Monday, August 1, 2016

EDI 837 File complete format - Ref 02


Loop ID Reference Name Codes Notes/Comments
 
1000A NM1 Submitter Name  

1000A NM109 Submitter Identification Code The existing trading partners will continue using the six-digit submitter code. Tufts Health Plan will work with new trading partners prior to implementation to determine the six-digit submitter code.  

2010AB Pay-To Address Name This loop has been changed to indicate a separate address for payments to the Billing Provider. Please note that Tufts Health Plan will continue making payments to the address in our backend system database instead of the address submitted in 2010AB.  

2000B SBR Subscriber Hierarchical Level  

2000B SBR01 Payer Responsibility Sequence Number Code This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment.  

2010BA NM1 Subscriber Name


2010BA NM109 Identification Code Each Tufts Health Plan member is uniquely identified by his or her member ID. Thus we require treating all members as subscribers, and submitting member ID in Element NM109 of Loop 2010BA.  

2010CA NM1 Patient Name Each Tufts Health Plan member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. Tufts Health Plan will not accept any data in the Patient Loop and will REJECT accordingly.  

2300 REF Payer Claim Control Number  

2300 REF02 Reference Identification For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. Tufts Health Plan also strongly recommends sending Original Reference Number with frequency types 2, 3, and 4.  

2300 HI01-2 Occurrence Code If a claim is accident or employment related, Tufts Health Plan requires the appropriate occurrence code. We will only process one iteration of HI01.  

2300 HI01-4 Date Time Period If a claim is accident or employment related, Tufts Health Plan requires the appropriate occurrence date. We will only process one iteration of HI01.


2310E NM1 Service Facility Location Name Tufts Health Plan REQUIRES that Service Facility Information always match Billing Provider Information given that the payee should always equal the provider on institutional claims.  

2320 Other Subscriber Information  

2320 SBR Other Subscriber Information Required by Tufts Health Plan to understand the payer responsibility sequence.  

2320 AMT COB Payer Paid Amount Tufts Health Plan requires the total amount paid at the claim level.  

2330A NM1 Other Subscriber Name Tufts Health Plan requires this segment for COB claims.  

2330B NM1 Other Payer Name Tufts Health Plan requires this segment for COB claims.  

2430 SVD Line Adjudication Information  

2430 SVD02 Monetary Amount Tufts Health Plan requires the amount paid by the payer in 2330B for this line.  

2430 CAS01 Claim Adjustment Group Code CO – Contractual Obligations Used to validate total amount billed in SV1 segment.  

2430 CAS01 Claim Adjustment Group Code PR – Patient Responsibility Also used to validate total amount billed in SV1 segment. (if applicable)



1000A NM1 Submitter Name  

1000A NM109 Submitter Identifier The existing trading partners will continue using the six-digit submitter code. Tufts Health Plan will work with new trading partners prior to implementation to determine the six-digit submitter code.  

2010AB Pay-To Address Name This loop has been changed to indicate a separate address for payment to the Billing Provider. Please note that Tufts Health Plan will continue making payments to the address in our backend system database instead of the address submitted in 2010AB.  

2000B SBR Subscriber Hierarchical Level  

2000B SBR01 Payer Responsibility Sequence Number Code This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment.  

2010BA NM1 Subscriber Name  

2010BA NM109 Identification Code Each Tufts Health Plan member is uniquely identified by his or her member ID. Thus we require treating all members as subscribers, and submitting member ID in NM109 of loop 2010BA.  

2010CA NM1 Patient Name Each Tufts Health Plan member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should be submitting member ID in Element NM109 of Loop 2010BA. Thus Tufts Health Plan will not accept any data in the Patient Loop and will REJECT accordingly.


2300 REF Payer Claim Control Number  

2300 REF02 Reference Identification For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. Tufts Health Plan also strongly recommends sending Original Reference Number with frequency types 2, 3, and 4.  

2320 Other Subscriber Information  

2320 SBR Other Subscriber Information Required by Tufts Health Plan to understand the Payer Responsibility sequence.  

2320 AMT COB Payor Paid Amount Tufts Health Plan requires the total amount paid at the claim level.  

2330A NM1 Other Subscriber Name Tufts Health Plan requires this segment for COB claims.  

2330B NM1 Other Payer Name Tufts Health Plan requires this segment for COB claims.  

2430 SVD Line Adjudication Information  

2430 SVD02 Monetary Amount Tufts Health Plan requires the amount paid by the payer in 2330B for this line.  

2430 CAS01 Claim Adjustment Group Code CO – Contractual Obligation Used to validate total amount billed in SV1 segment.  

2430 CAS01 Claim Adjustment Group Code PR – Patient Responsibility Also used to validate total amount billed in SV1 segment. (if applicable)

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