1. HL03 Hierarchical Level Code: Information Source Value: 20
2. HL04 Hierarchical Child Code Value: 1
3. PRV01 Provider Code: Billing Value: BI
4. PRV02 Reference Identification Qualifier: Health Care Provider Taxonomy Code Value: PXC
5. PRV03 Provider Taxonomy Code Value:
• 10-digit Provider Taxonomy code.
• If submitted, the provider’s taxonomy code may be used when processing the provider’s National Provider Identifier (NPI) to assist the department in appropriately cross-referencing the NPI to the provider’s LNI provider account number.
LOOP ID - 2010AA BILLING PROVIDER NAME
2010AA BILLING PROVIDER NAME – NM1*85
TR3 PAGE #
Segment/Field
ID FIELD NAME
Sample Data, TR3 Required Value [R] and Department Required Value [DRV]
Seg/Field USAGE
84 NM1 Billing Provider Name Required
85 NM101 Entity Code Identifier 85[R] R
85 NM102 Entity Type Qualifier 1 or 2 [R] R
85 NM103 Billing Provider Last or Organizational Name COMMUNITY HOSPITAL R 86 NM108 Identification Code Qualifier XX [R] S 86 NM109 Billing Provider Identifier 1234567890 S
87 N3 Billing Provider Address Required
87 N301 Billing Provider Address 123 MAIN ST R
88 N4 Billing Provider City/State/Zip Code Required
88 N401 Billing Provider City OLYMPIA R
89 N402 Billing Provider State WA S
89 N403 Billing Provider Zip 98555 S
90 REF Billing Provider Tax Identification Required
90 REF01 Reference Identification Qualifier EI or SY [R] R 90 REF02 Billing Provider Tax Identification Number 910000000 R
91 PER Billing Provider Contact Information Situational
92 PER01 Contact Function Code IC [R] R
92 PER02 Billing Provider Contact Name DOLLY MADISON S 92 PER03 Communication Number Qualifier TE R 92 PER04 Billing Provider Contact Phone 3607041776 R 92 PER05 Communication Number Qualifier EM S 93 PER06 Billing Provider Contact E-mail [email protected] S
Segment
Count Example EDI Data – Institutional 837
8 NM1*85*2*COMMUNITY HOSPITAL*****XX*1234567890~ 9 N3*123 MAIN ST~ 10 N4*OLYMPIA*WA*98555~ 11 REF*EI*910000000~ 12 PER*IC*DOLLY MADISON*TE*3607041776*EM*[email protected] NM1*85*2*COMMUNITY HOSPITAL~ N3*123 MAIN ST~ N4*OLYMPIA*WA*98555~ REF*EI*910000000~ PER*IC*DOLLY MADISON*TE*3607041776*EM*[email protected]
2010AA – Billing Provider notes
1. NM101 Entity Identifier Code: Billing Provider Value: 85
2. NM102 Entity Type Qualifier Value: 1 or 2
• Person (individual) “1”.
• Non-Person Entity (organization) “2”.
3. NM108 Identification Code Qualifier: CMS National Provider Identifier Value: XX • Required when the Billing Provider’s NPI is submitted in NM109.
2010AA – Billing Provider notes continued
4. NM109 Billing Provider Identifier Value:
• 10-digit National Provider Identifier (NPI).
• Individual provider types use your Individual NPI registered with LNI. • Clinic/Group Provider types use your Organizational NPI registered with LNI.
• Non NPI provider’s use 2010BB Payer Name Billing Provider Secondary Identification reference REF*G2. • Optional – Provider’s submitting their NPI may also include the Billing Provider Secondary Identification
reference in the 2010BB Payer Name loop using REF*G2.
• The submitted NPI is used as the provider’s primary identifier when the 2010BB Payer Name loop does not include the Billing Provider Secondary Identification segment REF*G2.
• If the submitted NPI (NM109) is not on file
Or is on file but not cross-referenced to an LNI provider account number
And 2010BB Payer Name loop does not include the Billing Provider Secondary Identification segment REF *G2
o Then bill formats with EDI formatting error H22
See EDI Formatting Errors - page 157-164
5. REF Billing Provider Tax Identification segment
REF01 Reference Identification qualifier: EIN or SSN Value: EI or SY
• Employer Identification Number (EIN) “EI”. • Social Security Number (SSN) “SY”.
