTIFIER
3169     SVD      Service Line Adjudication Information             REQ       SVD03-1    PRODUCT/SERVICE ID QUALIFIER                  R      ID     2/2          E      PRHP Processing Field
3170     SVD      Service Line Adjudication Information                                  HC HCPCS
3171     SVD      Service Line Adjudication Information                                  IV HIEC
3172     SVD      Service Line Adjudication Information                                  N1 NDC IN 4-4-2 FORMAT
3173     SVD      Service Line Adjudication Information                                  N2 NDC IN 5-3-2 FORMAT
3174     SVD      Service Line Adjudication Information                                  N3 NDC IN 5-4-1 FORMAT
3175     SVD      Service Line Adjudication Information                                  N4 NDC IN 5-4-2 FORMAT
3176     SVD      Service Line Adjudication Information                                  ZZ MUTUALLY DEFINED
3177     SVD      Service Line Adjudication Information             REQ       SVD03-2    234 PRODUCT/SERVICE ID                        R      AN     1/48         E      PRHP Processing Field
3178     SVD      Service Line Adjudication Information             SIT       SVD03-3    1339 PROCEDURE MODIFIER                       S      AN     2/2          E      PRHP Processing Field
3179     SVD      Service Line Adjudication Information             SIT       SVD03-4    1339 PROCEDURE MODIFIER                       S      AN     2/2          E      PRHP Processing Field
3180     SVD      Service Line Adjudication Information             SIT       SVD03-5    1339 PROCEDURE MODIFIER                       S      AN     2/2          E      PRHP Processing Field
       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
       1/22/2011, 6:51 AM                                                                                   Puerto Rico Health Plan, Inc.                                                            Page 75 of 152
                                                                                                        Detail Data Definition-837 Institutional

  1                                                           HIPAA - 837 Institutional Claim                                                                                              PRHP Processing Field
  2                                                       REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                                  Req/Loop Ref Desc Description                                          Use   Type         Len   Field   PRHP Processing Field

3181     SVD      Service Line Adjudication Information       SIT       SVD03-6    PROCEDURE MODIFIER                            S      AN     2/2          E      PRHP Processing Field
3182     SVD      Service Line Adjudication Information       SIT       SVD03-7    352 DESCRIPTION                               S      AN     1/80         E      PRHP Processing Field
3183     SVD      Service Line Adjudication Information       REQ       SVD04      PRODUCT/SERVICE ID                            R      AN     1/48         E      PRHP Processing Field
3184     SVD      Service Line Adjudication Information       REQ       SVD05      QUANTITY                                      R      R      1/15         E      PRHP Processing Field
3185     SVD      Service Line Adjudication Information       SIT       SVD06      ASSIGNED NUMBER                               S      NO     1/6          E      PRHP Processing Field
3186
3187              SERVICE LINE ADJUSTMENT                   SIT/2430
3188     CAS      Service Line Adjustment                     REQ       CAS01      CLAIM ADJUSTMENT GROUP CODE                   R      ID     1/2          E      PRHP Processing Field
3189     CAS      Service Line Adjustment                                          CO CONTRACTUAL OBLIGATIONS
3190     CAS      Service Line Adjustment                                          CR CORRECTION AND REVERSALS
3191     CAS      Service Line Adjustment                                          OA OTHER ADJUSTMENTS
3192     CAS      Service Line Adjustment                                          PI PAYOR INITIATED REDUCTIONS
3193     CAS      Service Line Adjustment                                          PR PATIENT RESPONSIBILITY
3194     CAS      Service Line Adjustment                     REQ       CAS02      CLAIM ADJUSTMENT REASON CODE                  R      ID     1/5          E      PRHP Processing Field
3195     CAS      Service Line Adjustment                     REQ       CAS03      MONETARY AMOUNT                               R      R      1/18         E      PRHP Processing Field
3196     CAS      Service Line Adjustment                     SIT       CAS04      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
3197     CAS      Service Line Adjustment                     SIT       CAS05      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
3198     CAS      Service Line Adjustment                     SIT       CAS06      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
3199     CAS      Service Line Adjustment                     SIT       CAS07      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
3200     CAS      Service Line Adjustment                     SIT       CAS08      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
3201     CAS      Service Line Adjustment                     SIT       CAS09      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
3202     CAS      Service Line Adjustment                     SIT       CAS10      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
3203     CAS      Service Line Adjustment                     SIT       CAS11      CLAIM ADJSUTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
3204     CAS      Service Line Adjustment                     SIT       CAS12      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
3205     CAS      Service Line Adjustment                     SIT       CAS13      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
3206     CAS      Service Line Adjustment                     SIT       CAS14      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
3207     CAS      Service Line Adjustment                     SIT       CAS15      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
3208     CAS      Service Line Adjustment                     SIT       CAS16      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
3209     CAS      Service Line Adjustment                     SIT       CAS17      CLAIM ADJUSTMENT REASON CODE                  S      ID     1/5          E      PRHP Processing Field
3210     CAS      Service Line Adjustment                     SIT       CAS18      MONETARY AMOUNT                               S      R      1/18         E      PRHP Processing Field
3211     CAS      Service Line Adjustment                     SIT       CAS19      QUANTITY                                      S      R      1/15         E      PRHP Processing Field
3212
3213              SERVICE ADJUDICATION DATE                 SIT/2430
3214     DTP      Service Adjudication Date                   REQ       DTP01      DATE/TIME/QUALIFIER                           R      ID     3/3          X
3215     DTP      Service Adjudication Date                                        573 DATE CLAIM PAID
3216     DTP      Service Adjudication Date                   REQ       DTP02      DATE TIME PERIOD FORMAT QUAL.                 R      ID     2/3          X
3217     DTP      Service Adjudication Date                                        D8 DATE EXPRESSED IN FORMAT
                                                                                   CCYYMMDD
3218     DTP      Service Adjudication Date                   REQ       DTP03      DATE TIME PERIOD                              R      AN     1/35         E      PRHP Processing Field
3219
3220              TRANSACTION SET TRAILER                     REQ
3221      SE      TRANSACTION SET TRAILER                     REQ       SE01       NUMBER OF INCLUDED SEGMENTS                   R      NO     1/10         E      PRHP Processing Field
3222                                                          REQ       SE02       TRANSACTION SET CONTROL #                     R      AN     4/9          E      PRHP Processing Field
3223                                                                               SEO2 MUST MATCH STO2.
3224
3225     GE       Functional Group Trailer                    REQ
3226     GE       Functional Group Trailer                    REQ       GE01       Number of Transaction Sets Included



       a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
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                                                                                                Detail Data Definition-837 Institutional

  1                                                   HIPAA - 837 Institutional Claim                                                                                            PRHP Processing Field
  2                                               REQ or R = Required; SIT or S = Situational
  3     Seg ID    Segment                          Req/Loop Ref Desc Description                                          Use   Type       Len   Field   PRHP Processing Field

3227     GE       Functional Group Trailer            REQ       GE02       Group Control Number



3228
3229     IEA      Interchange Control Trailer         REQ
3230     IEA      Interchange Control Trailer         REQ       IEA01      Number of Included Functional Groups
3231     IEA      Interchange Control Trailer         REQ       IEA02      Interchange Control Number




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                                                                                      Detail Data Definition-837 Institutional

               PRHP Processing Field

                 Inmediata Review Comments                       TPA Addendum Final
                                                                      Decision


Expect 00                                                        00

Blank if ISA01 = 00
Expect 00                                                        00


Blank if ISA03 = 00
Inmediata will send 30                                           30




Provider ID                                                      Provider Tax ID
PRHP will send 30                                                30




Inmediata's Federal Tax ID Number                                660610220
Format is YYMMDD
Format is HHMM




Must be identical to the associated Interchange Trailer IEA02.


         a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
          1/22/2011, 6:51 AM                                                        Puerto Rico Health Plan, Inc.          Page 78 of 152
                                                                                Detail Data Definition-837 Institutional

                PRHP Processing Field

                 Inmediata Review Comments           TPA Addendum Final
                                                          Decision




Colon ( : ) is most common                           Colon ( : ) will be used




Same as ISA                                          Provider Sender ID
Same as ISA                                          Inmediata ID
Use this for the functional group creation date;
Format is CCYYMMDD
Format is HHMM




                                                     TP: ALL

                                                     TP: ALL




                                                     TP: CH



                                                     TP: ALL




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                                                                           Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments           TPA Addendum Final
                                                        Decision

                                                   TP: ALL

                                                   TP: ALL




                                                   TP: ALL

Federal Tax ID Number                              < submitter's Fed Tax
                                                   ID Number >




                                                   TP: ALL


                                                   TP: ALL




                                                   TP: ALL




                                                   TP: ALL




                                                   TP: ALL

                                                   TP: ALL


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                                                                                    Detail Data Definition-837 Institutional

               PRHP Processing Field

                 Inmediata Review Comments                     TPA Addendum Final
                                                                    Decision




                                                               TP: ALL

PRHP's Federal Tax ID Number                                   660195325




                                                               TP: ALL

                                                               TP: ALL




                                                               TP: ALL


                                                               TP: ALL

Will be discontinued with 4010A, so no point in using in the
interim.




                                                               TP: ALL




         a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
     1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 81 of 152
                                                                     Detail Data Definition-837 Institutional

          PRHP Processing Field

           Inmediata Review Comments            TPA Addendum Final
                                                     Decision




                                                TP: ALL

                                                TP: ALL




                                                TP: 24, 34




G2                                              TP: G2




     a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 82 of 152
                                                                        Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments           TPA Addendum Final
                                                        Decision




Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >




                                                   TP: ALL




                                                   TP: ALL


                                                   TP: ALL




                                                   TP: ALL




                                                   TP: ALL




        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
     1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 83 of 152
                                                                     Detail Data Definition-837 Institutional

          PRHP Processing Field

           Inmediata Review Comments            TPA Addendum Final
                                                     Decision


                                                TP: ALL

                                                TP: ALL




                                                TP: 24, 34




G2                                              TP: G2




     a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 84 of 152
                                                                        Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments           TPA Addendum Final
                                                        Decision


Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >




                                                   TP: ALL

                                                   TP: ALL




                                                   TP: ALL



                                                   TP: ALL




                                                   TP: ALL




        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
         1/22/2011, 6:51 AM                                                                Puerto Rico Health Plan, Inc.          Page 85 of 152
                                                                                       Detail Data Definition-837 Institutional

               PRHP Processing Field

                 Inmediata Review Comments                        TPA Addendum Final
                                                                       Decision




                                                                  TP: ALL


                                                                  TP: ALL


                                                                  TP: ALL

                                                                  TP: ALL




MI                                                                TP: MI


Verify PRHP Member ID Number;                                     < PRHP Member ID
To accommodate Blue Exchange processing, Member ID                Number >
Number is required to include the 3 character Blue Card Prefix;
''ZTx" represents Blue Cross of Puerto Rico.




         a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 86 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL


a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 87 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL

                                           TP: ALL




                                           PRHP’s TaxID




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 88 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision



                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 89 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL


                                           TP: ALL



                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 90 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 91 of 152
                                                                 Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                 Decision
                                           TP: ALL


                                           TP: ALL


                                           TP: ALL


                                           TP: ALL


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL


a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 92 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL



                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 93 of 152
                                                                 Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                 Decision
                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 94 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 95 of 152
                                                                 Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                 Decision
                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 96 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL
a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 97 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP:ALL




                                           TP:ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 98 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP:ALL



                                           TP:ALL


                                           TP:ALL




                                           TP:ALL




                                           TP:ALL



                                           TP:ALL




                                           TP: ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 99 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision

                                           TP: ALL


                                           TP: ALL




                                           TP: ALL

                                           TP: ALL


                                           TP: ALL




                                           TP: ALL

                                           TP: ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 100 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 101 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                     Puerto Rico Health Plan, Inc.          Page 102 of 152
                                                                   Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           This loop repeats
                                           twice; 2nd occurrence
                                           stores first 3 "other
                                           Dx" codes


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 103 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL


a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 104 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL



                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 105 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL



                                           TP: ALL




                                           TP: D8




                                           TP: D8




                                           TP: D8




                                           TP: D8


a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 106 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: D8




                                           TP: D8




                                           TP: D8




                                           TP: D8




                                           TP: D8




                                           TP: D8



a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 107 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: D8




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL


a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 108 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 109 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 110 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 111 of 152
                                                                 Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                 Decision
                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 112 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision

                                           TP: ALL


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 113 of 152
                                                                 Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                 Decision
                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 114 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 115 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision



                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 116 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL



a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 117 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 118 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL

a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 119 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 120 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 121 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL



                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 122 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 123 of 152
                                                                        Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments           TPA Addendum Final
                                                        Decision




G2                                                 TP: G2




Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >




                                                   TP: ALL

                                                   TP: ALL




                                                   TP: 24, 34




        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 124 of 152
                                                                         Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments            TPA Addendum Final
                                                         Decision
                                                   TP: ALL



                                                   TP: ALL




G2                                                 TP: G2




Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >




                                                   TP: ALL

                                                   TP: ALL




        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 125 of 152
                                                                        Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments           TPA Addendum Final
                                                        Decision


                                                   TP: 24, 34




                                                   TP: ALL


                                                   TP: ALL




G2                                                 TP: G2




Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >




                                                   TP: ALL



        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 126 of 152
                                                                         Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments            TPA Addendum Final
                                                         Decision
                                                   TP: ALL




                                                   TP: 24, 34




                                                   TP: ALL

                                                   TP: ALL




G2                                                 TP: G2




Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >


        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
     1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 127 of 152
                                                                     Detail Data Definition-837 Institutional

          PRHP Processing Field

           Inmediata Review Comments            TPA Addendum Final
                                                     Decision



                                                TP: ALL

                                                TP: ALL




                                                TP: 24, 34




                                                TP: ALL

                                                TP: ALL




G2                                              TP: G2



     a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 128 of 152
                                                                        Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments           TPA Addendum Final
                                                        Decision




Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >




                                                   TP: ALL



                                                   TP: ALL




        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 129 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 130 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL



a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 131 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL



                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                       Puerto Rico Health Plan, Inc.          Page 132 of 152
                                                                     Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           This segment is used
                                           to convey the
                                           Medicare Inpatient
                                           Adjudication
                                           Information if returned
                                           in the 835.




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 133 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
     1/22/2011, 6:51 AM                                                       Puerto Rico Health Plan, Inc.          Page 134 of 152
                                                                          Detail Data Definition-837 Institutional

          PRHP Processing Field

           Inmediata Review Comments             TPA Addendum Final
                                                        Decision
                                                Required to convey
                                                the Medicare
                                                Outpatient
                                                Adjudication
                                                Information if returned
                                                in the Electronic
                                                Remittance Advice
                                                (835).




                                                TP: ALL

                                                TP: ALL




MI                                              TP: MI




     a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 135 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 136 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 137 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 138 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 139 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision



                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 140 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: ALL




                                           TP: ALL


                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 141 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 142 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL



                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 143 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 144 of 152
                                                                 Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                 Decision
                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




                                           TP: ALL




                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 145 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision


                                           TP: 24, 34




                                           TP: ALL



                                           TP: ALL




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 146 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL

                                           TP: ALL




                                           TP: 24, 34




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                   Puerto Rico Health Plan, Inc.          Page 147 of 152
                                                                 Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                 Decision
                                           TP: ALL




                                           TP : ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
     1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 148 of 152
                                                                     Detail Data Definition-837 Institutional

          PRHP Processing Field

           Inmediata Review Comments            TPA Addendum Final
                                                     Decision


                                                TP: ALL

                                                TP: ALL




                                                TP: 24, 34




                                                TP: ALL


                                                TP: ALL




G2                                              TP: G2




     a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
        1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 149 of 152
                                                                        Detail Data Definition-837 Institutional

             PRHP Processing Field

               Inmediata Review Comments           TPA Addendum Final
                                                        Decision


Verify PRHP Provider ID Number                     < PRHP Provider Id
                                                   Number >




                                                   TP: ALL

                                                   TP: ALL




                                                   TP: 24, 34




                                                   TP: ALL

                                                   TP: ALL




                                                   TP: ALL




        a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 150 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                  Puerto Rico Health Plan, Inc.          Page 151 of 152
                                                                Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments            TPA Addendum Final
                                                Decision




                                           TP: ALL




                                           TP: ALL

                                           TP: ALL




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls
1/22/2011, 6:51 AM                                                    Puerto Rico Health Plan, Inc.          Page 152 of 152
                                                                  Detail Data Definition-837 Institutional

     PRHP Processing Field

      Inmediata Review Comments             TPA Addendum Final
                                                  Decision
                                           Must be identical to
                                           the associated
                                           functional group
                                           header GS06.




a46fb2fc-8de2-469f-a68e-8e51957cb7fb.xls

				
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