Collection of Encounter Data from Medicare Advantage Organizations

_________________________________________________________________

Encounter Data System
Standard Companion Guide Transaction Information

Instructions related to the 837 Health Care Claim: Professional
Transaction based on ASC X12 Technical Report Type 3 (TR3), Version
005010X222A1

Companion Guide Version Number: 4.0
Created: December 9, 2011

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837 Professional Companion Guide Version 4.0/December 9, 2011

Preface
The Encounter Data System (EDS) Companion Guide contains information to assist Medicare Advantage
Organizations (MAOs) and other entities in the submission of encounter data. The EDS Companion
Guide is under development and the information in this version reflects current decisions and will be
modified on a regular basis. All versions of the EDS Companion Guide are identified by a version number
which is located in the version control log on the last page of the document. Users should verify they
are using the most current. Questions regarding the contents of the EDS Companion Guide should be
directed to eds@ardx.net.

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Table of Contents
1.0

Introduction
1.1
Scope
1.2
Overview
1.3
Major Updates
1.3.1 CAS Segment
1.3.2 Atypical Provider Operational Guidance
1.4
References

2.0

Contact Information
2.1
CSSC
2.2
eds@ardx.net
2.3
Applicable websites/email

3.0

File Submission
3.1
File Size Limitations
3.2
File Structure

4.0

Control segments/envelopes
4.1
ISA-IEA
4.2
GS-GE
4.3
ST-SE

5.0

Transaction Specific Information
5.1
837-P Transaction Specific Table

6.0

Acknowledgements and/or Reports
6.1
TA1
6.2
999
6.3
277CA

7.0

Front-End Edits

8.0

Duplicate Logic
8.1
Header Level
8.2
Detail Level

9.0

Business Cases
9.1
Standard Professional Encounter
9.2
Capitated Professional Encounter
9.3
Chart Review Professional Encounter – No Linked ICN
9.4
Chart Review Professional Encounter – Linked ICN
9.5
Complete Replacement Professional Encounter
9.6
Complete Deletion Professional Encounter
9.7
Atypical Provider Professional Encounter
9.8
Paper Generated Professional Encounter – UNDER DEVELOPMENT
9.9
True Coordination of Benefits Professional Encounter
9.10 Bundled Professional Encounter
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1.0

Introduction

1.1

Scope

The CMS Encounter Data System (EDS) Companion Guide for the 837-P transactions addresses how
MAOs and other entities conduct Professional claim HIPAA standard electronic transactions with CMS.
CMS’ Encounter Data transaction system supports transactions adopted under HIPAA, as well as
additional supporting transactions described in this guide.
The CMS EDS Companion Guide must be used in conjunction with the associated 837-P Implementation
Guide (TR3). The instructions in the CMS EDS Companion Guide are not intended to be a stand-alone
requirements document.
1.2

Overview

The CMS EDS Companion Guide includes information needed to begin and maintain communication
exchange with CMS. The information is organized in the sections listed below:
Contact Information: This section includes telephone and fax numbers for EDS contacts.
Control Segments/Envelopes: This section contains information needed to create the ISA/IEA,
GS/GE, and ST/SE control segments for transactions to be supported by EDS.
Acknowledgements and Reports: This section contains information on all transaction
acknowledgements sent by EDS, including the TA1, 999, and 277CA.
Transaction Specific Information: This section describes how X12N Implementation Guides (IGs)
adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each
segment with CMS specific information in addition to the information in the IGs. That
information can contain:
o
o
o
o
o

Limits on the repeat of loops, or segments
Limits on the length of a simple data element
Specifics on a sub-set of the IG’s internal code listings
Clarifications of the use of loops, segments, composite and simple data elements
Any other information tied directly to a loop, segment, and composite or simple data
element pertinent to trading electronically with CMS.

In addition to the row for each segment, one (1) or more additional rows are used to describe EDS’
usage for composite or simple data elements and for any other information.

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1.3

Major Updates

1.3.1

CAS Segment

MAOs and other entities were previously instructed to populate the following values to indicate an
encounter is a correction/replacement or deletion of a previously submitted encounter in the Encounter
Operational Data Store:
Loop 2300, REF01=’F8’ and REF02=ICN
Loop 2300, CLM05-3=’7’ (Correct/Replacement) or CLM05-3=’8’ (Deletion)
Loop 2320, CAS01=’CR’ (Correct/Replace) or CAS01=’OA’ (Delete), CAS02=’223’, and CAS03= the
amount affected by the correction/replacement or deletion encounter.
Upon further review of technical specifications and testing, MAOs and other entities are now instructed
to populate the following values to indicate an encounter is a correction/replacement or deletion of a
previously submitted encounter in the Encounter Operational Data Store:
Loop 2300, REF01=’F8’ and REF02=ICN
Loop 2300, CLM05-3=’7’ (Correct/Replacement) or CLM05-3=’8’ (Deletion)
NOTE: MAOs and other entities are not required to populate the CAS segment to indicate a
correction/replacement or deletion of a previously submitted encounter.
1.3.2

Atypical Provider Operational Guidance

In order to submit atypical provider encounters, it may be necessary for MAOs and other entities to
submit default values in order for the encounter to process correctly through the Encounter Data FrontEnd System and the Encounter Data Processing and Pricing System. MAOs and other entities were
previously instructed to submit specific default NPIs; however, the default NPI provided in Table 4, Loop
2010AA, NM109 should be used.
Atypical provider encounters will not be used for risk adjustment, but will be stored and used for
analytic purposes.

CMS is advising MAOs and other entities that we are relaxing the requirements for the
collection of Encounter claims from atypical providers for a period of time.
Providers who are not considered health care providers and do not provide health care services
are referred to as “atypical service providers.” Examples of atypical service providers include,
but are not limited to, Non-Emergency Transportation Providers such as Taxis, Personal Care
Attendants, Building Contractors, and Language Interpreters.
If MAOs and other entities are able to submit atypical provider Encounter claims they may;
however, this notification is to advise that the requirement to submit such claims will be
delayed.
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1.4

References

MAOs and other entities must use the ASC X12N IG adopted under the HIPAA Administrative
Simplification Electronic Transaction rule along with CMS’ Encounter Data Participant Guides, and CMS’
EDS Companion Guidelines for development of EDS transactions. These documents are accessible at the
following location: www.csscoperations.com
Additionally, the EDS submitter guidelines and application, testing documents, 5010 companion guides,
and Encounter Data Participant Guides can be found at that location.

MAOs and other entities must use the most current national standard code lists applicable to the 5010
transaction. The code lists may be accessed at the Washington Publishing Company (WPC) website:
http://www.wpc-edi.com
The applicable code lists are as follows:
Claim Adjustment Reason Code
Claim Status Category Codes
Claim Status Codes
CMS provides X12 5010 file format technical edit spreadsheets for the 837-I and 837-P. The edits
included in the spreadsheet are intended to clarify the WPC instructions or add Medicare specific
requirements. In order to determine the implementation date of the edits contained in the
spreadsheet, MAOs and other entities will first need to refer to the spreadsheet version. The version is
a 10 character identifier as follows:
Positions 1-2 indicate the line of business:
o EA – Part A (837-I)
o EB – Part B (837-P)
Positions 3-6 indicate the year (e.g. 2011)
Position 7 indicates the release quarter month
o 1 – January release
o 2 – April release
o 3 – July release
o 4 – October release
Positions 8-10 indicate the spreadsheet version iteration number (e.g. V01-first iteration, V02second iteration)
The effective date of the spreadsheet is the first calendar day of the release quarter month. The
implementation date is the first business Monday of the release quarter month. Federal holidays which
could potentially fall on the first business Monday must be accounted for when determining the
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implementation date. For example, the edits contained in a spreadsheet version of EB20113V01 are
effective July 1, 2011 and will be implemented on July 5, 2011.
2.0

Contact Information

2.1

The Customer Service and Support Center (CSSC)

The Customer Service and Support Center (CSSC) personnel are available for questions from 8:00A.M. –
7:00P.M. EST, Monday-Friday, with the exception of federal holidays and can be contacted at 1-877-534CSSC (2772).
2.2

Applicable websites/email

The following websites provide information to assist in EDS submission:
Resource
Encounter Data Participant
Guides
EDS Email
ANSI ASC X12 TR3
Implementation Guides
Washington Publishing Company
Health Care Code Sets
CMS Edits Spreadsheet
3.0

File Submission

3.1

File Size Limitations

Web Address
www.csscoperations.com
eds@ardx.net
www.wpc-edi.com
www.wpc-edi.com
http://www.cms.gov/MFFS5010D0/20_TechnicalDocumentation.asp

Due to system limitations, the combination of all ST-SE transaction sets per file cannot exceed certain
thresholds depending upon the connectivity method of the submitter. FTP and NDM users cannot
exceed 85,000 encounters per file. Gentran users cannot exceed 5,000 encounters per file. For all
connectivity methods, the TR3 allows no more than5000 CLMS per ST-SE. The following demonstrates
the limits due to connectivity methods:
Connectivity
FTP/NDM
Gentran

Maximum Number of
Encounters
85,000
5,000

Maximum Number of ST-SE
5,000
5,000

Note: Due to system processing overhead associated with smaller numbers of encounters within the
ST-SE, it is highly recommended that larger numbers of encounters within the ST-SE be used.

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In an effort to support and provide the most efficient processing system, it is recommended that FTP
submitters’ scripts should not upload more than one (1) file per five (5) minute interval to allow
maximum performance. Files that are zipped should contain one (1) file per transmission. MAOs and
other entities should refrain from submitting multiple files within the same transmission. NDM and
Gentran users may submit a maximum of 255 files per day.
3.2

File Structure – NDM/Connect Direct and Gentran Users Only

80 byte fixed block is a common mainframe term. This means every line (record) in a file must be
uploaded as 80 bytes/characters long. NDM/Connect Direct and Gentran submitters must use this
approach.
Files should be created in a manner where the segments are one continuous stream of information that
continues to the next line every 80 characters.
Segments should be stacked in the file, using only 80 characters per line. Using the Enter key or Carriage
Return in position 81 will ensure no more than 80 bytes/characters are contained in each record. If the
last line in the file does not fill to 80 bytes/characters, it should be spaced out to position 80 and then
save the file. Do not use the Enter key or Carriage Return at the end of the last record because this will
create an additional blank record at the end of the file.
For example the ISA record is 106 characters long:
ISA*00*
*00*
*ZZ*ENH9999
4*^*00501*000000031*1*P*:~

*ZZ*80882

*120430*114

The first line of the file will contain the first 80 characters of the ISA segment, the last 26 characters of
the ISA segment will be continued on the second line. The next segment will start in the 27th position
and continue until column 80.
4.0