REF02 Billing Provider Tax Identification Number Value:
• Use the Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes. • The provider’s EIN or SSN is a string of exactly nine (9) numbers with no separators.
6. PER Billing Provider Contact Information
• Use this segment to communicate the Billing Provider’s telephone and e-mail contact information.
• This segment is required when the contact information is different than that in the 1000A Submitter Name loop.
PER01 Contact Information Code: Information Contact Value: IC
PER02 Billing Provider Contact Name Value:
• Contact name of the person billing worker’s compensation with LNI.
PER03 Communication Number Qualifier: Telephone Number Value: TE
PER04 Billing Provider Phone Number Value:
• Contact phone number of the person billing workers’ compensation with LNI.
LOOP ID - 2010AB PAY-TO ADDRESS NAME
2010AB PAY-TO ADDRESS NAME – NM1*87
TR3 PAGE #
Segment/Field
ID FIELD NAME
Sample Data, TR3 Required Value [R] and Department Required Value [DRV]
Seg/Field USAGE
Pay-To Address Name Loop
This loop is only used when the address for payment is different than that of the Billing Provider.
Situational
94 NM1 Pay-to Address Name Required
94 NM101 Entity Code Identifier 87 [R] R
95 NM102 Entity Type Qualifier 1 or 2 [R] R
96 N3 Pay-to Provider Address Required
96 N301 Pay-to Provider Address R
97 N4 Pay-to Provider City/State/Zip code Required
97 N401 Pay-to Provider City R
98 N402 Pay-to Provider State S
98 N403 Pay-to Provider Zip code S
2010AB – Pay-To Address Name notes
• The department does not utilize this information in MIPS bill payment processing.
1. NM101 Entity Identifier Code: Pay-to Provider Value: 87
2. NM102 Entity Type Qualifier Value: 1 or 2
• Person (individual) “1”
Detail, Subscriber Hierarchical Level
LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL
2000B SUBSCRIBER HIERARCHICAL - HL
TR3 PAGE #
Segment/Field
ID FIELD NAME
Sample Data, TR3 Required Value [R] and Department Required Value [DRV]
Seg/Field USAGE
107 HL Hierarchical Level - Subscriber Required
107 HL01 Hierarchical ID Number 2 R
108 HL02 Hierarchical Parent ID Number 1 R
108 HL03 Hierarchical Level Code 22 [R] R
108 HL04 Hierarchical Child Code 0 [DRV] R
109
SBR
Subscriber Information
Insured/Patient information Required
109 SBR01 Payer Responsibility Sequence Number Code P[DRV] R 110 SBR02 Patient Relationship to Insured 18 [DRV] S 110 SBR03
Insured Group or Policy Number:
Washington State Department of Labor and Industries 7-character assigned Claim Number.
A123456 or AB12345 [Alpha+6Numeric] or [2Alpha+5Numeric]
S
110 SBR09 Claim Filing Indicator WC[DRV] S
Segment
Count Example EDI Data – Institutional 837
13 HL*2*1*22*0~
14 SBR*P*18*A123456******WC~ 2000B – Subscriber notes
1. HL03 Hierarchical Level Code: Subscriber Value: 22
2. HL04 Hierarchical Child Code: No subordinate HL segment in this structure Value: 0 • The Subscriber is the patient and there are no dependent claims.
3. SBR01 Payer Responsibility Sequence Number Code: Primary Value: P
4. SBR02 Patient Relationship to Insured: Self Value: 18
• If SBR02 is absent (not sent) and loop 2000C is absent (not sent) The transaction will fail EDI validation and be rejected.
Rejection reported in 999/997 Acknowledgment and 824 application advice.
5. SBR03 Insured Group or Policy Number Value:
• 7-character LNI Claim Number/Claim ID
• Begin with single alpha-character + 6 numbers or double alpha-characters + 5 numbers.
• LNI Claim Numbers are derived from the Report of Accident (ROA) completed by the injured worker or by the provider on behalf of the injured worker.
• A valid LNI claim number MUST be present in 2000B-SBR03 or/and 2010BA-NM109. If SBR03 is absent (not sent) and 2010BA NM109 is Invalid the bill formats with a blank Claim ID
• And with EDI formatting error H05
LOOP ID - 2010BA SUBSCRIBER NAME
2010BA SUBSCRIBER NAME – NM1*IL
TR3 PAGE #
Segment/Field
ID FIELD NAME
Sample Data, TR3 Required Value [R] and Department Required Value [DRV]
Seg/Field USAGE 112
NM1
Subscriber Name:
The subscriber will be the same person as the patient for Washington State Department of Labor and Industries Workers’ Compensation.
Required
112 NM101 Entity Identifier Code IL [R] R
113 NM102 Entity Type Qualifier 1 [DRV] R
113 NM103 Subscriber Last Name PUBLIC R
113 NM104 Subscriber First Name JOHN S
113 NM105 Subscriber Middle Name Q S
113 NM108 Identification Code Qualifier MI [DRV] R 114 NM109
Subscriber Primary Identifier: Washington State Department of Labor and Industries 7-character assigned Claim Number.
A123456 or AB12345 [Alpha+6Numeric] or [2Alpha+5Numeric]
R
115 N3 Subscriber Address Situational
115 N301 Subscriber Address PO BOX 123 R
116 N4 Subscriber City/State/ZIP Code Required
116 N401 Subscriber City OLYMPIA R
116 N402 Subscriber State WA S
117 N403 Subscriber Zip 98555 S
118 DMG Subscriber Demographic Information Situational
118 DMG01 Date Qualifier D8 [R] R
118 DMG02 Subscriber Birth Date: (CCYYMMDD) 19500101 R
119 DMG03 Subscriber Gender Code M or F or U R
120 REF Subscriber Secondary Identification Situational
120 REF01 Reference ID Qualifier SY [R] R
120 REF02 Subscriber Supplemental Identifier 444118888 R
Segment
Count Example EDI Data – Institutional 837
15 NM1*IL*1*PUBLIC*JOHN*Q***MI*A123456~ 16 N3*PO BOX 123~
17 N4*OLYMPIA*WA*98555~ 18 DMG*D8*19500101*M~ 19 REF*SY*444118888~ 2010BA – Subscriber Name notes
1. NM101 Entity Identifier Code: Insured or Subscriber Value: IL
2. NM102 Entity Type Qualifier: Person Value: 1
3. NM108 Identification Code Qualifier: Member Identification Number Value: MI
4. NM109 Subscriber Primary Identifier Value:
• 7-character LNI Claim Number/Claim ID.
• Begin with single alpha-character + 6 numbers or double alpha-characters + 5 numbers.
• LNI Claim Numbers are derived from the Report of Accident (ROA) completed by the injured worker or by the provider on behalf of the injured worker.
• A valid LNI claim number MUST be present in 2010BA-NM109 or/and 2000B-SBR03. If the LNI claim number is invalid (see 2000B-SBR03 notes)
Or is valid and NM108 is not equal to “MI”
Then bill formats with EDI formatting error H05
2010BA – Subscriber Name notes continued
5. NM103 Subscriber Last Name and NM109 Subscriber Primary Identifier
• LNI’s processing compares the first two characters of the last name and claim ID submitted and formatted on the MIPS bill to the Claim Id and first two characters of the claimant’s last name in the department’s Claim Master file.
• If the comparison does not match,
the bill may deny and returned on the provider’s remittance advice with:
EOB 259 DENIED. CLAIM ID/CLAIMANT NAME MISMATCH. CALL 1-800-831-5227 TO CONFIRM CLAIM ID BEFORE REBILLING.
6. REF Subscriber Secondary Identification
• Use this segment to send the injured worker’s Social Security Number (SSN) if known or available.
• The SSN is not required for bill adjudication but may be used by the department as a secondary Id source for bill processing if needed.
REF01 Reference Identification Qualifier: Social Security Number Value: SY
REF02 Subscriber Supplemental Identifier Value:
• 9-digit Social Security Number (SSN).
