ANSI ASC X12N 837P

Health Care Claim Professional

TCHP Companion Guide

Updated: October 10, 2017

 TCHP 837P Medicaid Companion Guide

Contents
Purpose ......................................................................................................................................................... 3
Security and Privacy Statement ................................................................................................................... 3
Overview of HIPAA Legislation.................................................................................................................. 3
Compliance according to HIPAA ............................................................................................................... 4
Compliance according to ASC X12 ............................................................................................................ 4
Contact Information / Trading Partner Testing ........................................................................................... 4
References .................................................................................................................................................... 5
Business Rules / Special Consideration ....................................................................................................... 5
837P Companion Guide................................................................................................................................ 5
Appendix A – 837P Example ...................................................................................................................... 13
STAR - 005010X222A1 - Professional Health Care Claim (837P) ............................................................ 13
CHIP - 005010X222A1 - Professional Health Care Claim (837P) ............................................................. 14
Appendix B – Change Log ........................................................................................................................... 15

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 TCHP 837P Medicaid Companion Guide

Purpose

This is the technical report document for the ANSI ASC X12N 837 Health Care Claims (837) transaction
for professional claims. This document provides a definitive statement of what trading partners must be
able to support in this version of the 837. This document is intended to be compliant with the data
standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its
associated rules.

The 837 Professional transaction is the electronic correspondent to the paper CMS-1500 claim forms;
therefore, any claim types submitted on the CMS-1500 forms correlate to the 837 Professional
transaction, if data is submitted electronically.

All required segments within the 837 Professional transactions must always be sent by the submitter
and received by the payer. Optional information is sent when it is necessary for processing. Segments
that are conditional are only sent when special criteria are met. Although required segments in the
incoming transaction may not be used during claims processing, some of these data elements are
returned in other transactions such as the Remittance Advice (835 Transaction Set).

Additional information on the Final Rule for Standards for Electronic Transactions can be found at
http://aspe.hhs.gov/admnsimp/final/txfin00.htm. The HIPAA Implementation Guides can be accessed at
http://www.wpc-edi.com/hipaa/HIPAA_40.asp.

Security and Privacy Statement

Overview of HIPAA Legislation

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for
administrative simplification. This requires the Secretary of the Department of Health and Human
Services (HHS) to adopt standards to support the electronic exchange of administrative and financial
health care transactions primarily between health care providers and plans. HIPAA directs the Secretary
to adopt standards for transactions to enable health information to be exchanged electronically and to
adopt specifications for implementing each standard HIPAA serves to:

 Create better access to health insurance

 Limit fraud and abuse
 Reduce administrative costs

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 TCHP 837P Medicaid Companion Guide

Compliance according to HIPAA

The HIPAA regulations at 45 CFR 162.915 require that covered entities not enter into a trading partner
agreement that would do any of the following:

 Change the definition, data condition, or use of a data element or segment in a standard.
 Add any data elements or segments to the maximum defined data set.
 Use any code or data elements that are marked “not used” in the standard’s implementation
specifications or are not in the standard’s implementation specification(s).
 Change the meaning or intent of the standard’s implementation specification(s).

Compliance according to ASC X12

ASC X12 requirements include specific restrictions that prohibit trading partners from:

 Modifying any defining, explanatory, or clarifying content contained in the implementation

guide.
 Modifying any requirement contained in the implementation guide.

Contact Information / Trading Partner Testing

Texas Children’s Health Plan is in compliance with HIPAA EDI requirements for all electronic
transactions. For additional assistance, please call Texas Children’s Health Plan Provider Care and
Coordination at 832-828-1008 or toll-free 1-800-731-8527.

Claim submissions are required within 95 days from date of service.

You can file your electronic claims several ways:

Payer Name Electronic Clearinghouse Payer Supported Transactions

ID

Texas Children’s Health Emdeon (Change Healthcare) 76048 Professional Claims (Medical)
Plan – CHIP Availity
Texas Children’s Health Emdeon (Change Healthcare) 75228 Professional Claims (Medical)
Plan – STAR /STAR KIDS Availity
STAR /Star Kids Availity TXCSM No Longer Used

Emdeon (Change Healthcare)

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 TCHP 837P Medicaid Companion Guide

References
 Texas Children’s Health Plan “Provider Manual”

http://www.texaschildrenshealthplan.org/for-providers/provider-resources

 The following websites provide information for where to obtain documentation for WPS
adopted EDI transactions and code sets.

ASC X12 TR3 Implementation Guides: http://store.x12.org

Washington Publishing Company Health Care Code Sets: http://www.wpc-edi.com/

Business Rules / Special Consideration

 Please contact your clearinghouse for hours of submissions and requirements.

837P Companion Guide

Loop ID Reference Name Codes Notes/Comments

ISA - INTERCHANGE CONTROL HEADER

ISA08 Interchange Receiver ID See Description TCHP requests the Receiver ID assigned.

Interchange Control TCHP will support the standards approved for Publication by
ISA12 00501
Version Number ACS X12 Procedures Review Board through October 2003.
ISA15 Usage Indicator P Production Claims
GS - FUNCTIONAL GROUP HEADER
Application Receiver
GS03 Must match the value in the ISA06
Code
TCHP will support the standards approved for Publication by
Version/Release/Industry ACS X12 Procedures Review Board through October 2003.
GS08 005010X222A2
Identifier Code *As of January 1, 2012 – 4010 Electronic Submissions (legacy)
are not permitted. 5010 formats are mandated for use.
BHT - BEGINNING OF HIERARCHICAL TRANSACTION
Transaction Set Purpose
BHT02 00 TCHP will only accept original transactions.
Code
BHT06 Transaction Type Code. CH TCHP will process all 837 transactions as Charges.
1000A - Submitter Name
PER01- If submitting via an EDI Vendor check specific requirements for
1000A
PER08 that vendor.
Billing Provider Hierarchical Level - Required
2000A - Billing Provider Specialty Information

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Loop ID Reference Name Codes Notes/Comments

Provider Identification
2000A PRV03 (Provider Taxonomy TCHP request that the billing taxonomy code be sent.
Code)
Billing Provider Detail - Required
2010AA - Billing Provider Name
Identification Code
2010AA NM108 XX If the NPI is submitted the qualifier must be "XX".
Qualifier
Must contained the 10 numeric NPI assigned to the Billing
2010AA NM109 Identification Code 10N
Provider.
N3 - Billing Provider Address
Billing Provider Address
2010AA N301 Must contain the physical street address on file with TCHP.
Line
N4 - Billing Provider City, State, Zip Code
2010AA N401 City Name Must contain the city name on file with TCHP.

2010AA N402 State Code 2AN Must contain 2 alphanumeric State Code on file with TCHP.

2010AA N403 Postal Code Must contain the zip code on file with TCHP.
REF - Billing Provider Tax Identification
Identification Code
2010AA REF01 EI, SY At least one REF segment is required.
Qualifier
Must contain 9 Numeric Tax ID or Social Security Number (A
Billing Provider Tax
2010AA REF02 9N single string of numbers should be sent. No separators should
Identification Number
be used)

Payer Name

N3 - Pay-To Provider Address

2010AB N301 Pay-To Address Line Must contain the physical street address on file with TCHP.
N4 - Pay-To Provider City, State, Zip Code
2010AB N401 City Name Must contain the city name on file with TCHP.
2010AB N402 State Code 2AN Must contain 2 alphanumeric State Code on file with TCHP.
2010AB N403 Postal Code Must contain the zip code on file with TCHP.
Subscriber Detail (Required)
This segment is used to record information specific to the primary insured and the insurance carrier for the insured.
Note: As an assumption for Medicaid, the Subscriber is the same individual as the Patient then the Patient Loop (2000C) is not to be
populated per HIPAA compliance
SBR - Subscriber Information (Required)
NM1 - Subscriber Name
Identification Code For correct identification of the Subscriber "MI" should be
2010BA NM108 MI
Qualifier used.
Enter the member/patient policy number as indicated on the
ID card. TCHP member/patient policy numbers are 9 digits in
9N
length. All TCHP members are subscribers.
2010BA NM109 Identification Code or
Subscriber: 111111111 (9N)
11-12AN
Newborn (Single): 111111111NB (11AN)
Newborn (Twins): 111111111NB1 , 111111111NB2 (12AN)
N3 - Subscriber Address (Required)

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Loop ID Reference Name Codes Notes/Comments

N301-
2010BA Subscriber Address TCHP requires the Subscriber address.
N302
N4 - Subscriber City, State, Zip Code (Required)
N401- Subscriber City, State, Zip
2010BA TCHP requires the Subscriber City, State, Zip Code.
N403 Code
DMG - Subscriber Name (All segments required)
2010BA DMG01 Date Qualifier D8 Date of birth expressed as CCYYMMDD
2010BA DMG02 Date Time Period CCYYMMDD Subscriber Date of Birth
2010BA DMG03 Gender Code F, M, U Subscriber Gender
REF - Subscriber Secondary Identification
Reference Identification TCHP Request the Subscriber Supplemental Identifier (SSN) if
2010BA REF01 SY
Qualifier available. This is not a required field.
2010BA REF02 Reference Identification 9N Subscriber Supplemental Identifier
Payer Name (Required)
NM1 - Payer Name
Identification Code
2010BB NM108 PI Payer Identification
Qualifier
2010BB NM109 Identification Code Payer Identifier
N3 - Payer Address
N301-
2010BB Payer Address TCHP Request the Payer Address.
N302
N4 - Payer City, State, Zip Code
N401- Payer City, State, Zip
2010BB TCHP Request the Payer Zip Code.
N403 Code
REF - Payer Secondary Identifier
Reference Identification REF01 must contain G2 (Provider Commercial Number) when
2010BB REF01 G2
Number the API (Atypical Provider Identifier) is sent in REF02.
If an API (Atypical Provider Identifier) is sent, REF02 must
2010BB REF02 Reference Identification
contain the API (Atypical Provider Identifier).
Claim Detail (Required)

CLM - Claim Information

Claims Submitter
2300 CLM01 Patient Control Number - Only the first 17 bytes will be used.
Identifier
TCHP requires the Place of Service Code. For appropriate
values please refer to the Texas Medicaid Provider Procedures
2300 CLM05-01 Facility Code Value
Manual located at the following link:
Texas Medicaid Provider Procedures Manual
Claim Frequency Values are seen as noted below:
1 - Original claim
Claim Frequency Type 7 - Replacement or corrected claim. The information present
2300 CLM05-03
Code on this bill represents a complete replacement of the
previously issued bill.
8 - Voided/canceled claim
Medicare Assignment TCHP request "A". Other values or missing values may result in
2300 CLM07 A
Code denial of claim.

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Loop ID Reference Name Codes Notes/Comments

Patient Signature Source The Patient Signature Source Code (CLM10) is required when
2300 CLM10 P
Code Release of Information Code (CLM09) does not equal N.
DTP - Admission Date
2300 DTP01 Date Qualifier 435 Admission Date
Date Time Period Format
2300 DTP02 Date expressed as CCYYMMDD
Qualifier D8
The Related Hospital Admission Date is required for the
following:
- All inpatient services
- When the place of service in 2300 CLM05-1 = 21, 31, 51, 52,
2300 DTP03 Date Time Period CCYYMMDD
or 61
- All ambulance claims when the patient is known to be
admitted to the hospital
- Admission date must not be after the condition date.
DTP - Discharge Date
2300 DTP01 Date Qualifier 435 Discharge Date
Date Time Period Format
2300 DTP02 Date expressed as CCYYMMDD
Qualifier D8
The Related Hospital Discharge Date is a required segment
2300 DTP03 Date Time Period CCYYMMDD when CLM05 -1 = 21,31,51,52 or 61 and DTP has admission
date.
PWK - Claim Supplemental Information
Identification Code
2300 PWK05 AC Attachment control number.
Qualifier
2300 PWK06 Identification Code 17AN Only the first 17 bytes will be used.
AMT - Patient Amount Paid
2300 AMT01 Amount Qualifier Code F5 Patient Amount Paid
The patient paid amount cannot be negative.
2300 AMT02 Monetary Amount Max length is 18 bytes. 9 bytes will be used at this time by
TCHP.
REF - Referral Number
*Unique segment from Prior Authorization Number
Reference Identification
2300 REF01 9F Referral Number
Number
TCHP request the Referral Number if the service requires a
referral. The referring/ordering provider will be required when
2300 REF02 Reference Identification
services require a referral. Example(s): Clinical or Radiological
Laboratory Services
REF - Prior Authorization Number
*Unique segment from Referral Number
Reference Identification
2300 REF01 G1 Prior Authorization Number
Number
TCHP request the Prior Authorization number if the service
2300 REF02 Reference Identification
requires a prior authorization.
REF - Payer Claim Control Number
Reference Identification
2300 REF01 F8 Original Reference Number
Number

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Loop ID Reference Name Codes Notes/Comments

The Payer Claim Control Number is required when the CLM05-
2300 REF02 Reference Identification 03 (claim frequency code) indicates this claim is a replacement
or void to a previously adjudicated claim.
REF - Clinical Laboratory Improvement Amendment (CLIA) Number
Reference Identification Clinical Laboratory Improvement Amendment (CLIA)
2300 REF01 X4
Qualifier Number
TCHP request the CLIA number if required. CLIA numbers are
2300 REF02 Reference Identification
10 digits with letter "D" in third position
NTE - Claim Note
Reference Identification TCHP Request that when sending NTE claim notes that "ADD"
2300 NTE01 ADD
Qualifier be used.
2300 NTE02 Reference Identification Free Text added here with needed details.
CRC - EPSDT Referral
TCHP Requires the EPSDT when early & periodic screening,
2300 CRC01 Code Category ZZ
diagnosis, and treatment are billed.

2300 CRC02 Yes/No Condition Y, N If no, then NU in the CRC03 indicating no referral was given

Required when a first condition code is necessary. Use codes

2300 CRC03 Condition Indicator AV, NU, S2, ST
listed in the CRC03
Required when a second condition code is necessary. Use
2300 CRC04 Condition Indicator AV, NU, S2, ST
codes listed in the CRC03
Required when a third condition code is necessary. Use codes
2300 CRC05 Condition Indicator AV, NU, S2, ST
listed in the CRC03
HI - Health Care Diagnosis Code
Required Diagnosis codes must be coded to the highest level of
specificity, i.e., coding to the fourth or fifth digit. There are
multiple iterations of this segment, all must have valid
HI01 thru diagnosis codes.
2300
HI12 Mixed Diagnosis Codes with ICD9 and ICD10 are NOT
permitted.
ICD9 - BK, BF
ICD10 - ABK, ABF
NM1 - Referring Provider Name
DN (Referring Provider) or P3 (Primary Care Provider)
2310A NM101 Entity Identifier Code DN, P3 TCHP requires the referring provider when there is a referral.
Example(s): Clinical or Radiological Laboratory Services
Identification Code If the NPI is submitted, the value of NM108 must contain “XX”
2310A NM108 XX
Qualifier (NPI).
NM109 must contain the Referring Provider’s assigned NPI (10
2310A NM109 Identification Code 10N
numeric).
REF - Rendering Provider Name
*Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider Loop 2010AA.
Identification Code If the NPI is submitted, the value of NM108 must contain “XX”
2310B NM108 XX
Qualifier (NPI).

2310B NM109 Identification Code 10N NM109 must contain the provider’s assigned NPI (10 numeric).

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 TCHP 837P Medicaid Companion Guide

Loop ID Reference Name Codes Notes/Comments

REF - Rendering Provider Specialty Information
Reference Identification
2310B PRV02 PXC Qualifier value that is sent in PRV02.
Qualifier
PRV03 must contain the provider’s assigned taxonomy code.
This is a 10-byte taxonomy code. For a list of the taxonomy
2310B PRV03 Reference Identification 10AN codes,
visit web site www.wpc-edi.com (See Code List: "Health Care
Provider Taxonomy Code Set ")
NM1 - Service Facility Information (Required)
Identification Code
2310C NM108 XX The value of NM108 must contain “XX” (NPI).
Qualifier
NM109 must contain the Laboratory or Facility Primary
2310C NM109 Identification Code 10N
Identifier's assigned NPI (10 numeric).
N3 - Service Facility Address
N301-
2310C Required for print to paper payers.
N302
N4 - Service Facility City, State, Zip Code
N401-
2310C Required for print to paper payers.
N403
NM1 - Supervising Provider Name
Identification Code If the NPI is submitted, the value of NM108 must contain “XX”
2310D NM108 XX
Qualifier (NPI).
NM109 must contain the Supervising Provider’s assigned NPI
2310D NM109 Identification Code 10N
(10 numeric).

Other Subscriber Information

CAS - Claim Level Adjustments

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 TCHP 837P Medicaid Companion Guide

Loop ID Reference Name Codes Notes/Comments

TCHP requires all COB information be sent and must balance.
COB Paid amounts of $0.00 in 2320 AMT02 indicates a paid
claim and the date of the zero paid amounts should be
submitted to TCHP.

• Loop 2300 CLM02 (Total Claim Charge) must equal the sum
of Loop 2400 SV102 (Line Item Charge).
• Loop 2320 AMT02 (COB Payer Paid Amount) must equal the
sum of Loop 2430 SVD02 (Line Adjudication Information) less
the sum of Loop 2300 CAS (Claim Level Adjustments).
Other Subscriber • Loop 2400 SV102 (Line Item Charge Amount) must equal the
2320 CAS
Information sum of Loop 2430 SVD02 (Line Adjudication Information) plus
the sum of Loop 2430 CAS (Claim Level Adjustments).

