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) 

https://www.cms1500claimbilling.com/2016/08/edi-837-file-complete-format-ref-02.html

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