HIPAA Transaction Standard Companion Guide 837 Institutional (UB92)

 

Page #	Loop ID	Reference	Name	Required Value	Notes/Comments
537		ISA	Interchange Control Header
537		ISA01	Authorization Information Qualifier	00
538		ISA03	Security Information Qualifier	00
538		ISA07	Interchange ID Qualifier	ZZ
539		ISA08	Interchange Receiver ID	SHM	With 12 trailing spaces
540		ISA16	Component Element Separator	:	Sentara recommends using a colon (:)
542		GS	Functional Group Header
542		GS03	Application Receiver Code	SHM	Identifies Sentara Health Management
67	1000B	NM1	Receiver Name
68		NM103	Last Name or name of Organization	SHM	Identifies Sentara Health Management
68		NM108	Identification Code Qualifier	46	ETIN
68		NM109	Identification Code	SHM	Identifies Sentara Health Management
77	2010AA	NM1	Billing Provider Name
77		NM108	Identification Code Qualifier	24	Employer’s Identification Number
78		NM109	Billing Provider Identifier		Provider Tax ID
108	2010BA	NM1	Subscriber Name
110		NM108	Identification Code Qualifier	MI
110		NM109	Identification Code		Sentara member's number without asterisk (member number 123456*01 will come across as 12345601)
126	2010BC	NM1	Payer Name
127		NM108	Identification Code Qualifier	PI	Payer Identification
127		NM109	Identification Code	SENTARA	Identifies Sentara as Payer
145	2010CA	NM1	Patient Name
147		NM108	Identification Code Qualifier	MI	Member ID
		NM109	Identification Code		Sentara member's number without asterisk (member number 123456*01 will come across as 12345601)