Control Segments/Envelopes

4.1

ISA-IEA

The term interchange denotes the ISA-IEA envelope that is transmitted. Interchange control is achieved
through several “control” components, as defined in Table 2. The interchange control number is
contained in data element ISA13 of the ISA segment. The identical control number must also occur in
data element IEA02 of the IEA segment. All elements in the ISA-IEA interchange must be populated.
There are several elements within the ISA-IEA interchange that must be populated specifically for
encounter data purposes. Table 2 below provides EDS Interchange Control (ISA-IEA) specific elements.
Note: Only those elements that provide specific details relevant to encounter data are presented in the
table. When developing the encounter data system, users should base their logic on the highest level of
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specificity. First, consult the WPC/TR3. Second, consult the CMS edits spreadsheets. Third, consult the
Encounter Data Companion Guide. If there are options expressed in the WPC/TR3 or the CEM edits
spreadsheet that are broader then the options identified in the Encounter Data Companion Guide, the
rules identified in the Encounter Data Companion Guide must be used.
Legend
SHADED rows represent segments in the X12N Implementation Guide
NON-SHADED rows represent data elements in the X12N Implementation Guide
TABLE 1 – ISA-IEA INTERCHANGE ELEMENTS
Loop ID

Reference

ISA
ISA01

ISA02
ISA03

ISA04
ISA05

Name
Interchange
Control Header
Authorization
Information
Qualifier
Authorization
Information
Security
Information
Qualifier
Security
Information
Interchange ID
Qualifier

Codes

00

00

ZZ

ISA06

Interchange
Sender ID

ISA07

Interchange ID
Qualifier

ZZ

ISA08

Interchange
Receiver ID
Repetition
Separator

80882

ISA11

Notes/Comments

No authorization
information
present
Use 10 blank
spaces
No security
information
present
Use 10 blank
spaces
CMS expects to
see a value of “ZZ”
to designate that
the code is
mutually defined
EN followed by
Contract ID
Number
CMS expects to
see a value of “ZZ”
to designate that
the code is
mutually defined

^

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TABLE 1 – ISA-IEA INTERCHANGE ELEMENTS (CONTINUED)
Loop ID

Reference
ISA13

Name
Interchange Control Number

Codes

ISA14

Acknowledgement
Requested

1

ISA15

Usage Indicator

IEA02

Interchange Control Trailer
Interchange Control Number

IEA

4.2

Notes/Comments
Must be a fixed length with
nine (9) characters and
match IEA02
Interchange
Acknowledgement
Requested (TA1)
A TA1 will be sent if the file is
syntactically incorrect,
otherwise only a ‘999’ will be
sent.
Test
Production

T
P

Must match the value in
ISA13

GS-GE

The functional group is outlined by the functional group header (GS segment) and the functional group
trailer (GE segment). The functional group header starts and identifies one or more related transaction
sets and provides a control number and application identification information. The functional group
trailer defines the end of the functional group of related transaction sets and provides a count of
contained transaction sets.
All elements in the GS-GE functional group must be populated. There are several elements within the
GS-GE that must be populated specifically for encounter data collection. Table 3 provides EDS functional
group (GS-GE) specific elements.
Note: Only those elements that require explanation are presented in the table.
TABLE 2 - GS-GE FUNCTIONAL GROUP ELEMENTS
Loop ID
GS

Reference
GS02
GS03

Name
Functional Group Header
Application Sender’s
Code
Application Receiver’s
Code

Codes

Notes/Comments

80882

EN followed by
Contract Number
This value must
match the value
in ISA08
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TABLE 2 - GS-GE FUNCTIONAL GROUP ELEMENTS (CONTINUED)
Loop ID

Reference
GS06

Name
Group Control Number

GS08

Version/Release/Industry 005010X222A1
Identifier Code
Functional Group Trailer
Group Control Number

GE
GE02

4.3

Codes

Notes/Comments
This value must
match the value
in GE02

This value must
match the value
in GS06

ST-SE

The transaction set (ST-SE) contains required, situational, and unused loops, segments, and data
elements. The transaction set is outlined by the transaction set header (ST segment) and the
transaction set trailer (SE segment). The transaction set header identifies the start and identifies the
transaction set. The transaction set trailer identifies the end of the transaction set and provides a count
of the data segments, which includes the ST and SE segments. There are several elements that must be
populated specifically for encounter data purposes. Table 5 provides EDS transaction set (ST-SE) specific
elements.
Note: Only those elements that require explanation are presented in the table.
TABLE 3 - ST-SE TRANSACTION SET HEADER AND TRAILER ELEMENTS
Loop ID

Reference

ST
ST01
ST02

ST03

Name
Transaction Set
Header
Transaction Set
Identifier Code
Transaction Set
Control Number
Implementation
Convention
Reference

Codes

Notes/Comments

837
This value must
match the value in
SE02
005010X222A1

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TABLE 3 - ST-SE TRANSACTION SET HEADER AND TRAILER ELEMENTS (CONTINUED)
Loop ID

Reference

SE
SE01

SE02

5.0

Name
Transaction Set
Trailer
Number of
Included
Segments

Codes

Notes/Comments

Must contain the
actual number of
segments within
the ST-SE
This value must be
match the value in
ST02

