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
157 CLM Claim Information Required
158 CLM01 Patient Control Number: PUBLICJQ-00100 R
159 CLM02 Total Claim Charge Amount 175.50 R
159 CLM05-1 Place of Service 11 R
159 CLM05-2 Facility Code Qualifier B [R] R
159 CLM05-3 Claim Frequency Code: Original 1 or 7 or 8 [DRV] R 159 CLM06 Provider or Supplier Signature Indicator Y R
160 CLM07 Provider Accept Assignment Code A R
160 CLM08 Assignment of Benefits Indicator Y R
161 CLM09 Release of Information Code Y R
161 CLM10 Patient Signature Source Code P S
161 CLM11-1 Related Causes Code EM [DRV] R
168 DTP Date – Accident: Injury Date Situational
168 DTP01 Date Time Qualifier 439 [R] R
168 DTP02 Date Time Format Qualifier: CCYYMMDD D8 [R] R
168 DTP03 Accident Date 20110305 R
193 REF Referral Number Situational
193 REF01 Reference ID Qualifier 9F [R] [DRV] R
193 REF02 Referral Number R
194 REF Prior Authorization Situational
194 REF01 Reference ID Qualifier G1 [R] [DRV] R 195 REF02 Prior Authorization Number 2501234567 R
196 REF Payer Claim Control Number Situational
196 REF01 Reference ID Qualifier F8 [R] R
196 REF02 Payer Claim Control Number (ICN) R
202 REF Claim Identifier for Transmission Intermediaries Situational
202 REF01 Reference ID Qualifier D9 [R] R
203 REF02 Value Added Network Trace Number VANTN012345 R
204 REF Medical Record Number (optional) Situational
204 REF01 Reference ID Qualifier EA [R] R
204 REF02 Medical Record Number R
209 NTE Claim Note Situational
209 NTE01 Note Reference Code ADD [R] [DRV] R
210 NTE02 Claim Note Text (bill level remarks) R
226 HI Health Care Diagnosis Code (Principal) Required
226 HI01-1 Diagnosis Type Code BK [R] ICD-9 orABK [R] ICD-10 R 227 HI01-2 Diagnosis Code: Principal Diagnosis 724 or 7240 or 72401 [ICD-9-CM] R
HI Health Care Diagnosis Code (Other) Situational
228-238 HI02-1/HI12-1 Diagnosis Type Code BF [R] ICD-9 orABF [R] ICD-10 S 228-238 HI02-2/HI12-2 Diagnosis Code : Other Diagnosis 821 or 8210 or 82101 [ICD-9-CM] S
Segment
Count Example EDI Data – Professional 837
22 CLM*98765432101234567890*175.50***11:B:1*Y*A*Y*Y**EM ~ 23 DTP*439*D8*20110305~
24 REF*G1*2501234567 25 REF*D9*VANTN012345 26 HI*BK:7241*BF:8210~
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.
o 277 Unsolicited Notification (3070) - 2200D-TRN02 Patient Control Number.
o 277 Pended Notification (3070) – 2200D-TRN02 Patient Control Number.
2. CLM02 Total Claim Charge Amount Value:
• Must balance to the sum of all service line charge amounts reported in SV1-SV102 Line Item Charge Amount. • The Total Claim Charge amount is returned in the following outbound transactions:
o 835 Payment Advice (5010/4010) – 2100-CLP03 Total Claim Charge Amount.
o 277 Notification (5010) – 2200D-STC04 Total Claim Charge Amount.
o 277 Unsolicited Notification (3070) - 2200D-STC04 Total Claim Charge Amount.
o 277 Pended Notification (3070) – 2200D-STC04 Total Claim Charge Amount.
3. CLM05-1 Place of Service Code Value:
• Place of Service codes are two-digit codes used to indicate the setting in which the health care service(s) is provided.
• See Appendix for Place of Service codes and descriptions.
4. CLM05-2 Facility Code Qualifier: Place of Service for Professional/Dental services Value: B
5. CLM05-3 Claim Frequency Code: Original, Replacement, Void Value: 1 or 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 2300 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. CLM06 Provider or Supplier Signature Indicator: Provider signature is on file Value: Y
7. CLM07 Provider Accept Assignment Code: Assigned Value: A
8. CLM08 Assignment of Benefits Indicator: Yes Value: Y
• Insured or authorized person authorizes benefits to be assigned to the provider
9. CLM09 Release of Information Code: Yes Value: Y
• Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim.
10. CML10 Patient Signature Source Code Value: P
• Patient signature generated by provider because the patient was not physically present for services. • Patient signature generated by an entity other than the patient according to State or Federal law.
11. CLM11-1 Related Causes code: Employment Value: EM
• Must equal “EM” for Washington State Workers’ Compensation billing for work related injuries and occupational disease.