• The Social Security Number is a string of exactly nine numbers with no separators. 7. REF Property and Casualty Claim Number
• Recommendation – Do not use for WA State workers’ compensation billing
• LNI does not expect to receive this segment for identification of the worker’s Claim ID
• If sent, the value in REF02 must be the same LNI 7-digit Claim ID sent in 2010BA NM109 or 2000B SBR03. • If not a valid claim ID, the bill will format with an invalid Claim ID
REF01 Reference Identification Qualifier: Agency Claim Number Value: Y4
REF02 Property Casualty Claim Number Value:
LOOP ID - 2010BB PAYER NAME
2010BB PAYER NAME – NM1*PR TR3 PAGE # Segment/Field ID FIELD NAMESample Data, TR3 Required Value [R] and Department Required Value [DRV]
Seg/Field USAGE
122 NM1 Payer Name Required
122 NM101 Entity Identifier Code PR [R] R
123 NM102 Entity Type Qualifier 2 [R] R
123 NM103 Payer Name WASHINGTON STATE DEPT OF LABOR & INDUSTRIES R 123 NM108 Identification Code Qualifier PI [R] R 123 NM109
Payer Identifier (ETIN):
Washington State Department of Labor and
Industries Federal Tax Identification Number. 916001069 [DRV]
R
125 N4 Payer City, State, Zip Code Required
125 N401 Payer City Name OLYMPIA R
125 N402 Payer State Code WA S
126 N403 Payer Zip Code 98504 S
129 REF Billing Provider Secondary Identification Situational
129 REF01 Reference ID Qualifier: Provider Commercial
Number G2 [DRV] R
130 REF02
Billing Provider Secondary ID:
The provider’s Washington State Department of Labor and Industries assigned 7-digit provider account number (if available. Leading
zeros are not required). 0012345
R
Segment
Count Example EDI Data – Institutional 837
20 NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI*916001069~ 21 N4*OLYMPIA*WA*98504~
NM1*PR*2*WASHINGTON STATE DEPT OF LABOR & INDUSTRIES*****PI*916001069~ N4*OLYMPIA*WA*98504~
REF*G2*12345~ 2010BB – Payer Name notes
• The Billing Provider Secondary ID segment is moved from the 2010AA Billing Provider loop in 4010A1 to the 2010BB Payer Name loop in the 5010 format.
• REF01 qualifier “G2” Provider Commercial Number replaces qualifier “X5” State Industrial Accident Provider Number.
• When the Billing Provider Secondary ID REF*G2 is present, it will be used as the provider’s primary Billing Provider identifier.
1. NM101 Entity Identifier Code: Payer Value: PR
2. NM102 Entity Type Qualifier: Non-person Entity Value: 2
3. NM108 Identification Code Qualifier: Payer Identification Value: PI
4. NM109 Payer Identifier Value: 916001069
2010BB – Payer Name notes continued
5. REF Billing Provider Secondary Identification
• Use this segment to report the Billing Provider’s LNI Provider Account Number as the Billing Provider’s Secondary Identification in addition to the provider’s NPI submitted in 2010AA NM109.
• Use this segment to report the Billing Provider’s LNI Provider Account Number as the Billing Provider’s Primary Identification when the provider is not NPI enumerated or the Provider’s NPI is unknown.
• When Segment/Qualifier REF*G2 is present, REF02 will be used as the provider’s identifier for bill formatting and adjudication processing.
REF01 Reference ID Qualifier: Provider Commercial Number Value: G2
If 2010AA-NM109 is not submitted (NPI) And REF01 not equal “G2”
Then bill formats with EDI formatting error H02
See EDI Formatting Errors - page 157-164
REF02 Billing Provider Secondary Identifier Value:
• 7-digit LNI provider account number.
