|
Page # |
Loop ID |
Reference |
Name |
Codes |
Notes/Comments |
|
|
|
ISA |
Interchange Control Header |
|
|
|
|
|
ISA04 |
|
|
SENTARAADS |
|
198 (B.4) |
|
ISA07 |
Interchange ID Qualifier |
ZZ |
|
|
199 |
|
ISA08 |
Interchange Receiver ID |
SUNTRUST |
|
|
199 |
|
ISA16 |
Component Element Separator |
> |
|
|
202 |
|
GS |
Functional Group Header |
|
|
|
|
|
GS03 |
Application Receiver Code |
SUNTRUST |
|
|
44 |
|
BPR |
Financial Information |
|
|
|
45 |
|
BPR01 |
Transaction Handling Code |
D |
D = Make Payment Only |
|
46 |
|
BPR02 |
Monetary Amount |
|
Check amount |
|
46 |
|
BPR03 |
Credit/Debit Flag Code |
C |
Credit |
|
46 |
|
BPR04 |
Payment Method Code |
ACH |
Automated Clearing House |
|
47 |
|
BPR05 |
Payment Format Code |
CTX |
Corporate Trade Exchange |
|
48 |
|
BPR06 |
(DFI) ID Number Qualifier |
01 |
ABA Transit Routing Number including Check digits (9 digits) |
|
48 |
|
BPR07 |
(DFI) ID Number |
|
SUNTRUST Routing Number |
|
49 |
|
BPR09 |
Account Number |
|
Sender Bank Acct Number |
|
49 |
|
BPR10 |
Originating Company Identifier |
|
1+Tax ID number - must be identical to TRN03 |
|
49 |
|
BPR11 |
Originating Company Supplemental Code |
|
|
|
49 |
|
BPR12 |
DFI ID No Qualifier |
01 |
ABA Transit Routing Number Including Check Digits (9 digits) |
|
50 |
|
BPR13 |
DFI ID Number |
|
Provider Bank Routing # |
|
50 |
|
BPR14 |
Account Number Qualifier |
SG or DA |
Provider Bank Account Type DA = Demand Deposit; SG = Savings |
|
50 |
|
BPR15 |
Account Number |
|
Provider Bank Account Number |
|
50 |
|
BPR16 |
Date |
|
Current Date (CCYYMMDD) |
|
52 |
|
TRN |
Reassociation Trace Number |
|
|
|
|
|
TRN01 |
Trace Type Code |
1 |
Current Transaction Trace Numbers |
|
53 |
|
TRN02 |
Reference Ident |
|
Optima Check Number |
|
53 |
|
TRN03 |
Originating Company ID |
|
1+Tax ID Number Originating Co Tax ID Number preceded by 1 |
|
57 |
|
REF |
Receiver Identification |
|
|
|
57 |
|
REF01 |
Reference Ident Qual |
EV |
Receiver Identification Number |
|
57 |
|
REF02 |
Reference Ident |
|
VAN Indicator |
|
60 |
|
DTM |
Production Date |
|
|
|
60 |
|
DTM01 |
Date/Time Qualifier |
405 |
Production |
|
61 |
|
DTM02 |
Date |
|
Current Date (CCYYMMDD) |
|
62 |
1000A |
N1 |
Payer Identification |
|
|
|
|
|
N101 |
Payer |
PR |
Payer |
|
|
|
N102 |
Company name |
Sentara |
Payer Company Name |
|
64 |
1000A |
N3 |
Payer Address |
|
|
|
|
|
N301 |
Address Information |
4417 Corporation Lane |
Optima Address |
|
65 |
1000A |
N4 |
Payer City, State, Zip Code |
|
|
|
65 |
|
N401 |
City Name |
Virginia Beach |
|
|
65 |
|
N402 |
State |
VA |
|
|
65 |
|
N403 |
Postal Code |
23462 |
|
|
72 |
1000B |
N1 |
Payee Identification |
|
|
|
72 |
|
N101 |
Entity Identifier Code |
PE |
Payee |
|
73 |
|
N102 |
Name |
|
Vendor Name |
|
|
|
|
|
|
|
|
73 |
|
N103 |
Identification Code Qualifier |
FI |
Federal Taxpayer's ID Number |
|
73 |
|
N104 |
Identification Code |
|
Actual Tax ID Number |
|
77 |
1000B |
REF |
Payee Additional Identification |
|
|
|
77 |
|
REF01 |
Reference Identification Qualifier |
PQ |
Payee Identification |
|
77 |
|
REF02 |
Reference Identification |
|
Optima Assigned Vendor Number |
|
79 |
2000 |
LX |
Header Number |
|
|
|
|
|
LX01 |
Assigned Number |
1 |
|
|
89 |
2100 |
CLP |
Claim Payment Information |
|
|
|
89 |
|
CLP01 |
Claim Submitter's Identifier |
|
Patient ID |
|
90 |
|
CLP02 |
Claim Status Code |
1,2 or 4 |
1 = Processed as Primary
2 = Processed as Secondary
4 = Denied |
|
91 |
|
CLP03 |
Monetary Amount |
|
Requested Amount |
|
91 |
|
CLP04 |
Monetary Amount |
|
Paid Amount |
|
91 |
|
CLP05 |
Monetary Amount |
|
Amount not allowed - Patient Responsible Amount |
|
92 |
|
CLP06 |
Claim Filing Indicator Code |
HM |
Health Maintenance Organization |
|
93 |
|
CLP07 |
Reference Identification |
|
Optima Claim Number |
|
93 |
|
CLP08 |
Facility Code Value |
|
Bill Type - Number in the CLM05 of the 837 claims |
|
93 |
|
CLP09 |
Claim Frequency Type Code |
|
Claim Frequency Code - specific to institutional claims - Number in the CLM05-2 of the 837 claim |
|
93 |
|
CLP11 |
Diagnosis Related Group (DRG) Code |
|
Specific to institutional Claims. |
|
102 |
2100 |
NM1 |
Patient Name |
|
|
|
102 |
|
NM101 |
Entity Identifier Code |
QC |
QC = Patient |
|
103 |
|
NM102 |
Entity Type Qualifier |
1 |
Person |
|
103 |
|
NM103 |
Name Last or Organization Name |
|
Last name of Optima Member |
|
103 |
|
NM104 |
Name First |
|
First name of Optima Member |
|
103 |
|
NM108 |
Identification Code Qualifier |
MI |
|
|
104 |
|
NM109 |
Identification Code |
|
Optima member's number will include the asterisk to designate member |
|
108 |
2100 |
NM1 |
Corrected Patient/Insured Name |
|
|
|
|
|
NM101 |
Entity Identifier Code |
74 |
Corrected Insured |
|
|
|
NM102 |
Entity Type Qualifier |
1 |
|
|
|
|
NM103 |
Name Last or Organization Name |
|
Corrected Member Last Name |
|
|
|
NM104 |
Name First |
|
Corrected Member First Name |
|
126 |
2100 |
REF |
Other Claim Related Identification |
|
|
|
126 |
|
REF01 |
Reference Identification Qualifier |
IL |
IL = Group or Policy Number |
|
127 |
|
REF02 |
Reference Identification |
|
Optima Plan code, Company, and Group Number
EX: OHIC#01#12345-ABC Company |
|
135 |
2100 |
AMT |
Claim Supplemental Information |
|
|
|
|
|
AMT01 |
Amount Qualifier Code |
AU |
|
|
|
|
AMT02 |
Monetary Amount |
|
Max amount allowed for claim |
|
139 |
2110 |
SVC |
Service Payment Information |
|
|
|
141 |
|
SVC01-1 |
Product/Service ID Qualifier |
HC or NU |
HC = HCPCS code
NU = CPT code |
|
141 |
|
SVC01-2 |
Product/Service ID |
|
HCPCS or CPT code |
|
141 |
|
SCV01-3 |
Procedure Modifier |
|
Modifier if present |
|
142 |
|
SVC02 |
Monetary Amount |
|
Requested Amount
(COB Claim the SVC02 and SCV03 will be the same. CAS segment will adjust amounts and match CLP04) |
|
142 |
|
SVC03 |
Monetary Amount |
|
Amount Paid |
|
142 |
|
SVC05 |
Quantity |
|
Unit of Service Paid Count |
|
146 |
2110 |
DTM |
Service Date |
|
|
|
147 |
|
DTM01 |
Date/Time Qualifier |
472, 150, or 151 |
If Single Day of Service then use 472; otherwise use 150 (service begin) or 151 (service end) |
|
|
|
DTM02 |
Date |
|
CCYYMMDD; DOS, DTP=150 then DTP02 = Beginning DOS; DTP = 151 then DTP02 = Ending DOS. |
|
148 |
2110 |
CAS |
Service Adjustment |
|
Different Scenarios for Adjustment Group Codes (Example A) |
|
150 |
|
CAS01 |
Claim Adjustment Group Code |
OA |
|
|
150 |
|
CAS02 |
Claim Adjustment Reason Code |
|
|
|
150 |
|
CAS03 |
Monetary Amount |
|
Amount not allowed |
|
148 |
2110 |
CAS |
Service Adjustment |
|
Different Scenarios for Adjustment Group Codes (Example B) |
|
150 |
|
CAS01 |
Claim Adjustment Group Code |
PI |
|
|
150 |
|
CAS02 |
Claim Adjustment Reason Code |
104 |
Withhold |
|
150 |
|
CAS03 |
Monetary Amount |
|
Withhold amount |
|
151 |
|
CAS05 |
Claim Adjustment Reason Code |
41 |
Discount |
|
151 |
|
CAS06 |
Monetary Amount |
|
|
|
148 |
2110 |
CAS |
Service Adjustment |
|
Different Scenarios for Adjustment Group Codes (Example C) |
|
150 |
|
CAS01 |
Claim Adjustment Group Code |
PR |
|
|
150 |
|
CAS02 |
Claim Adjustment Reason Code |
2 |
|
|
150 |
|
CAS03 |
Monetary Amount |
|
Withhold amount |
|
151 |
|
CAS05 |
Claim Adjustment Reason Code |
41 |
Discount |
|
151 |
|
CAS06 |
Monetary Amount |
|
|
|
148 |
2110 |
CAS |
Service Adjustment |
|
Different Scenarios for Adjustment Group Codes (Example D)
COB Claim |
|
150 |
|
CAS01 |
Claim Adjustment Group Code |
CO |
|
|
150 |
|
CAS02 |
Claim Adjustment Reason Code |
23 |
|
|
150 |
|
CAS03 |
Monetary Amount |
|
COB Amount from Primary Payer |
|
151 |
|
CAS05 |
Claim Adjustment Reason Code |
94 |
Processed in Excess of charges. |
|
151 |
|
CAS06 |
Monetary Amount |
|
Difference in COB amount and amount we pay |
|
148 |
2110 |
CAS |
Service Adjustment |
|
Different Scenarios for Adjustment Group Codes (Example E) |
|
150 |
|
CAS01 |
Claim Adjustment Group Code |
OA |
|
|
150 |
|
CAS02 |
Claim Adjustment Reason Code |
24 |
Capitated Adjustment |
|
150 |
|
CAS03 |
Monetary Amount |
|
Capitated Amount + Amount not allowed |
|
154 |
2100 |
REF |
Service Identification |
|
|
|
154 |
|
REF01 |
Reference Identification Qualifier |
LU |
|
|
155 |
|
REF02 |
Reference Identification |
|
Place Code |
|
154 |
|
REF01 |
Reference Identification Qualifier |
6R |
Provider Control Number |
|
155 |
|
REF02 |
Reference Identification |
|
PCP Number - (Sentara 5 digit provider numbers) |
|
158 |
2110 |
AMT |
Service Supplemental Amount |
|
|
|
158 |
|
AMT01 |
Amount Qualifier Code |
B6 |
Allowed Actual |
|
159 |
|
AMT02 |
Monetary Amount |
|
Max Allowed Amount for Service |
|
162 |
2110 |
LQ |
Health Care Remark Codes |
|
|
|
162 |
|
LQ01 |
Code List Qualifier Code |
HE |
Claim Payment Remark Codes (Remittance Remark Codes) |
|
163 |
|
LQ02 |
Industry Code |
|
Remark Code |