Transaction Set
Control Number

837 Professional: Data Element Table

Within the ST-SE transaction set, there are multiple loops, segments, and data elements that provide
billing provider, subscriber, and patient level information. MAOs and other entities should reference
www.wpc-edi.com to obtain the most current Implementation Guide. EDS transactions must be
submitted using the most current transaction version.
The 837 Professional Data Element table identifies only those elements within the X12N Implementation
Guide that require comment within the context of EDS submission. Table 6 identifies the 837
Professional Implementation Guide by loop name, segment name and identifier, and data element
name and identifier for cross reference. Not all data elements listed in the table below are required, but
if they are used, the table reflects the values CMS expects to see.
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM
Loop ID

Reference
BHT
BHT03

1000A

BHT06
NM1
NM102
NM109

Name
Beginning of Hierarchical
Transaction
Originator Application
Transaction Identifier
Claim Identifier
Submitter Name
Entity Type Qualifier
Submitter Identifier

Codes

CH
2

Notes/Comments

Must be a unique identifier
across all files
Chargeable
Non-Person Entity
EN followed by Contract
Number

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TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
Loop ID
1000A

Reference
PER
PER03

1000A

PER05

Communication Number
Qualifier

PER

Submitter EDI Contact
Information
Communication Number
Qualifier

PER07

1000B

2010AA

Name
Submitter EDI Contact
Information
Communication Number
Qualifier

NM1
NM102
NM103
NM109

Receiver Name
Entity Type Qualifier
Receiver Name
Receiver ID

NM1
NM108

Billing Provider Name
Billing Provider ID
Qualifier
Billing Provider Identifier

NM109

Codes

TE

EM

N4
N403

It is recommended that MAOs
and other entities populate
the submitter’s telephone
number
It is recommended that MAOs
and other entities populate
the submitter’s email address

FX

It is recommended that MAOs
and other entities populate
the submitter’s fax number

2

Non-Person Entity
EDSCMS
Identifies CMS as the receiver
of the transaction and
corresponds to the value in
ISA08 Interchange Receiver ID

80882

XX

NPI Identifier
Must be populated with a ten
digit number, must begin with
the number 1.

1999999984
2010AA

Notes/Comments

Billing Provider City,
State, Zip Code
Zip Code

Atypical professional provider
default NPI

The full nine (9) digits of the
ZIP Code are required. If the
last four (4) digits of the ZIP
code are not available,
populate a default value of
“9999”.

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TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
Loop ID
2010AA

Reference
REF
REF01
REF02

2000B

SBR
SBR01
SBR09

2010BA

2010BB

2010BB
2010BB

Name
Billing Provider Tax
Identification
Reference Identification
Qualifier
Reference Identification

Subscriber Information
Payer Responsibility
Number Code
Claim Filing Indicator
Code

NM1
NM108

Subscriber Name
Subscriber Id Qualifier

NM109

Subscriber Primary
Identifier

NM1
NM103
NM108

Payer Name
Payer Name
Payer ID Qualifier

NM109
N3
N301
N4

Payer Identification
Payer Address
Payer Address Line
Payer City, State, ZIP
Code
Payer City Name
Payer State
Payer ZIP Code

N401
N402
N403

Codes

Notes/Comments

EI

Employer’s Identification
Number
199999998 - Atypical
professional provider default
EIN

S

EDSCMS is considered the
destination (secondary) payer
Must be populated with a
value of MB – Medicare Part
B.

MB

MI

PI

Must be populated with a
value of MI – Member
Identification Number
This is the subscriber’s Health
Insurance Claim (HIC) number.
Must match the value in Loop
2330A, NM109.
EDSCMS
Must be populated with the
value of PI – Payer
Identification

80882
7500 Security Blvd

Baltimore
MD
212441850

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TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
Loop ID
2010BB

Reference
REF
REF01
REF02

2300

CLM
CLM02
CLM05-3

2300

PWK
PWK01

2300

2300

Claim Information
Total Claim Charge
Amount
Claim Frequency Type
Code
Claim Supplemental
Information
Report Type Code

PWK02

Attachment
Transmission Code

CN1
CN101

Contract Information
Contract Type Code

REF

Payer Claim Control
Number
Original Reference
Number
Payer Claim Control
Number

REF01
REF02

2320

Name
Other Payer Secondary
Identifier
Contract ID Identifier
Contract ID Number

SBR
SBR01

Other Subscriber
Information
Payer Responsibility
Sequence Number Code

Codes

Notes/Comments

2U
MAO or other entity’s
Contract ID number

1
7
8

09
AA

05

Must balance to the sum SV2
service lines in Loop 2400.
1=Original claim submission
7=Replacement
8=Deletion

Populated for chart review
submissions only
Populated for chart review
submissions only. Available
upon request at provider site
Populated for capitated
arrangements

F8
Identifies ICN from original
claim when submitting
adjustment or chart review
data.

P
T

P=Primary (when MAOs or
other entities populate the
payer paid amount)
T=Tertiary (when MAOs or
other entities populate a true
COB

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TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
Loop ID

2320

2320

2320

2330A

Reference
SBR09

Name
Claim Filing Indicator
Code

CAS
CAS02

Claim Adjustment
Adjustment Reason Code

AMT
AMT02

COB Payer Paid Amount
Payer Paid Amount

OI
OI03

Coverage Information
Benefits Assignment
Certification Indicator
Other Subscriber Name
Identification Code
Qualifier
Subscriber Primary
Identifier
Other Payer Name
Identification Code
Qualifier
Other Payer Primary
Identifier

NM1
NM108
NM109

2330B

NM1
NM108
NM109

Codes
16

If a claim is denied in the MAO
or other entities’ adjudication
system, the denial reason
should be populated.
MAO and other entity’s paid
amount
Must match the value in Loop
2300, CLM08
MI
Must match the value in Loop
2010BA, NM109
XV
MAO or other entity’s
Contract ID.

Payer01
2330B

N3
N301

Notes/Comments
Health Maintenance
Organization (HMO) Medicare
Risk

Other Payer Address
Other Payer Address
Line

Only populated if there is no
Contract ID available for a
true other payer
MAO or other entity’s address

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TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
Loop ID
2330B

2400

2430

Reference
N4
N401

Name
Other Payer City, State,
ZIP Code
Other Payer City Name

N402
N403

Other Payer State
Other Payer ZIP Code

CN1
CN101

Contract Information
Contract Type Code

SVD

Line Adjudication
Information
Other Payer Primary
Identifier
Line Adjustments
Adjustment Reason Code

SVD01
2430

CAS
CAS02

6.0

Acknowledgements and Reports

6.1

TA1 – Interchange Acknowledgement

Codes

Notes/Comments

MAO or other entity’s City
Name
MAO or other entity’s State
MAO or other entity’s ZIP
Code. The full nine (9) digits
of the ZIP Code are required.
If the last four (4) digits of the
ZIP code are not available,
populate a default value of
“9999”.
05

Populated for each capitated/
staff service line.

Must match the value in Loop
2330B, NM109
If a service line is denied in
the MAO or other entities’
adjudication system, the
denial reason should be
populated.

The TA1 report enables the receiver to notify the sender that problems were encountered with the
interchange control structure. As the interchange envelope enters the EDFES, the EDI translator
performs TA1 validation of the control segments/envelope. You will only receive a TA1 if you have
syntax errors in your file. Errors found in this stage will cause the entire X12 interchange to be rejected
with no further processing.
MAOs and other entities will receive a TA1 interchange report acknowledging the syntactical
incorrectness of an X12 interchange header ISA and trailer IEA, and the envelope’s structure.
Encompassed in the TA1 is the interchange control number, interchange date and time, interchange
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acknowledgement code, and interchange note code. The interchange control number, date, and time
are identical to those that were populated on the original 837-I or 837-P ISA line, which allows for MAOs
and other entities to associate the TA1 with a specific file previously submitted.
Within the TA1 segment, MAOs and other entities will be able to determine if the interchange was
rejected by examining the interchange acknowledgement code (TA104) and the interchange note code
(TA105). The interchange acknowledgement code stipulates whether the interchange (ISA/IEA) rejected
due to syntactical errors. An “R” will be the value in the TA104 data element if the interchange was
rejected due to errors. The interchange note code is a numeric code that notifies MAOs and other
entities of the specific error. The TA1 interchange acknowledgment report is generated and returned
within 24 hours after submitting the interchange if a fatal error occurs. If a TA1 interchange control
structure error is identified, MAOs and other entities must correct the error and resubmit the
interchange file.
6.2

999 – Functional Group Acknowledgement

After the interchange passes the TA1 edits, the next stage of editing is to apply Implementation Guide
(IG) edits and verify the syntactical correctness of the functional group(s) (GS/GE). Functional groups
allow for like data to be organized within an interchange; therefore, more than one (1) functional group
with multiple claims within the functional group can be populated in a file. The 999 acknowledgement
report provides information on the validation of the GS/GE functional group(s) and their consistency
with the data contained. The 999 report provides MAOs and other entities information on whether the
functional group(s) were accepted or rejected.
If a file has multiple GS/GE segments and errors occurred at any point within one of the syntactical and
IG level edit validations, the GS/GE segment will be rejected, and processing will continue to the next
GS/GE segment. For instance, if a file is submitted with three (3) functional groups and the second
functional group encounters errors, the first functional group will be accepted the second functional
group will be rejected and processing will continue to the third functional group.
The 999 transaction set is designed to report on adherence to IG level edits and CMS standard syntax
errors as depicted in the CMS edit spreadsheet. Three (3) possible acknowledgement values are:
“A” – Accepted
“R” – Rejected
“E” – Accepted with non-syntactical errors
When viewing the 999 report, MAOs and other entities should navigate to the IK5 and AK9 segments. If
an “A” is displayed in the IK5 and AK9 segments, the claim file is accepted and will continue processing.
If an “R” is displayed in the IK5 and AK9 segments, an IK3 and an IK4 segments will be displayed. These
segments indicate what loops and segments contain the error that needs correcting so the interchange
can be resubmitted. The third element in the IK3 segment tells the loop that contains the error. The
first element in the IK3 and IK4 indicate the segment and element that contain the error. The third
element in the IK4 segment indicates the reason code for the error.
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6.3

277CA – Claim Acknowledgement

After the file is accepted at the interchange and functional group levels, the third level of editing occurs
at the transaction set level within the CEM in order to create the Claim Acknowledgement Transaction
(277CA) report. The CEM checks the validity of the values within the data elements. For instance, data
element N403 must be a valid nine (9) digit zip code. If a non-existent zip code is populated, the CEM
will reject the encounter. The 277CA is an unsolicited acknowledgement report from CMS to MAOs and
other entities.
The 277CA is used to acknowledge the acceptance or rejection of encounters submitted using a
hierarchical level (HL) structure. The first level of hierarchical editing is at the Information Source level.
This entity is the decision maker in the business transaction receiving the X12 837 transactions
(EDSCMS).The next level is at the Information Receiver level. This is the entity that expects the response
from the Information Source. The third hierarchal level is at the Billing Provider of Service level and the
fourth and final level is done at the Patient level. Acceptance or rejection at this level is based on the
WPC and the CMS edits spreadsheet. Edits received at any hierarchical level will stop and no further
editing will take place. For example, if there is a problem with the Billing Provider of Service submitted
on the 837, individual patient edits will not be performed. For those encounters not accepted, the
277CA will detail additional actions required of MAOs and other entities in order to correct and resubmit
those encounters.
If an MAO or other entity receives a 277CA indicating an encounter was rejected, the MAO or other
entity must resubmit the encounter until the 277CA indicates no errors were found.
If an encounter is accepted, the 277CA will provide the ICN assigned to that encounter. The ICN
segment for the accepted encounter will be located in 2200D REF segment, REF01=IK and REF02=ICN.
The ICN is a unique 13-digit number.
If an encounter is rejected, the 277CA will provide edit information in the STC segment. The STC03 data
element will convey whether the HL structures accepted or rejected. The STC03 is populated with a
value of “WQ”, if the HL was accepted. If the STC03 data element is populated with a value of “U”, the
HL is rejected and the STC01 data element will list the acknowledgement code.
7.0

Permanently Deactivated Front-End Edits

Several CEM edits currently active in the Fee-For-Service CEM edits spreadsheet will be permanently
deactivated in order to ensure syntactically correct encounters pass front-edit editing. Table 5 provides
the current EDS front-end edits that will be deactivated. The edit reference column provides the exact
edit reference that will be deactivated. The edit description column provides the Claim Status Category
Code (CSCC), the Claim Status Code (CSC), and the Entity Identifier Code (EIC), when applicable. The
notes column provides a description of the edit reason. MAOs and other entities should reference the
WPC website at www.wpc-edi.com for a complete listing of all CSCC, CSC, and EICs.

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TABLE 5 - 837 PROFESSIONAL PERMANENTLY DEACTIVATED CEM EDITS
Edit Reference
Edit Description
X222.087.2010AA.NM109.050 CSCC A8: “Acknowledgement/Rejected
for relational field in error”
CSC 496: “Submitter not approved for
electronic claim submission on behalf
of this entity”
EIC 85: “Billing Provider”
X222.091.2010AA.N301.070
CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 503: "Entity's Street Address"
EIC: 85 Billing Provider
X222.091.2010AA.N302.060

CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 503: "Entity's Street Address"
EIC: 85 Billing Provider

X222.138.2010BB.REF.010

CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 732: "Information submitted
inconsistent with billing guidelines."
CSC 560: "Entity's
Additional/Secondary Identifier."
EIC: PR "Payer"
CSCC A8: "Acknowledgement /
Rejected for relational field in error"
CSC 496 "Submitter not approved for
electronic claim submissions on behalf
of this entity."
EIC: 85 Billing Provider
CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 535: "Claim Frequency Code"
CSCC A8: "Acknowledgement /
Rejected for relational field in error"
CSC 306: “Detailed description of
service”

X222.140.2010BB.REF02.075

X222.157.2300.CLM05-3.020

X222.351.2400.SV101-7.020

Edit Notes
2010AA.NM109 billing provider
must be "associated" to the
submitter (from a trading partner
management perspective) in
1000A.NM109.
2010AA.N301 must not contain the
following exact phrases (not case
sensitive): "Post Office Box", "P.O.
Box", "PO Box", "P O Box", "Lock
Box", "Lock Bin".
2010AA.N302 must not contain the
following exact phrases (not case
sensitive): "Post Office Box", "P.O.
Box", "PO Box", "P O Box", "Lock
Box", "Lock Bin".
Non-VA claims: 2010BB.REF with
REF01 = "2U", "EI", "FY" or "NF"
must not be present.
VA claims: 2010BB.REF with REF01
= "EI", "FY" or "NF" must not be
present.
2010BB.REF02 billing provider must
be "associated" to the submitter
(from a trading partner
management perspective) in
1000A.NM109.
2300.CLM05-3 must be "1".

2400.SV101-7 must be present
when 2400.SV101-2 is present on
the table of procedure codes that
require a description.

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8.0

Duplicate Logic

In order to ensure encounters submitted are not duplicates of encounters previously submitted, header
and detail level duplicate checking will be performed. If the header and/or detail level duplicate
checking determines the file is a duplicate, the file will be rejected as a duplicate, and an error report
will be returned to the submitter.
8.1

Header Level

When a file (ISA – IEA) is received, the system assigns a hash total to the file based on the entire ISA-IEA
interchange. Hash totals are a method for ensuring the accuracy of processed data. The hash total is a
total of several fields or data in a file, including fields not normally used in calculations, such as account
number. At various stages in the processing, the hash total is recalculated and compared with the
original. If a file comes in later in a different submission or a different submission of the same file, and
gets the same hash total, it will be rejected as a duplicate. There will be other duplicate edits in the
processing system.
8.2

Detail Level

Once an encounter passes through the institutional or professional processing and pricing system, it is
stored in an internal repository, the Encounter Operational Data Store (EODS). If a new encounter is
submitted that matches specific values to another stored encounter, the encounter will be rejected and
will be considered a duplicate encounter. The encounter will be returned to the submitter with an error
message identifying it as a duplicate encounter. Currently the following values are the minimum set of
items being used for matching an encounter in the EODS:
Beneficiary Demographic
o Health Insurance Claim Number (HICN)
o Name
Date of Service
Place of Service (2 digits)
Type of Service
Procedure Code(s) and 4 modifiers
Rendering Provider NPI
Paid Amount*
* The Paid Amount is the amount paid by the MAO or other entity and should be populated in Loop ID2320, AMT02.