• Leading zeros may be included but are not required. If REF02 is not a valid LNI provider account number
Then bill formats with EDI formatting error H03
Detail, Patient Hierarchical Level
LOOP ID - 2300 CLAIM INFORMATION
2300 CLAIM INFORMATION - CLM
TR3 PAGE #
Segment/Field
ID FIELD NAME
Sample Data, TR3 Required Value [R] and Department Required Value [DRV]
Seg/Field USAGE
143 CLM Claim Information Required
144 CLM01 Patient Account Number PUBLICJQ-00100 R
145 CLM02 Total Claim Charge Amount 468.00 R
145 CLM05-1 Facility Type Code 11 R
145 CLM05-2 Facility Code Qualifier A [R] R
145 CLM05-3 Claim Frequency Code 1 or 7 or 8 [DRV] R 146 CLM07 Assignment or Plan Participation Code A [DRV] R 146 CLM08 Assignment of Benefits Indicator Y [R] R
147 CLM09 Release of Information Code Y [R] R
150 DTP Statement Dates Required
150 DTP01 Date Time Qualifier 434 [R] R
150 DTP02 Date Time Period Format Qualifier RD8 R 150 DTP03 Statement From and To Date 20110815-20110815 R
151 DTP Admission Date/Hour (Required on inpatient bills) Situational
151 DTP01 Date/Time Qualifier 435 [R] R
151 DTP02 Date/Time Format Qualifier DT [R] R
151 DTP03 Admission Date and Hour 201108151800 R
153 CL1 Institutional Claim Code (Inpatient only) Required
153 CL101 Admission Type Code 3 S
153 CL102 Admission Source Code 1 S
153 CL103 Patient Status Code 30 R
164 REF Prior Authorization Number Situational
164 REF01 Reference Identification Qualifier G1 [R] R 165 REF02 Prior Authorization Number 2501234567 R
166 REF Payer Claim Control Number Situational
166 REF01 Reference ID Qualifier F8 [R] R
166 REF02 Payer Claim Control Number (ICN) R
170 REF Claim Identifier for Transmission Intermediaries Situational
170 REF01 Reference Identification Qualifier D9 [R] R
171 REF02 Value Added Network Trace Number R
173 REF Medical Record Number Situational
173 REF01 Reference Identification Qualifier EA [R] R
173 REF02 Reference Identification: 10315-1 R
178 NTE Claim Note Situational
178 NTE01 Note Reference Code: (DME, MED, UPI, etc.) R
179 NTE02 Description: (bill level remarks) R
180 NTE Billing Note Situational
180 NTE01 Note Reference Code: Additional Information ADD [R] R
180 NTE02 Description: Additional remarks R
184 HI Principal Diagnosis Required
184 HI01 Health Care Code Information R
184 HI01-1 Code List Qualifier: Principal BK [R] ICD-9 orABK [R] ICD-10 R
185 HI01-2 Principal Diagnosis Code 7241 R
187 HI Admitting Diagnosis (Required for Inpatient) Situational
187 HI01 Health Care Code Information R
187 HI01-1 Code List Qualifier: Admitting Diagnosis BJ [R] ICD-9 orABJ [R] ICD-10 R
188 HI01-2 Admitting Diagnosis Code 7241 R
193 HI External Cause of Injury (E-Code) Situational
193 HI01 Health Care Code Information R
193 HI01-1 Code List Qualifier BN [R] ICD-9 orABN [R] ICD-10 R 193 HI01-2 External Cause of Injury Code (E-Code) E8210 R
220 HI Other Diagnosis Information Situational
220 HI01 Health Care Code Information R
221 HI01-1 Code List Qualifier: Other Diagnosis BF [R] ICD-9 orABF [R] ICD-10-CM R 221 HI01-2 Other Diagnosis 821 or 8210 or 82101 R
239 HI Principal Procedure Information Situational
240 HI01-1 Code List Qualifier: Principal Procedure Codes BR [R] ICD-9 orBBR [R] ICD-10-PCS R
240 HI01-2 Principal Procedure Code R
240 HI01-3 Date Format Qualifier D8 [R] R
240 HI01-4 Principal Procedure Date R
242 HI01 Health Care Code Information R 243 HI01-1 Code List Qualifier: Procedure Code BQ [R] ICD-9 orBBQ [R] ICD-10-PCS R
243 HI01-2 Procedure Code R
243 HI01-3 Date Format Qualifier D8 [R] R
243 HI01-4 Procedure Date R
258 HI Occurrence Span Information Situational
258 HI01 Health Care Code Information R
258 HI01-1 Code List Qualifier : Occurrence Span BI [R] R
258 HI01-2 Occurrence Span Code R
259 HI01-3 Date Format Qualifier RD8 [R] R
259 HI01-4 Occurrence Span Date R
271 HI Occurrence Information Situational
271 HI01 Health Care Code Information R
271 HI01-1 Code List Qualifier: Occurrence BH [R] R 271 HI01-2 Occurrence Code: Accident/Employment Related 04 [R] R 272 HI01-3 Date Qualifier: (CCYYMMDD) D8 [R] R 272 HI01-4 Occurrence Date: Injury Date 20110315 R
294 HI Condition Information Situational
294 HI01 Health Care Code Information R
294 HI01-1 Code List Qualifier: Condition BG [R] R
294 HI01-2 Condition Code 17 R
Segment
Count Example EDI Data – Institutional 837
22 CLM* PUBLICJQ-00100*468*13:A:1*Y**Y*********Y~ 23 DTP*434*RD8*20110815-20110815~ 24 DTP*435*DT*201108151800~ 25 CL1*3*1*30~ 26 REF*G1*2501234567~ 27 REF*D9*VANTN012345~ 28 REF*EA*MEDRECNUM001~ 29 NTE*ADD*ADDITIONAL REMARKS~ 30 HI*BK:724.1*BJ:724.1*BN:E821.0~ 31 HI*BH:04:D8: 20110315~
Electronic Adjustment - Replacement
CLM* PUBLICJQ-00100*468*13:A:7*Y**Y*********Y~ REF*F8*71125008000000300
NTE*ADD*CORRECTED PROC/REV CODE SVC LINE 2
Electronic Adjustment - Void
CLM* PUBLICJQ-00100*468*13:A:8*Y**Y*********Y~ REF*F8*71125008000000300
NTE*ADD*BILLED INCORRECT CLAIMID FOR DOS 2300 – Claim Information notes
1. CLM01 Patient Account Number Value:
• This number identifies the patient’s account number in the provider’s medical billing system. • MIPS processing supports up to 20 characters for the patient account number.
• The patient account number is returned in following outbound transactions:
o 835 Payment Advice (5010/4010) – 2100-CLP01 Patient Control Number.
o 277 Notification (5010) – 2200D-TRN02 Patient Control Number.
2300 – Claim Information notes continued
3. CLM05-1 Facility Type Code Values: 11, 13 or 18
Code identifying where services were, or may be, performed;
The first and second positions of the Uniform Bill Type Code for Institutional services: • Code 11 used for Inpatient services.
• Code 13 used for Outpatient services.
• Code 18 used for Critical Access Hospitals, Swing Beds for Sub-Acute care.
4. CLM05-2 Facility Code Qualifier: Uniform Billing Claim Form Bill Type Value: A
5. CLM05-3 Claim Frequency Code: Original, Replacement, Void Value: 1, 7, or 8 • This field will be used to determine if the submitted bill is one of the following:
o Original “1” - Original bill submission or resubmission of a previously denied bill.
o Replacement “7” - Request for Adjustment to a previously paid bill that is fully or partially paid.
o Void “8” - Request for Void to a previously paid bill or a bill still in process. • If CLM05-3 equals 7 (Replacement) or 8 (Void)
Then Payer Claim Control Number REF*F8 segment is required • If CLM05-3 not equal 1 (Original) or 7 (Replacement) or 8 (Void)
Then bill formats with EDI formatting error H08
See EDI Formatting Errors - page 157-164
6. CLM07 Assignment or Plan Participation Code: Assigned Value: A
7. CLM08 Assignment of Benefits Indicator: Yes Value: Y
• “Y” – Insured or authorized person authorizes benefits to be assigned to the provider.
8. CLM09 Release of Information Code: Yes Value: Y
• “Y” – Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim 9. DTP Statement Dates
DTP01 Date Time Qualifier: Statement Value: 434
DTP02 Date Time Period Format Qualifier Value: RD8
• Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD.