1. THCIC 837 Claim Technical Discussion
Texas Health Care Information Collection
THCIC 837 Claim Technical Discussion
SLIDE 1 DISCUSSION
Purpose of presentation:
How to create a THCIC 837 claim submission using the minimum required THCIC dataset.
Target audience:
Those with experience with programming of UB92 hospital clams that are beginning development of the THCIC 837 submission.
Goal:
Under ANSI standards, claims can be constructed with varying levels of complexity. This presents a minimum submission that results in a data submission that is simple yet meets THCIC requirements.
With this presentation and the technical specifications manual, you will have the necessary guidance to be able to create a claim submission that meets the THCIC requirements.
Note: This presentation has been revised for version 14 of the Technical Specification Manual.
March 31, 2005
THCIC 837 Technical Discussion

2. Terminology UB92 verses 837 837 Control Structure THCIC 837 Example
Agenda
Terminology
UB92 verses 837
837 Control Structure
THCIC 837 Example
SLIDE 2 DISCUSSION
Items addressed in this presentation:
Terminology used with the 837.
Differences between the UB92 and the 837.
The control structure used for the 837 submission.
Example of a simple THCIC 837 submission.
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THCIC 837 Technical Discussion

3. Multiple physical records per claim. 837 Transaction sets
Terminology
UB92
Batches of claims
Multiple physical records per claim.
837
Transaction sets
1 or more physical records per transaction set
SLIDE 3 DISCUSSION
Terminology differences between UB92 and 837:
UB92 claims were submitted in batches.
Each UB92 claim consists of multiple physical records – 20, 22, 30… etc.
837 claims are submitted in transaction sets.
There can be one or more physical records for the 837 claim and those records comprise a transaction set.
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THCIC 837 Technical Discussion

4. UB92 837 Each record contains logically related data elements.
Terminology
UB92
Each record contains logically related data elements.
837
Segments
one or more related data elements
Loops
one or more segments (groups of semantically related segments)
SLIDE 4 DISCUSSION
Terminology differences between UB92 and 837 continued:
For a UB92 claim, each record contains logically related data elements:
10 record – provider data
20 record – data about the patient
30 record – data on the payers
40 record – claim data
etc………
The 837 uses segments that contain related data elements.
Segments are somewhat equivalent to an UB92 record in that segments contain small sets of logically related data elements, although the amount of data is usually less than would be found in a UB92 record.
Segments are organized into semantically related groups called loops. Loops can have one or more segments.
Similar to the numbering scheme for the UB92 lexicon, segments and loops are identified in shorthand by numbers and alpha suffixes.
For instance, 1000A identifies segments comprising the submitter data and 1000B, the receiver data. However, unlike the UB92, these identifiers are not used in the submission.
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THCIC 837 Technical Discussion

5. Variable length fields and records
Terminology
UB92
Fixed length fields and records
Every data element that can be reported has a place.
Know exactly where to look for each data element.
837
Variable length fields and records
Data elements do not have specific locations in a record.
Identifiers used to locate data element.
SLIDE 5 DISCUSSION
This slide identifies the key differences between the UB92 and the 837.
In the UB92 claim, every data element that can be reported has a place somewhere in a record. We know exactly where to look for the data element. If the data element is not reported, then the area in the record is either blank or zeros, but places for the maximum size of the data element are reserved in the record.
Therefore, every record is a defined length. The length of the UB92 is fixed at 192 characters and does not change.
In the 837, there are no specific physical locations in an 837 segment for data elements, only a specific order in which the data elements must occur – if they exist.
If a data element is not needed, it is not reported and no space is allocated in the record.
If a group of data elements that comprise a segment are not needed, then the segment is not reported.
In the 837, each data element is given a maximum size. But the data element can be smaller. That means the same data element, such as last name, can be different lengths in two different claims.
Given that a data element has no specified character location in a segment, and it can change sizes, or it might not be there at all, it seems that it would be difficult for programmers to find the data element.
The 837 uses delimiters, identifiers and qualifiers to locate and identify the data elements.
A delimiter is a special character that is used as a marker to indicate the end of something.
An identifier is a code value whose purpose is to identify what is in the next data element(s).
A qualifier is a code value whose purpose is to identify the format of what is in the next data element.
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THCIC 837 Technical Discussion

6. UB92 versus 837
Patient Data
Name, address, city, state, zip, birth date
UB92 Record: 20
Loop: 2010CA
Segments: NM1, N3, N4, DMG
SLIDE 6 DISCUSSION
This slide exemplifies the discussion on the previous slide and demonstrates the difference in construction.
The intent is to report patient data – name, street address, city, state, zip code and birth date.
In the UB92, this data is reported in the 20 record. The specific start and end positions of each field are known as are the characteristics of each data element (number, alpha, length).
The 837 claim also contains these data elements. The 837 uses segments to hold the data elements. And the segments are grouped semantically into loops.
The patient data listed above is in the segments that comprise a patient sub-loop known in shorthand as 2010CA – Patient Name. The sub-loop consists of a name segment (NM1), street address segment (N3), geographic segment (N4) for city, state and zip code, and a demographic segment (DMG) that contains the birth date.
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7. 20⌂⌂WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂
UB92 versus 837
Patient Last Name
Patient First Name
UB92
20⌂⌂WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂
33 characters
837
NM1*QC*1*WEISS*RON*
19 characters
SLIDE 7 DISCUSSION
Now, contrast how the patient name would look in the UB92 record and in the 837 segment.
In both the UB92 and the 837, the patient name is reported as two separate data elements, last name and first name. [The home plate looking boxes represent spaces.]
Notice that the size of the 837 is smaller than that of the UB92. This is a benefit of variable length structures. They use less space than an equivalent fixed length structure. So, less physical disk space is consumed and transmission time is less.
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THCIC 837 Technical Discussion

8. 20WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂
UB92 versus 837
First Name
Record Type
Last Name
20WEISS⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂⌂RON⌂⌂⌂⌂⌂⌂
NM1*QC*1*WEISS*RON*
Seq No
Name Segment
Person
SLIDE 8 DISCUSSION
Looking at the example in more detail:
First, the UB92 record:
As the UB92 record is fixed length, the start and stop positions for each data element is known.
“20” in the first two positions identifies that this record contains patient data.
Last name begins in position 5 and ends in position 24, for a length of 20.
First name begins in position 25 and ends in 33, for a length of 9.
Both names are shorter than the maximum allowed length. So, the fields are padded with spaces. [The home plate looking boxes represent spaces.]
Next, the 837 segment:
The asterisk is used as the delimiter.
NM1 indicates this to be a name segment of something.
The second data element is a qualifier. The value “QC” identifies this segment as being a name segment for a patient.
The “QC” is followed by another qualifier “1” that says the entity being named is a person.
The last name and first name follow. Notice that the last and first name fields are only as long as the actual characters of the names.
This is the key to the differences between the UB92 and the 837.
In the UB92 every data element that can be reported has a place in a record and the location of the data element is known. Even if the data element is not reported, places for the maximum size of the data element is reserved in the record. Every record is a defined length. The length is fixed and does not change.
With the 837, while each segment has an ordered place if it exists, and each data element has a relative position if it exists, the physical location can vary from claim to claim.
Last Name
Patient
First Name
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THCIC 837 Technical Discussion

9. File Control Structure
ISA (Interchange Header) only one per file
GS (Functional Group start) multiple per submission
used for a group of similar transaction sets
ST (Transaction Start) used to identify the type of transaction multiple per GS
…Transaction Segments claim data
SE (Transaction End) one for each ST
used for balancing transaction set
GE (Functional Group End) one for each GS
used for balancing functional group
IEA (Interchange End) one per submission
used for balancing submission
SLIDE 9 DISCUSSION
The file control structure contains the envelope segments that provide description and controls for the submission.
In the UB92, there is one envelope layer: 01 and 99 records.
In the 837, there are three layers in the control envelope:
Interchange Control segments (ISA – IEA)
Functional Group segments (GS – GE)
Transaction Set segments (ST – SE).
The Interchange Control segments are equivalent to the 01 – 99 records in the UB92. Only one set of segments is included in each submission.
The Functional Group segments provide a grouping level for multiple groups of similar transaction sets. As THCIC requires only one claim type (837), there is no need for more than one functional group.
The Transaction Set segments provide controls and description for the claims that are enclosed. While the number of claims that can be enclosed is unlimited, THCIC is abiding by the ANSI recommendation of no more than 5000 claims per transaction set.
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THCIC 837 Technical Discussion

10. Issues found during test review
Building A Submission
Use example to
Describe segments
Their usage
Key data elements
Issues found during test review
Spaces in this example are represented by “^” for clarity.
SLIDE 10 DISCUSSION
The remainder of the presentation will be an example of a submission that meets THCIC requirements.
The example will describe
the required segments and their usages
required and key data elements
highlight and issues or difficulties that have been noted in the test submissions that have been received and reviewed to-date.
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THCIC 837 Technical Discussion

11. Case admission through discharge claims
One submission from EL GRANDE SUBMITTER,
Submitter ID = SUB000
Submitting for one hospital, TEXAS STATE HOSPITAL,
THCIC ID =
Submission includes two claims
admission through discharge claims
one where the subscriber is the patient, and
one where the patient is the son of the
subscriber.
SLIDE 11 DISCUSSION
The ANSI 837 specifications allow for complex submissions, but this example will focus on providing a submission that will be simple and straight forward and yet meet THCIC requirements for an 837 claim based submission.
All segments and data elements that are required for a submission are shown.
The example will be for a submitter, El Grande Submitter, who has been assigned a submitter ID of SUB000. El Grande is submitting for one hospital, Texas State Hospital, whose THCIC ID is
The submission contains two claims, both admission through discharge (111 bill types) claims.
The first claim is for a patient that is a dependent of an insured individual (subscriber).
The second claim is for a patient that is also the insured individual (patient is subscriber).
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12. Interchange Control Header - Trailer
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*
SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*1455*
U*00401* *0*T*:~
GS functional group
ST transaction set SE GE
IEA*1* ~
ISA and IEA segments wrap the submission.
ISA segment is only segment that is fixed length.
All positions within each data element must be filled.
SLIDE 12 DISCUSSION
The example begins with the envelope control segments:
the Interchange Control segments,
the Functional Group segments, and
the Transaction Set segments.
The first and last segments in the submission are the Interchange Control Header (ISA) segment and the Interchange Control Trailer (ISE) segment.
The first segment in the submission must be the ISA segment. In addition to providing an interchange control number, the ISA segment identifies the delimiters that will be used in the submission.
The ISA segment is the only segment that is fixed length. All positions within each data element must be the maximum required size, e.g. the maximum and minimum sizes of the elements are the same.
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13. Interchange Control Header - Trailer1
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*
SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*
1455*U*00401* *0*T*:~
1 The character in position 4 (first element separator) defines the element separator to be used throughout the entire interchange.
2 Submitter ID assigned by CCS.
3 Receiver ID – ensures that claims are intended for THCIC.
4 Date for this submission.
5 Time for this submission.
SLIDE 13 DISCUSSION
First, an explanation of numbering scheme (above) used in this presentation for identifying data elements:
For each segment there is a number (orange) above each of the data elements that are important for the segment. There are other data elements that are required and that are listed here, but are usually qualifiers that are self-evident.
All of this information is drawn from the THCIC 837 Technical Specifications manual. The most recent version of the manual, version 14, is on the THCIC website.
ISA segment data elements:
The character in position 4 (first element separator) defines the element separator to be used throughout the entire interchange (submission).
Submitter ID obtained from Commonwealth.
Receiver ID – must be “YTH837”. This identifies the submission as being intended for THCIC.
Date for this submission. Usually the date the submission was created.
Time for this submission. Usually the time the submission was created.
Note: The Submitter ID is a separate ID assigned to submitters. If a hospital submits data for themselves, then the hospital will be a submitter and will have both a Submitter ID and a THCIC hospital ID. The Submitter ID is obtained from Commonwealth. The THCIC hospital ID is assigned by THCIC.
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14. Interchange Control Header - Trailer1
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*
SUB000^^^^^^^^^*ZZ*YTH837^^^^^^^^^*040917*
1455*U*00401* *0*T*:~
6 Interchange control number – unique to this submission. Must match element IEA02 in the IEA segment.
7 Identifies submission as Test or Production
8 Component element separator – “:” will be used to separate components within elements.
9 Defines the segment terminator to be used throughout the entire interchange.
SLIDE 14 DISCUSSION
Continuation of ISA segment discussion:
Interchange Control Number – this number is unique to this submission. It must match the value in data element IEA02 in the IEA segment (last segment in the submission).
Identifies the submission as being Test or Production. This identifier is used by Commonwealth to determine how the submission should be processed.
Component element separator – “:” will be used to separate components within data elements.
Segment terminator – defines the delimiter that will be used throughout the entire interchange for terminating segments.
It is important that the ISA segment is correct as all of the rest of the submission depends on its contents.
Issues found during test reviews (relative to data elements):
Element 1: To assist with consistency in test review and problem solving by THCIC and Commonwealth, preference is for using an asterisk as the element separator.
Element 2: The THIN submitter ID is being used instead of the THCIC submitter ID. The THIN submitter ID begins with SP. The THCIC submitter ID begins with SUB.
Element 6: The ICN must be 10 numeric digits in length.
Element 8: To assist with consistency in test review and problem solving by THCIC and Commonwealth, preference is for using a colon as the component element separator.
Element 9: To assist with consistency in test review and problem solving by THCIC and Commonwealth, preference is for using a tilde (~) as the component element separator.
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15. Interchange Control Header - Trailer
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ*
YTH837^^^^^^^^^*040917*1455*U*00401* *0*T*:~
GS functional group
ST transaction set SE GE
IEA*1* ~
1 Number of functional groups in submission.
2 Interchange control number – unique to this submission. Must match element ISA13 in the ISA segment.
SLIDE 15 DISCUSSION
The last segment in the submission is the IEA. This segment provides the controls for balancing the submission.
Count of the number of functional groups in the submission.
2 Contains the interchange control number which is used to validate against the value in element ISA13 (item 6 on previous slide) in the ISA segment.
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16. Functional Group ST transaction set
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ*
YTH837^^^^^^^^^*040917*1455*U*00401* *0*T*:~
GS*HC*SUB000*YTH837* *1455*22*X*004010X096A1~
ST transaction set SE
GE*1*22~
IEA*1* ~
GS and GE segments wrap one or more transaction sets of like transactions.
Identifies the version of the EDI standard used.
SLIDE 16 DISCUSSION
There is no equivalency to the functional group control in the UB92 lexicon. At least one functional group is required in a submission. The purpose of the functional group is the wrap similar transaction sets. THCIC uses only one transaction type, the So, there is no need for more than one functional grouping.
Note that beginning with the GS segment, all data elements are actual length and not maximum length as is for the ISA segment.
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17. Functional Group Header - Trailer
GS*HC*SUB000*YTH837* *1455*22*X* 6
004010X096A1~
1 Submitter ID assigned by CCS.
2 Receiver ID – ensures that claims are intended for THCIC.
3 Date for this functional group.
4 Time for this functional group.
5 Group control number – unique to this functional group. Must match element GE02 in the GE segment.
SLIDE 17 DISCUSSION
GS segment data elements:
This is the same Submitter ID as used in the ISA segment.
This the same Receiver ID (YTH837) as used in the ISA segment.
Date for this functional group. Usually the date the functional group was created. Can be the same as for the ISA segment.
Time for this functional group. Usually the time the functional group was created. Can be the same as for the ISA segment.
Group Control Number – unique to the functional group. This must balance to the value in GE02 in the corresponding functional group trailer (GE) segment.
Issues found during test reviews (relative to data elements):
Element 1: The THIN submitter ID is used instead of the THCIC submitter ID. The THIN submitter ID begins with SP. The THCIC submitter ID begins with SUB.
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18. Functional Group Header - Trailer
GS*HC*SUB000*YTH837* *1455*22*X*004010X096A1~
1 2
GE*1*22~
1 Number of transaction sets in group.
2 Group control number – unique to this submission. Must match element GS06 in the GS segment.
SLIDE 18 DISCUSSION
Like the IEA segment, the functional group trailer segment provides the controls for balancing the functional group.
GE segment data elements:
Contains the number of transactions sets included in the functional group.
Group Control Number – unique to functional group. This must balance to the value in GS06 in the functional group header (GS) segment.
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19. Transaction Set ST*837*3333~ SE*10*3333~
ISA*00*^^^^^^^^^^*00*^^^^^^^^^^*ZZ*SUB000^^^^^^^^^*ZZ*
YTH837^^^^^^^^^*040917*1455*U*00401* *0*T*:~
GS*HC*SUB000*YTH837* *1455*22*X*004010X096A1~
ST*837*3333~
SE*10*3333~
GE*1*22~
IEA*1* ~
ST and SE segments wrap the data segments that comprise the claims for the transaction.
SLIDE 19 DISCUSSION
The third and last of the envelope controls is the transaction set (ST and SE segments).
The transaction set header and transaction set trailer segments wrap the segments containing the data elements that comprise the claims.
There can be one or more than one transaction set within a functional group.
Regarding data volume: The defacto standard for claim volume is no more than 5,000 claims per transaction set. So, unless there are more than 5,000 claims being submitted, there needs be only one transaction set.
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20. Transaction Set Header - Trailer
1 2
ST*837*3333~
3 4
SE*10*3333~
claims are being reported in this transaction set.
2 Transaction set control number – unique to this transaction set. Must match element SE02 in the SE segment.
3 Number of segments in this set, including ST and SE segments.
4 Transaction Set control number – unique to this transaction set. Must match element ST02 in the ST segment.
SLIDE 20 DISCUSSION
The ST segment contains two data elements.
1 The first indicates that 837 claims are being reported.
2 The second is the transaction control number for validating completion of the transaction set. This must match element 4 in the SE segment.
The SE segment also contains two data elements.
3 The first is the number of segments included in the transaction set, inclusive of the ST and SE segments.
4 The second is the transaction control number used to validate against the control number submitted in element 2 in the ST transaction.
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21. Transmission 1 Describes hierarchical application structure.
BHT*0019*00*5* *1455*CH~ 5
REF*87*004010X96DA1~
1 Describes hierarchical application structure.
2 Transaction set reference ID.
3 Date transaction was created.
4 Time transaction was created.
5 Identifies transaction as production or test and which version of the EDI standard is used.
SLIDE 21 DISCUSSION
At this point, discussion moves into the segments comprising the transaction set.
At the beginning of the transaction are two segments that provide transmission information, The Beginning of Hierarchical Transaction segment and the Transmission Type Identification segment.
The first item of the BHT segment describes the hierarchical application structure used in the transaction set. This structure has three levels: info source (provider), subscriber, and dependent.
Transaction set reference ID – used as an inventory file number by the submitter.
Date the transaction was created.
Time the transaction was created.
Identifies the transaction set as being intended for production or test and which version of the EDI standard is used in creating the submission.
Issues found during test reviews (relative to data elements):
Element 5: The “D” is sometimes left out of the value. This indicates that the submission is intended for production. This quite often contradicts the value in element ISA15 of the ISA segment.
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22. Transmission Submitter and Receiver
ST*837*3333~
BHT*0019*00*5* *1455*CH~
REF*87*004010X96DA1~
NM1*41*2*El Grande Submitter*****46*SUB000~
NM1*40*2*THCIC*****46*YTH837~
Data segments identifying submitter and receiver.
SLIDE 22 DISCUSSION
The next two segments continue with transmission information describing the submitter and the receiver.
Notice that both segments are name (NM1) segments. The distinguishing feature is the segment identifiers 41 and 40.
The identifier 41 identifies the first segment as being a name segment for the submitter.
The identifier 40 identifies the second segment as being a name segment for the receiver. The receiver always is THCIC.
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23. NM1*41*2*El Grande Submitter*****46*SUB000~
Submitter & Receiver
ST*837*3333~
BHT*0019*00*5* *1455*CH~
REF*87*004010X96DA1~
NM1*41*2*El Grande Submitter*****46*SUB000~
NM1*40*2*THCIC*****46*YTH837~
1 Identifies segment as for submitter
2 Submitter Name THCIC Submitter ID.
4 Identifies segment as for receiver
5 THCIC – receiver name Receiver identifier
SLIDE 23 DISCUSSION
The first segment identifies the submitter.
41 – identifies the segment as being for the submitter.
Submitter name. If a hospital is submitting for itself, this will be the hospital name.
THCIC Submitter ID. This, again, is the submitter ID assigned to the submitting entity by Commonwealth.
The next segment identifies the receiver.
– identifies the segment as being for the receiver.
5 Name of the receiver. This is always “THCIC”.
6 Receiver ID. This is “YTH837”.
Commonwealth uses these two segments to identify the submitter and it’s submission status – testing or production and to ensure that the submission is intended for THCIC.
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24. Billing / Pay-To Provider
ST*837*3333~
BHT*0019*00*5* *1455*CH~
REF*87*004010X96DA1~
NM1*41*2*El Grande Submitter*****46*SUB000~
N1*40*2*THCIC*****46*YTH837~
HL*1**20*1~
PRV*BI*ZZ~
NM1*85*2*TEXAS STATE HOSPITAL*****24* ~
N3*4901 W. 49 ST*SUITE 660~
N4*AUSTIN*TX*78751~
REF*1J*000116~
Goal with these segments is to identify the service provider.
SLIDE 24 DISCUSSION
At this point in the transaction set, the hierarchical structure identified by the value 0019 in the previous BHT segment begins; that structure being info source (provider), subscriber, dependent.
This first group of segments identify the billing provider. The 837 format allows for three different providers to be reported: the billing provider, the pay-to provider and, if the billing provider or the pay-to provider did not provide the service, the service facility provider.
The first segment in the group is the provider HL, the hierarchical level (HL) segment for the provider.
In this example, the billing provider is also the service provider. This will be the situation for most all submissions. It is rare that the pay-to provider is the service provider and it is unusual that the service provider is other than the billing provider.
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25. HLs used in our example: 1 Provider 2 Subscriber 3 Patient
HL segments identify levels of detail information using a hierarchical structures.
HLs used in our example:
1 Provider
2 Subscriber
3 Patient
4 Subscriber
SLIDE 25 DISCUSSION
Background on hierarchical level structure used in the 837 claim submission
There are three HL levels – info source (provider), subscriber, dependent (patient).
This submission example has one provider and two claims. The first claim is for a dependent of a subscriber. The second is for a subscriber that is also the patient.
So, for this example, there are four HLs.
The first for the provider.
The second for the subscriber of the dependent.
The third for the dependent (patient).
The fourth for the subscriber that is also the patient. As the subscriber is the patient, there is no need for a separate patient HL.
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26. HLs HL*1**20*1~ provider 1 2 3 4 HL*2*1*22*1~ subscriber
HL*1**20*1~ provider
HL*2*1*22*1~ subscriber
HL*3*2*23*0~ patient
HL*4*1*22*0~ subscriber
The first HL in transaction set is for the provider.
1 HL ID
2 No parent HL
3 Characteristic - 20 – information source
4 Subordinate HLs follow
SLIDE 26 DISCUSSION
The first HL in any transaction set is for the provider.
The first data element of the HL is the hierarchical identification number. The first HL in the transaction set always begins with 1.
The second data element of the HL is the identification number of the HL that is the parent of this HL. As this is the provider HL (highest level of hierarchy), there is no parent HL and the field contains no value and is left empty.
The third element contains the characteristic of the HL that describes the HL. The value for the provider HL is 20 (information source).
The last element indicates whether there are subordinate HLs. As this is the provider HL and there are claims, then there are subordinate HLs, and thus the data element has a value of “1”.
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27. HLs HL*1**20*1~ provider 1 2 3 4 HL*2*1*22*1~ subscriber
HL*2*1*22*1~ subscriber
HL*3*2*23*0~ patient
HL*4*1*22*0~ subscriber
The second HL in transaction set is for the subscriber.
1 HL ID is one more than previous HL
2 Parent HL is the provider
3 Characteristic - 22 Subscriber
4 Subordinate HLs follow
SLIDE 27 DISCUSSION
The second HL in this transaction set is for the subscriber. A subscriber HL always follows a provider HL.
The HL identification number is always one more than that of the previous HL. In this example, the previous HL is the provider HL with an ID of 1.
The identification number of the parent HL. In this case it is the ID of the provider HL, which is 1.
The characteristic code for the subscriber HL is 22 (subscriber).
As the first claim in this example is for a dependent of a subscriber, there must be a third level of HL, that for the patient (dependent). Thus, the value of “1”.
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28. HLs HL*1**20*1~ provider HL*2*1*22*1~ subscriber 1 2 3 4
HL*3*2*23*0~ patient
HL*4*1*22*0~ subscriber
3rd HL in transaction set is for the patient.
1 ID of HL is one more than previous HL
2 Parent HL is that of subscriber
3 Characteristic - 23 – patient
4 No subordinate HLs follow
SLIDE 28 DISCUSSION
As this claim is for a patient where the patient is not the subscriber, the third HL in this transaction set is for the dependent (patient).
The HL identification number is one more than that of the previous HL, which is the subscriber HL (HL ID = 2). Thus, the ID of this HL is 3.
Parent of this patient HL is the HL of the subscriber. Thus the value of 2.
The characteristic for this HL is “23” for dependent.
There are no HLs that are subordinate to the dependent HL as there are only three tiers in this hierarchy. Thus, the value of “0”.
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29. HLs HL*1**20*1~ provider HL*2*1*22*1~ subscriber HL*3*2*23*0~ patient
HL*4*1*22*0~ subscriber
4th HL in transaction set is for the next subscriber.
1 ID of HL is one more than the previous HL
2 Parent HL is the provider
3 Characteristic - 22 subscriber
4 No subordinate HLs follow
SLIDE 29 DISCUSSION
The fourth and last HL in the transaction set starts the next claim, where the subscriber is also the patient.
The identification number of this HL is one more than the ID of the previous HL. The previous HL is the HL of the patient for the previous claim. In this situation, there is no hierarchical connection to the parent HL, merely a sequential numbering.
The identification number of the parent HL is 1 as the parent of a subscriber is always the provider. Thus, the parent identification number of any subscriber HL is always the HL ID of the most recent provider HL.
The characteristic of this HL is a subscriber - “22”.
When the subscriber is also the patient, all patient information is submitted within the subscriber HL and there is no subordinate (patient) HL. Thus the value is “0”.
HL guides:
A provider HL has no parent, so the parent ID number is always empty.
The parent of a subscriber is always the HL ID of the preceding provider.
The parent of a dependent (patient) is always the HL ID of the immediately preceding subscriber.
Issues noted with HLs:
CCS treats each provider HL as a batch and processes and reports based on provider HLs. Each provider HL results in a set of results reports. Thus, if 300 claims are submitted, each under a separate provider HL, CCS will return 300 sets of reports.
In addition, a system limitation exists for a maximum of 999 batches per submission.
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30. Billing / Pay-To Provider
HL*1**20*1~
PRV*BI*ZZ~
NM1*85*2*TEXAS STATE HOSPITAL*****24* ~
N3*4901 W. 49 ST*SUITE 660~
N4*AUSTIN*TX*78751~
REF*1J*000116~
Starts the Billing Provider Hierarchical Level
1 The first HL ID number is 1
2 There is no parent HL as this is the first.
3 Code defining characteristics of the HL level
20 – information source
4 Child code indicator – 1 indicates that there are HLs that are subordinate to this HL.
SLIDE 30 DISCUSSION
Continuing the discussion from slide 24 of the submission example beginning with the provider HL.
Data elements:
The first data element of this first HL is the HL identification number. The first HL in the transaction set begins with 1.
As this is the provider HL (highest level of hierarchy) there is no parent HL.
The characteristic describes the HL. The value for the provider HL is 20 (information source).
As this is a provider HL and there are claims, then there are subordinate HLs, and thus the data element has a value of 1.
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31. Billing / Pay-To Provider
HL*1**20*1~ 1
PRV*BI~
NM1*85*2*TEXAS STATE HOSPITAL*****24* ~
N3*4901 W. 49 ST*SUITE 660~
N4*AUSTIN*TX*78751~
REF*1J*000116~
Identifies which of the reported providers is the service provider.
1 Options are BI (billing) and PT (pay-to).
If the service provider is not the billing provider or the pay-to provider, then there is no PRV segment and the service provider is reported in the 2310E segments within the claim.
SLIDE 31 DISCUSSION
Immediately following the provider HL segment is the Billing/Pay-to Provider Specialty segment. The purpose of this segment is to identify either the Billing or the Pay-to Provider as the service provider. This segment must exist if the billing provider or the pay-to provider provided the service.