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9.0

837 Professional Business Cases

In accordance with 45 CFR 160.103 of the Health Insurance Portability and Accountability Act (HIPAA),
Protected Health Information has been removed from all business cases. As a result, the business cases
have been populated with fictitious information about the Subscriber, Medicare Advantage Organization
(MAO), and provider(s). The business cases reflect 2012 dates of service; however, when submitting
encounter data files, MAOs and other entities must use the date(s) of service provided on the claim
received from the provider.
Although the business cases are provided as examples of possible encounter submissions, MAOs and
other entities must populate valid data in order to successfully pass translator and CEM level editing.”
Questions regarding the contents of the EDS Test Case Specifications should be directed to
eds@ardx.net.

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9.1

Business Case 1: Standard Professional Encounter

Business Scenario 1: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smith
because she was experiencing abdominal pain. Happy Health Plan is the Medicare Advantage
Organization (MAO). Dr. Smith diagnosed Mary with abdominal pain in her right upper quadrant
(78901).

File String 1:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*200000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*69*X*005010X222A1~
ST*837*0534*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*12999999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:1*Y*A*Y*Y~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
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LX*1~
SV1*HC:99212*100.50*UN*1***1~
DTP*472*D8*20120401~

SVD*H9999*100.50*HC:99212**1~
DTP*573*D8*20120403~
SE*38*0534~
GE*1*69~
IEA*1*200000031~

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9.2

Capitated Professional Encounter

Business Scenario 2: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smart
because she was experiencing abdominal pain. Happy Health Plan is the Medicare Advantage
Organization (MAO) and has a capitated arrangement with Mercy Hospital. Dr. Smart diagnosed Mary
with abdominal pain in the upper quadrant.

File String 2:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000032*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*82*X*005010X222A1~
ST*837*0037*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344345879~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*0.00***11:B:1*Y*A*Y*Y~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
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LX*1~
SV1*HC:99212*0.00*UN*1***1~

DTP*472*D8*20120401~
CN1*05~
SVD*H9999*100.50*HC:99212**1~
DTP*573*D8*20120403~
SE*40*0037~
GE*1*82~
IEA*1*000000032~

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9.3

Chart Review Professional Encounter – No Linked ICN

Business Scenario 3: Mary Dough is the patient and the subscriber. Happy Health Plan is the
Medicare Advantage Organization (MAO) and Dr. Elizabeth A. Smart is the professional service
provider. Happy Health Plan performs a chart review at Dr. Smith’s office and determines that
Mary Dough was diagnosed with necrosis of artery. Dr. Smith never submitted a claim to
Happy Health Plan. The medical record does not contain enough information to submit a full
claim, yet there is enough information to support the diagnosis and link the chart review
encounter back to the medical record. Happy Health Plan submits a chart review encounter
with no linked ICN to add necrosis of artery diagnosis.
File String 3:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120530*114
7*^*00501*000000056*1*P*:~
GS*HC*ENH9999*80882*20120530*1147*89*X*005010X222A1~
ST*837*0043*005010X222A1~
BHT*0019*00*3920394930206*20120530*1147*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*456789032~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*0.00***11:B:1*Y*A*Y*Y~
PWK*09*AA~
HI*BK:4475~
SBR*P*18*XYZ1234567******16~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
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N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
NM1*82*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
REF*T4*Y~
LX*1~
SV1*HC:99212*0.00*UN*1***1~
DTP*472*D8*20120401~

SVD*H9999*100.50*HC:99212**1~
DTP*573*D8*20120403~

SE*41*0043~
GE*1*89~
IEA*1*000000056~

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9.4

Chart Review Professional Encounter – Linked ICN

Business Scenario 4: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth
A. Smart because she was experiencing abdominal pain. Happy Health Plan is the Medicare
Advantage Organization (MAO). Dr. Smart diagnosed Mary with abdominal pain. Happy Health
Plan submits the encounter to CMS and receives an ICN 1298768987657. Happy Health Plan
performs a chart review related to ICN 1298768987657 and determines that the incorrect NPI
was populated for the Billing Provider.
File String 4:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120530*114
7*^*00501*000000056*1*P*:~
GS*HC*ENH9999*80882*20120530*1147*89*X*005010X222A1~
ST*837*0043*005010X222A1~
BHT*0019*00*3920394930206*20120530*1147*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999899~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*456789032~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*0.00***11:B:1*Y*A*Y*Y~
PWK*09*AA~
REF*F8*1298768987657~
HI*BK:4475~
SBR*P*18*XYZ1234567******16~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
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NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
NM1*82*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
REF*T4*Y~
LX*1~
SV1*HC:99212*0.00*UN*1***1~
DTP*472*D8*20120401~

SVD*H9999*100.50*HC:99212**1~
DTP*573*D8*20120403~

SE*43*0043~
GE*1*89~
IEA*1*000000056~

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9.5

Complete Replacement Professional Encounter

Business Scenario 5: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth
A. Smart because she was experiencing abdominal pain. Happy Health Plan is the Medicare
Advantage Organization (MAO). Dr. Smart diagnosed Mary with abdominal pain in the lower
right quadrant (78903). Happy Health Plan submits the encounter to CMS and receives an ICN
1212278567098. Happy Health Plan determines that the diagnosis submitted was incorrect and
was actually for the upper right quadrant (78901). Happy Health Plan submits a correct and
replace adjustment encounter to replace encounter 1212278567098 with the newly submitted
encounter.
File String 5:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120530*114
2*^*00501*000000045*1*P*:~
GS*HC*ENH9999*80882*20120530*1142*299*X*005010X222A1~
ST*837*0421*005010X222A1~
BHT*0019*00*3920394930206*20120430*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*765876890~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:7*Y*A*Y*Y~
REF*F8*1212278567098~
HI*BK:78903~
SBR*P*18*XYZ1234567******16~
CAS*CO*39*50.00~
AMT*D*50.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
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N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV1*HC:99212*100.50*UN*1***1~

DTP*472*D8*20120401~
SVD*H9999*50.50*HC:99212**1~
DTP*573*D8*20120403~
SE*41*0421~
GE*1*299~
IEA*1*000000045~

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9. 6

Deletion Professional Encounter

Business Scenario 6: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth
A. Smart because she was experiencing abdominal pain. Happy Health Plan is the Medicare
Advantage Organization (MAO). Dr. Smart diagnosed Mary with abdominal pain. Happy Health
Plan submits the encounter to CMS and receives ICN 1212487000032. Happy Health Plan then
determines that they mistakenly sent the encounter without it being adjudicated in their
internal system, so they want to delete the encounter. Happy Health Plan submits an
adjustment encounter to delete the previously submitted encounter 1212487000032.
File String 6:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000298*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*82*X*005010X222A1~
ST*837*0290*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*765879876~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:8*Y*A*Y*Y~
REF*F8*1212487000032~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
CAS*CO*223*100.50~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
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NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV1*HC:99212*100.50*UN*1***1~

DTP*472*D8*20120401~
SVD*H9999*0.00*HC:99212**1~
DTP*573*D8*20120403~
SE*41*0290~
GE*1*82~
IEA*1*000000298~

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9. 7

Atypical Provider Professional Encounter

Business Scenario 7: Mary Dough is the patient and the subscriber, and receives services from an
atypical provider. Happy Health Plan was the Medicare Advantage Organization (MAO).

File String 7:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*79*X*005010X222A1~
ST*837*0034*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*2*MERCY SERVICES*XX*1999999984~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*199999998~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*PAYER01~
CLM*2997677856479709654A*100.50***11:B:1*Y*A*Y*Y~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV1*HC:99212*150.00*UN*1*1***1~
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DTP*472*D8*20120401~
SVD*H9999*150.00*HC:99212**1~
DTP*573*D8*20120403~
SE*39*0034~
GE*1*79~
IEA*1*000000031~

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837 Professional Companion Guide Version 4.0/December 9, 2011

9.8

Paper Generated Professional Encounter – Under Development

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837 Professional Companion Guide Version 4.0/December 9, 2011

9.9

True Coordination of Benefits Professional Encounter

Business Scenario 9: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smith
because she was experiencing abdominal pain. Happy Health Plan is the Medicare Advantage
Organization (MAO). Other Health Plan also provided payment for Mary Dough. Dr. Smith diagnosed
Mary with abdominal pain in her right upper quadrant (78901).

File String 9:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*79*X*005010X222A1~
ST*837*0034*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*12999999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*712.00***11:B:1*Y*A*Y*Y~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
CAS*CO*A2*12.00~
AMT*D*700.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
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SBR*T*18*XYZ1234388******16~
CAS*CO*A2*0.00~
AMT*D*12.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*OTHER HEALTH PLAN*****XV*PAYER01~
N3*400 W 21 ST~
N4*NORFOLK*VA*235059999~
REF*T4*Y~
LX*1~
SV1*HC:99212*712.00*UN*1***1~

DTP*472*D8*20120401~
SVD*H9999*712.00*HC:99212**1~
DTP*573*D8*20120403~
SE*50*0034~
GE*1*79~
IEA*1*000000031~

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9.10

Bundled Professional Encounter

Business Scenario 10: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A.
Smith because she was experiencing abdominal pain. Happy Health Plan is the Medicare Advantage
Organization (MAO). Dr. Smith diagnosed Mary with abdominal pain in her right upper quadrant
(78901).

File String 10:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*79*X*005010X222A1~
ST*837*0034*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*PE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*12999999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 SPAPE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:1*Y*A*Y*N~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH SP~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
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837 Professional Companion Guide Version 4.0/December 9, 2011

LX*1~
SV1*HC:80051*100.50*UN*1*12**1~

DTP*472*D8*20120401~
SVD*H9999*100.50*HC:80051**1~
DTP*573*D8*20120403~
SE*39*0034~
GE*1*79~
IEA*1*000000031~

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837 Professional Companion Guide Version 4.0/December 9, 2011

REVISION HISTORY
Version

Date

2.1

9/9/2011

Description of Revision
Baseline Version

3.0

11/16/2011 Release 1

4.0

12/2/2011

4.0

12/2/2011

4.0

12/2/2011

4.0

12/2/2011

Section 3.0 – Added the maximum number of files
Gentran and NDM users may submit in per day
Section 7.0 – Added “Front-End Edits” section

4.0

12/2/2011

Section 8.0 – Changed to “Duplicate Logic”

4.0

12/2/2011

Section 9.0 – Added Business Cases

Section 1.3.2 – Added atypical provider operational
guidance
Section 1.4 – Corrected www.wpc-edi.com reference

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837 Professional Companion Guide Version 4.0/December 9, 2011