2300 – Claim Information notes continued 12. Date of Accident
• The Date of Accident (Injury Date) is required for Washington State Workers’ Compensation billing for work related injuries and/or occupational disease.
• Date of Accident is required when CLM11-1 Related Causes Code equal “EM”.
DTP01 Date Time Qualifier: Accident Value: 439
DTP02 Date Time Period Format Qualifier: CCYYMMDD Value: D8
DTP03 Accident Date – Date of Accident or Industrial Illness or injury Value: 13. REF Referral Number
REF01 Reference Identification Qualifier: Referral Number Value: 9F
REF02 Referral Number Value:
• For Vocational Rehabilitation bills, this number represents the Voc Referral ID number 14. REF Prior Authorization
REF01 Reference Identification Qualifier: Prior Authorization Number Value: G1
REF02 Prior Authorization Number Value:
• 10 digit Prior Authorization number assigned by Claim Manager/Qualis for procedure/service 5010 note – If Referral Number REF*F8 and Prior Authorization REF*G1 each are submitted in 2300 CLM. MIPS processing will use Prior Authorization REF*G1 for bill formatting and processing.
4010 note – If Referral Number REF*F8 and Prior Authorization REF*G1 each are submitted in 2300 CLM, MIPS processing will use the REF 9F/G1 segment occurring first in sequence for bill formatting and processing. 15. Payer Claim Control Number
• Required for electronic adjustment request
• CLM05-3 Claim Frequency Code equals 7 (Replacement) or 8 (Void)
REF01 Reference Identification Qualifier: Original Reference Number Value: F8 REF02 Payer Claim Control Number (LNI Internal Control Number) Value:
• 17-digit LNI Internal Control Number (ICN) assigned to the Original bill
• There exists a series of possible EDI formatting errors associated to electronic adjustments H31 – H39
See EDI Formatting Errors - page 157-164
16. REF Claim Identifier for Transmission Intermediaries
REF01 Reference Identification Qualifier: Claim Number Value: D9
REF02 Value Added Network Trace Number/Clearinghouse Trace Number Value: • Clearinghouses may assign and submit this number for their tracing purposes.
• If submitted, LNI will support up to 20 characters of the Clearinghouse assigned trace number. • The clearinghouse trace number will be returned in the following outbound transactions:
2300 – Claim Information notes continued 17. REF Medical Record Number
REF01 Reference Identification Qualifier: Medical Record Identification Number Value: EA
REF02 Medical Record Number Value:
• The provider may submit this number at their discretion.
• If submitted, the Medical Record Number will be returned in the following outbound transactions:
o 835 (5010/4010) – 2100 REF*EA REF02
Returned when received in the 837 transaction AND the bill contains an invalid Claim ID (i.e. EDI formatting error H05)
o 277 Notification (5010) – Not supported.
o 277 Unsolicited Notification (3070) – 2200E REF*EA REF02
o 277 Pended Notification (3070) – 2200E REF*EA REF02 18. NTE Bill Level Claim Note
NTE01 Note Reference Code: Additional Information Value: ADD
NTE02 Claim Note Text: free-form description for Bill Level Remarks Value: • This segment applies to the entire bill
• If submitted, will cause the bill to suspend during MIPS processing requiring manual adjudication of the bill to a finalized (paid/denied) status,
• Caution - improper use of billing remarks may cause delay in the processing and payment of the bill. Remarks such as routine descriptions of procedures or diagnosis codes or the results of diagnostic studies or requests for authorization of services should be avoided and not entered. In some cases, further explanation of services rendered is required when the procedure code references an unlisted service or contains a modifier(s). In these cases, you may provide the nature of the unlisted service or explain the nature for additional charges (modifier - 22) where applicable.
• If submitted on electronic adjustment Replacement, will cause the replacement bill to suspend and require manual adjudication to a finalized status.
• If submitted on electronic adjustment Void, will not cause the void bill to suspend. Bill remarks retained for reference purposes.
19. HI Health Care Diagnosis Code (Required) • HI01 Health Care Code Information.
• The diagnosis listed in this field is assumed to be the principal diagnosis. • Do Not transmit the decimal point for ICD codes. The decimal point is implied.
HI01-1 Diagnosis Type Code Value: BK or ABK
• ICD-9-CM Principal Diagnosis is reported using code BK
• ICD-10-CM Principal Diagnosis is reported using code ABK (effective October 1, 2013)
HI01-2 Diagnosis Code Value:
• Principal Diagnosis of injury or illness
HI02 through HI12 Health Care Code Information (Situational)
• Use HI02 through HI12 to report additional diagnosis as applicable.
HI02-1 through HI12-1 Diagnosis Type Code Value: BF or ABF
• ICD-9-CM additional/other diagnosis is reported using code BF
• ICD-10-CM additional/other diagnosis is reported using code ABF (effective October 1, 2013)
HI02-2 through HI12-02 Diagnosis Code Value: