Commonly referred to as the HCFA 1500

Refers to the X12N Implementation Guide ANSI Version 4010A1

The Optima Health 837 Professional Companion Guide is to be used with the HIPAA-AS Implementation Guide, which provides comprehensive information needed to create an ANSI 837 transaction.  The Optima Health Companion Guide is used in conjunction with the HIPAA Implementation Guide; it is intended to clarify issues where the HIPAA Implementation Guide provides options or choices to be made.  Download the HIPAA Implementation Guide from: http://www.wpc-edi.com/hipaa/HIPAA_40.asp

LEGEND for Optima Health Matrix for 837 Professional

Shaded rows represent segments; Non-shaded rows represent "data elements."

*Members in the Optima Health system can uniquely be identified using their unique member number.  Dependent loops and Hierarchy Levels will not be used.

 

Loop ID	Reference	Name	Codes	Length	Notes/Comments
	ISA	Interchange Control Header
	ISA07	Interchange ID Qualifier	27	2	The value must equal 27
	ISA08	Interchange Receiver ID	SHM	15	With 12 trailing spaces
	ISA16	Component Element Separator	:		Optima Health recommends using a colon (:)
	GS	Functional Group Header
	GS03	Application Receiver Code	SHM		Identifies Optima Health
1000B	NM1	Receiver Name
	NM103	Last Name or name of Organization	SHM
	NM108	Identification Code Qualifier	46
	NM109	Identification Code	SHM		Identifies Optima Health
2000A	PRV	Billing/Pay-to Provider Hierarchical Level
	PRV01	Provider Code	BI		Billing Provider
2010AA	REF	Billing Provider Secondary Identification
	REF01	Reference Identification Qualifier	G2
	REF02	Reference Identification			Optima Health provider number
2000B	SBR	Subscriber Information
	SBR09	Claim Filing Indicator Code	ZZ
2010BA	NM1	Subscriber Name
	NM108	Identification Code Qualifier	MI
	NM109	Identification Code			Optima Health member's number without asterisk (member number 123456*01 will come across as 12345601)
	DMG	Subscriber Demographic Information
	DMG03	Subscriber Gender Code	M F		Optima Health does not use U for "unknown"
2010BB	NM1	Payer Name
	NM103	Last Name or name of Organization	SHM
	NM108	Identification Code Qualifier	PI		Payer Identification
	NM109	Identification Code	SHM		Identifies Optima Health
2010CA	NM1	Patient Name
	NM103	Patient Last Name			Member validation is based on first 13 characters of the last name.
	NM104	Patient First Name			Member validation is based on the first 3 characters of the first name.
	NM108	Identification Code Qualifier	MI
	NM109	Identification Code			Optima Health member's number without asterisk (member number 123456*01 will come across as 12345601)
2300	CLM	Claim Information
	CLM05-3	Claim Frequency Type Code			Permissible code values for this sub element: 1 - ORIGINAL (Admit thru Discharge Claim) 6 - CORRECTED (Adjustment of Prior Claim) for reconsideration
2300	NTE	Claim Note			Free text for notes in NTE02
	NTE01	Note Reference Code			ADD
	NTE02	Description			If submitting anesthesia claims please provide the anesthesia time in military 24 hour format: Start HHMM Stop HHMM (ex:  Start 1500 Stop 2230)
2300	CRC	EPSDT Referral
	CRC01	Code Category	ZZ
	CRC02	Yes/No Condition or Response Code	N or Y
	CRC03	Condition Indicator
	CRC04	Condition Indicator			Use if additional condition codes are needed.  Use CRC03 list.
	CRC05	Condition Indicator			Use if additional condition codes are needed.  Use CRC03 list.

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 Download the HIPAA Transaction Standard Companion Guide 837 Professional - Commonly referred to as the HCFA 1500 in PDF format