The sum of all line level payment amounts (Loop ID-2430

SVD02) less any claim level adjustment amounts (Loop ID-2320
CAS adjustments) must balance to the claim level payment
amount (Loop ID-2320 AMT02).
Expressed as a calculation for given payer: {Loop ID-2320
AMT02 payer payment} = {sum of Loop ID-2430 SVD02
payment amounts} minus {sum of Loop ID-2320 CAS
adjustment amounts}.
N3 - Other Subscriber Address
N301- Only the first 30 bytes will be used from the Other Insured
2330A Address Information
N302 Address Line 1 and Line 2.
Service Line Number
SV1 - Professional Service
The line item charge amount cannot be negative. Max length is
2400 SV102 Monetary Amount
18 bytes. 10 bytes will be used at this time by TCHP.
NTE - Line Note
Required when procedure code used is 'Not Otherwise
2400 NTE02 Line Note Text
Classified" or as directed by payer.
LIN - Drug Identification
Product/Service ID The value of LIN02 must be equal to N4 when the National
2410 LIN02 N4
Qualifier Drug Code (NDC) is sent in LIN03.
Product/Service ID LIN02 must contain a valid 11 numeric NDC in the 5-4-2 format.
2410 LIN03 11AN
Qualifier No dashes should be sent or text that is not an NDC value.
CTP - Drug Quantity

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Loop ID Reference Name Codes Notes/Comments

NDC drug unit quantity
If milliliters are administered, then total number administered
is the quantity reported
“Each” or “ea” in the NDC description indicates a vial or tablet,
which is a quantity of 1
Examples:
2410 CTP04 Quantity –00002-1407-01, Quinidine gluconate, 10ml/vial
If 10 ml were given, then NDC unit = 10
If 5 ml given, then NDC unit = 5
–00069-0058-02, Heparin sodium, 1000 USPS/ML (10 ml/vial)
If 1 ml was given, then NDC unit = 1
–00409-1135-02, Morphine sulfate, 25 mg/ml
If 25 mg were given, then NDC unit = 1
Unit or Basis for F2, GR, ME, ML, CTP05-01 must be equal to one of the valid Units Of
2410 CTP05-01
Measurement Code UN Measurement (UOM) for each NDC.
Detail Provider (2420A - 2420F)
2420A through 2420F: TCHP expects all provider/facility
2420A
detail(s) to be sent at the header (2310A-2310D). Provider
through
Details sent at the 2420A-2420F will NOT be used for
2420F
adjudication.
2430 - SVD, CAS, DTP, AMT - Service Line Adjudication, Adjustments, Adjudication Date and Amount
TCHP requires all COB information be sent and must balance.
COB Paid amounts of $0.00 in 2320 AMT02 indicates a paid
claim and the date of the zero paid amounts should be
submitted to TCHP.

• Loop 2300 CLM02 (Total Claim Charge) must equal the sum
of Loop 2400 SV102 (Line Item Charge).
• Loop 2320 AMT02 (COB Payer Paid Amount) must equal the
sum of Loop 2430 SVD02 (Line Adjudication Information) less
the sum of Loop 2300 CAS (Claim Level Adjustments).
SVD, CAS, • Loop 2400 SV102 (Line Item Charge Amount) must equal the
2430
DTP, AMT sum of Loop 2430 SVD02 (Line Adjudication Information) plus
the sum of Loop 2430 CAS (Claim Level Adjustments).

The sum of all line level payment amounts (Loop ID-2430

SVD02) less any claim level adjustment amounts (Loop ID-2320
CAS adjustments) must balance to the claim level payment
amount (Loop ID-2320 AMT02).
Expressed as a calculation for given payer: {Loop ID-2320
AMT02 payer payment} = {sum of Loop ID-2430 SVD02
payment amounts} minus {sum of Loop ID-2320 CAS
adjustment amounts}.

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 TCHP 837P Medicaid Companion Guide

Appendix A – 837P Example

This section is used to describe the required data sets for Medicaid claim processing. The 837P format is
used for submission of Electronic Claims for health care professionals. As an assumption for these file
formats, if the Subscriber is the same individual as the Patient then the Patient Loop (2000C) is not to be
populated per HIPAA compliance.

