2100 Claim Payment Information – CLP (Standard 835)
TR3 PAGE #
Segment/Field
ID FIELD NAME
Sample Data, TR3 Required Value [R] and Department Returned Value [DRV]
Seg/Field USAGE
123 CLP Claim Payment Information Required
123 CLP01 Patient Control Number PUBLICJQ-00100 R 124 CLP02 Claim Status Code 1 or 4 or 22 [DRV] R 125 CLP03 Total Claim Charge Amount 500.00 R
125 CLP04 Claim Payment Amount 450.00 R
125 CLP05 Patient Responsibility Amount 0 S
126 CLP06 Claim Filing Indicator Code WC [DRV] R 127 CLP07 Payer Claim Control Number 70320001000000100 R 128 CLP11 Diagnosis Related Group (DRG) Code S 128 CLP12 Diagnosis Related Group (DRG) Weight S
129 CAS Claim Adjustment Situational
131 CAS01 Claim Adjustment Group Code CO R
131 CAS02 Claim Adjustment Reason Code 42 R
132 CAS03 Adjustment Amount 50.00 R
132 CAS04 Adjustment Quantity S
137 NM1 Patient Name Required
137 NM101 Entity Identifier Code QC [R] R
138 NM102 Entity Type Qualifier 1 [R] R
138 NM103 Patient Last Name PUBLIC S
138 NM104 Patient First Name JOHN S
138 NM105 Patient Middle Q S
139 NM108 Identification Code Qualifier MI [DRV] S
139 NM109 Patient Identifier H010101 S
146 NM1 Service Provider Name Situational
147 NM101 Entity Identifier Code: Rendering Provider 82 [R] R 147 NM102 Entity Type Qualifier: 1-Person; 2-Non-person 1 or 2 R 147 NM103 Last Name or Organization WASHINGTON S
147 NM104 First Name GEORGE S
148 NM105 Middle Name S
148 NM108 Identification Code Qualifier: Provider Commercial
Number (PC) or NPI (XX) PC or XX [DRV] R
149 NM109 Identification Code: Number or 10-digit 7-character LNI Provider Account National Provider Identifier 0012345 or 1234567890 R
159 MIA Inpatient Adjudication Information Situational
160 MIA01 Quantity: Covered Days or Visits Count R
160 MIA02 Quantity: PPS Outlier Amount S
161 MIA04 DRG Amount S
161 MIA05 Reference Identification: Remark Code/EOB S
166 MOA
Outpatient Adjudication Information: Used for all
services except Inpatient. Situational
166 MOA01 Percent: Reimbursement Rate S
167 MOA02 Monetary Amount: HCPCS Payable Amount 450.00 S 167 MOA03 Reference Identification: Remark Code/EOB S
169 REF Other Claim Related Identification Situational
169 REF01 Reference Identification Qualifier EA R
171 REF Rendering Provider Identification Situational
171 REF01 Reference Identification Qualifier G2 [DRV] R 172 REF02 Rendering Provider Secondary Identifier 0012345 R
173 DTM Statement From or To Date Situational
174 DTM01 Date Time Qualifier 232 [DRV] R
174 DTM02 Claim Date 20110815 R
173 DTM Statement From or To Date Situational
174 DTM01 Date Time Qualifier 233 [DRV] R
174 DTM02 Claim Date 20110815 R
182 AMT Claim Supplemental Information Situational
183 AMT01 Amount Qualifier Code: Outlier Amount ZZ R
183 AMT02 Monetary Amount S
Segment
Count Example EDI Data – 835
17 CLP*PUBLICJQ-00100*1*500*450*0*WC*70320001000000100~ 18 CAS*CO*42*50~ 19 NM1*QC*1*PUBLIC*JOHN*Q***MI*H010101~ 20 NM1*82*1*WASHINGTON*GEORGE***XX*1234567890~ 21 MOA**450~ 22 REF*EA*MEDRECNUM001~ 23 REF*G2*0012345~ 24 DTM*232*20110815~ 25 DTM*233*20110815~
2100 Claim Payment Information notes:
1. CLP01 Patient Control Number: Patient Account Number Value:
• Based on Bill Medium type
ICN 7 – value received in 837 2300-CLM01 Patient Account Number
ICN 5 – value received in Box 26 Patient Account No. of the Direct Entry online bill form ICN 3 – value received in EMC format - Record Type C1, Field 10, Patient Account Number ICN 0 – value received in Box 26 Patient’s Account No. of the CMS-1500 paper form (1st digit position of LNI Internal Control Number - CLP07)
2. CLP02 Claim Status Code: Finalized Bill Status Value: 1 or 4 or 22
• 1 – Processed as Primary. Bill paid (full or partial payment). • 4 – Denied. (Bill denied, no payment issued)
• 22 – Reversal of Previous Payment (adjustment)
3. CLP03 Total Claim Charge Amount Value:
• Based on Bill Medium type
ICN 7 – value received in 837 2300-CLM02 Total Claim Charge
ICN 5 – value received in Box 28 Total Charge of the Direct Entry online bill form ICN 3 – value received in EMC format - Record Type T2, Field 6, Total Charges ICN 0 – value received in Box 28 total charge of the CMS-1500 paper form (1st digit position of LNI Internal Control Number - CLP07)
4. CLP04 Claim Payment Amount: Total amount the Department paid on this bill Value: • MIPS bill – AMT-PD
5. CLP05 Patient Responsibility Amount Value: 0 (zero)
• Patient’s responsibility is always zero for Washington State workers’ compensation billing.
6. CLP06 Claim Filing Indicator Code : Value: WC
• Workers’ Compensation Health Claim
7. CLP07 Payer Claim Control Number: Value:
• 17-digit LNI Internal Control Number (ICN)
• The first position of the ICN identifies the medium type of the submitted bill to LNI. 7 = HIPAA EDI 837 Professional or Institutional bill
5 = Direct Entry bill (effective 6/23/2009) 4 = Credits/Adjustments bill
3 = Proprietary EMC format bill 0 = Paper bill
8. CLP11 Diagnosis Related Group (DRG) Code Value:
• Returned on Institutional bills when adjudicated using DRG. 9. CLP12 Quantity
• Diagnosis Related Group (DRG) Weight Value:
2100 Claim Payment Information notes continued 10. CAS Segment
• Claim Adjustment Segments will be used to report claim level (bill level) adjustments.
• Used when the Claim Payment Amount CLP04 is different than the Total Claim Charge Amount CLP03. • The information in CAS01 and CAS02 is derived from the HIPAA EOB cross-reference associated to LNI’s
assigned EOB (Explanation of Benefits) codes returned for the bill on the payee’s remittance advice.
CAS01 Claim Adjustment Group Code Value:
• Descriptions are defined in the 835 Implementation Guide (TR3) • CO – Contractual Obligations
• OA – Other Adjustments • PI – Payer Initiated Reductions • PR – Patient Responsibility
• CR – Correction and Reversal used when CLP02=22 (4010A1)
o Note: Code CR not available in 5010A1 format
CAS02 Claim Adjustment Reason Code Value:
• Defined by the Washington Publishing Company (WPC).
• Codes are mapped and cross-referenced to LNI’s EOB (Explanation of Benefits) codes
CAS03 Adjustment Amount Value:
• Difference between Claim Payment Amount CLP04 and Total claim Charge CLP03
CAS04 Adjustment Quantity Value:
11. NM1 Patient Name Segment
NM101 Entity Identifier Code: Patient Value: QC
NM102 Entity Type Qualifier: Person Value: 1
NM103 Patient Last Name Value:
• Claimant’s Last name or UNKNOWN • 2010BA NM103 Subscriber Last name
NM104 Patient First Name Value:
• Claimant’s First name or UNKNOWN • 2010BA NM104 Subscriber First Name
NM105 Patient Middle Name Value:
• Claimant’s Middle name/initial
2100 Claim Payment Information notes continued
NM108 Identification Code Qualifier: Value: MI
• Member Identification Number
NM109 Patient Identifier Value:
• 7-digit LNI Claim Number or UNKNOWN • 2010BA NM109 or 2000B SBR03
• If NM109 Patient Identifier equal “UNKNOWN” AND the 1st digit of the ICN begins with “7” (CLP07)
Then the LNI Claim ID received in the 837 2010BA-NM109 and/or 2000B-SBR03 is invalid. The MIPS bill is formatted and denied with EDI formatting error:
EOB H05 INVALID/MISSING WORKERS’ COMPENSATION CLAIM NUMBER OR
If NM109 Patient Identifier equal “UNKNOWN AND the 1st digit of the ICN begins with “0” (CLP07)
Then the LNI Claim ID provided in Box 11 Insured’s Policy Group or FECA Number of the CMS-1500 Health Insurance Claim Form is missing or invalid and no valid Claim ID was found in Box 1a. Insured’s ID Number. The MIPS bill is formatted and denied with:
EOB 989 DENIED. CLAIM NUMBER MISSING. RESUBMIT NEW BILL WITH CLAIM NUMBER.
12. NM1 Service Provider segment
This segment identifies the rendering provider of service.
NM101 Entity Identifier Code: Rendering Provider Value: 82
NM102 Entity Type Qualifier: Person or Non-Person Entity Value: 1 or 2 • 1 – Person
• 2 – Non-Person Entity
NM103 Rendering Provider Last Name Value:
NM104 Rendering Provider First Name Value:
NM108 Identification Code Qualifier: Value: PC
• PC – Provider Commercial Number • XX - National Provider Identifier (NPI)
NM109 Rendering Provider Identifier Value:
• 7-digit LNI provider account number or 10-digit National Provider Identifier (NPI)
o 7-digit LNI Provider Account Number when NM108 equal “PC”
2100 Claim Payment Information notes continued
13. MIA Inpatient Adjudication Information segment • Required for 837 Institutional Inpatient bills.
• Not applicable to the Pharmacy 835 Remittance Advice.
MIA01 Covered Days or Visits Count: Value: 0
• Always 0 (zero)
MIA02 PPS Operating Outlier Amount Value: 0
MIA04 Claim DRG Amount Value:
MIA05 Claim Payment Remark Code Value:
• Remittance Advice Remark Codes defined by the Washington Publishing Company (WPC). • Mapped and cross-referenced to LNI’s assigned EOB (Explanation of Benefits) codes. 14. MOA Outpatient Adjudication Information segment
• Required for 837 Institutional outpatient bills.
• Not applicable to the Pharmacy 835 Remittance Advice.
MOA01 Reimbursement Rate: percentage expressed as a decimal Value:
MOA02 Claim HCPCS Payable Amount Value:
MOA03 Claim Payment Remark Code Value:
• Remittance Advice Remark Codes defined by the Washington Publishing Company (WPC). • Mapped and cross-referenced to LNI’s assigned EOB (Explanation of Benefits) codes. 15. REF Other Claim Related Identification segment(s)
a. Medical Record Identification Number
• Returned if received in 837 bill transaction – CLM 2300 REF*EA*REF02
REF01 Reference Identification Qualifier: Medical Record Number Value: EA
REF02 Other Claim Related Identifier Value:
b. Original Reference Number
• Returned on finalized request for adjustment (Replacement and Void) bills. • Identifies the bill being adjusted.
• Value received in 837 2300 CLM REF*F8 REF02
REF01 Reference Identification Qualifier: Original Reference Number Value: F8
REF02 Other Claim Related Identifier Value:
2100 Claim Payment Information notes continued 17. DTM Statement From or To Date segment
DTM01 Date Time Qualifier: Statement Period Start date Value: 232
DTM02 Claim Date: formatted as CCYYMMDD Value:
• Beginning Date of Service
DTM01 Date Time Qualifier: Statement Period End date Value: 233
DTM02 Claim Date: formatted as CCYYMMDD Value:
• Ending Date of Service
18. AMT Claim Supplemental Information segment
• Note: Qualifier ZZ returned in 4010A1 format. ZZ is not available/valid for 5010 format. • Replace ZZ with ??
AMT01 Amount Qualifier Code: Mutually Defined (4010A1 format) Value: ZZ