In the following example, carriage return line feeds are inserted in place of ~ character for improved
readability purposes.

STAR - 005010X222A1 - Professional Health Care Claim (837P)

ISA*00* *00* *ZZ*133052274 *ZZ*TXCSM0001 *160308*2119*^*00501*000005555*0*P*:

GS*HC*133052274*TXCSM0001*20160308*211916*5555*005010X222A1
ST*837*000000055*005010X222A1
BHT*0001*00*00011111*20160308*211916*CH
NM1*41*2*SUBMITTER ABC*****46*111111111
PER*IC*EMDEON CUSTOMER SOLUTIONS*TE*8008456592
NM1*40*2*RECEIVER ABC*****46*TXCSM0001
HL*1**20*1
PRV*BI*PXC*208000000X
NM1*85*2*BILLING NAME ABC*****XX*1111111111
N3*11111 NO NAME ROAD
N4*HOUSTON*TX*770744336
REF*EI*111111111
HL*2*1*22*0
SBR*P*18*******MC
NM1*IL*1*LASTNAME*FIRST****MI*111111111
N3*ADDRESSLINE ONE
N4*HOUSTON*TX*770744336
DMG*D8*11111111*M
NM1*PR*2*TEXAS CHILDRENS WELL*****PI*TXCSM
CLM*1111111111*210.01***11:B:1*Y*A*Y*Y
REF*D9*11111111111111~
HI*ABK:Z00129~
NM1*77*2*FACILITY ABC*****XX*1111111111
N3*11111 NO NAME ROAD
N4*HOUSTON*TX*770744336
LX*1
SV1*HC:99392:AM:25*150*UN*1***1
DTP*472*D8*20160307
REF*6R*1
LX*2
SV1*HC:96110:U6*20*UN*1***1

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DTP*472*D8*20160307
REF*6R*2
LX*3
SV1*HC:90633*.01*UN*1***1
DTP*472*D8*20160307
REF*6R*3
LX*4
SV1*HC:90460*40*UN*1***1
DTP*472*D8*20160307
REF*6R*4
SE*41*000000055
GE*1*5555
IEA*1*000005555

CHIP - 005010X222A1 - Professional Health Care Claim (837P)

ISA*00* *00* *ZZ*133052274 *ZZ*752280001 *160527*2139*^*00501*000004444*0*P*:

GS*HC*133052274*752280001*20160527*213905*4444*X*005010X222A1
ST*837*000000044*005010X222A1
BHT*0001*00*00018091A*20160527*213905*CH
NM1*41*2*SUBMITTER ABC*****46*111111111
PER*IC*EMDEON CUSTOMER SOLUTIONS*TE*8008456592
NM1*40*2*RECEIVER ABC*****46*TXCSM0001
HL*1**20*1
PRV*BI*PXC*208D00000X
NM1*85*BILLINGNAME*FIRST*M***XX*1111111111
N3*11111 NO NAME ROAD
N4*HOUSTON*TX*770744336
REF*EI*111111111
PER*IC*BILLINGCONTACT*TE*8321111111
HL*2*1*22*0
SBR*P*18**MEDICAID OF TX*****CI
NM1*IL*1*LASTNAME*FIRST*M***M111111111
N3*11111 NO NAME ROAD
N4*HOUSTON*TX*770744336
DMG*D8*11111111*M
NM1*PR*2*TCHPCHIP 76048*****PI*75228
CLM*1111111111*292***11:B:1*Y*A*Y*Y
REF*D9*111111111111111
HI*ABK:Z00129*ABF:J309*ABF:J029
LX*1
SV1*HC:87880:QW*22*UN*1***1:2:3
DTP*472*D8*20160525
REF*6R*1
NTE*ADD*207R00000X

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LX*2
SV1*HC:99392:AM*100*UN*1***1:2:3
DTP*472*D8*20160525
REF*6R*2
NTE*ADD*207R00000X
LX*3
SV1*HC:99213:25*150*UN*1***1:2:3
DTP*472*D8*20160525
REF*6R*3
NTE*ADD*207R00000X
LX*4
SV1*HC:96110:U6*20*UN*1***1:2:3
DTP*472*D8*20160525
REF*6R*4
NTE*ADD*207R00000X
SE*43*0000000044
GE*1*4444
IEA*1*000004444

Appendix B – Change Log

Version Change Date Description of Change

1.0 07/20/2016 Published
1.1 10/10/2017 Update Payer Listing

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