In most cases, the billing provider also provided the services. If the service provider is not the billing provider or the pay-to provider, then there is no PRV segment, and the service provider is reported in the 2310E segment within the claim.
The situation where either the billing or pay-to provider is not the service provider is not discussed any further in this presentation. If this situation exists for your provider, we would be glad to discuss this further. Call or us and we will be glad to discuss the requirements for reporting when the service provider is not the billing or pay-to provider.
Issue noted during test reviews:
This segment is often missing from test submissions.
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32. Billing / Pay-To Provider
HL*1**20*1~
PRV*BI~
NM1*85*2*TEXAS STATE HOSPITAL*****24* ~
N3*4901 W. 49 ST*SUITE 660~
N4*AUSTIN*TX*78751~
REF*1J*000116~
Segment names billing provider.
1 Identifies the segment as being for the billing provider.
2 This is the only place that the provider name is reported.
3 EIN of the billing provider. Must match EIN in THCIC Provider
Database.
Contact Dee Shaw at to verify information.
SLIDE 32 DISCUSSION
This next segment, a NM1 segment, names the billing provider.
The qualifier ’85’ identifies this segment as being for the billing provider.
This is the only place where the provider name and EIN are reported.
NOTE: The Provider EIN, THCIC ID and 1st 15 characters of the street address are used to validate the provider and must match the THCIC database.
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33. Billing / Pay-To Provider
HL*1**20*1~
PRV*BI~
NM1*85*2*TEXAS STATE HOSPITAL*****24* ~
N3*4901 W. 49 ST*SUITE 660~
N4*AUSTIN*TX*78751~
REF*1J*000116~
1 Line one of the street address of the provider.
2 Line two of the street address of the provider.
3 City of the provider State of the provider.
5 Zip code of the provider.
1st 15 characters of address line 1 are used to validate provider.
SLIDE 33 DISCUSSION
The next two segments, N3 and N4, provide the address of the provider.
It is important that the street address line 1 in the N3 segment match that on THCIC’s provider file as the first 15 characters of the street address are validated as part of provider verification.
Street address line 2 is not used for validation.
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34. Billing / Pay-To Provider
HL*1**20*1~
PRV*BI~
NM1*85*2*TEXAS STATE HOSPITAL*****24* ~
N3*4901 W. 49 ST*SUITE 660~
N4*AUSTIN*TX*78751~ 1
REF*1J*000116~
THCIC hospital identifier.
1 The THCIC 6-digit hospital ID.
Replaces the 3-digit alphanumeric THCIC facility ID
used in the UB92.
Same as record 10, field 10 of the UB92T
SLIDE 34 DISCUSSION
The REF segment is the key segment in identifying the provider. This segment contains the provider’s 6-digit THCIC ID.
This ID replaces and eliminates the need for the 3-digit facility code that was used with the UB92.
This is the same ID that was used in record 10, field 10 of the UB92T.
This is the last segment in the provider HL. Thus, in this example, the billing provider has been reported and has been identified as also providing the services.
Issues noted during test reviews:
This segment is often missing.
This segment, when there, sometimes contains the submitter ID or 3-digit facility ID.
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35. Subscriber – Primary Payer
HL*2*1*22*1~
SBR*P********CI~
NM1*PR*2*ALWAYS PAYS CLAIM*****PI*HH4504~
HL and subordinate segments describing the
subscriber of a claim where the subscriber is not
the patient.
SLIDE 35 DISCUSSION
The next set of segments are for the subscriber for the first claim. In this example, the first claim is for a patient that is not the insuring subscriber. In other words, the patient is a dependent of the subscriber.
These segments are the HL for the subscriber and two segments describing the insurer.
Because the subscriber is not the patient, no information about the subscriber is required, only payer information.
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36. Subscriber – Primary Payer
HL*2*1*22*1~
SBR*P********CI~
NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~
HL segment for subscriber with a subordinate HL for patient
1 HL ID number
2 ID of parent HL
3 HL level code – 22 for subscriber
4 Child code – 1 subordinate HL follows
SLIDE 36 DISCUSSION
The first segment is the subscriber hierarchical level segment.
The identification number of this HL is one more than the previous, which is the provider HL, whose ID is 1.
A subscriber HL is subordinate to the immediately preceding provider HL (HL ID = 1).
The characteristic of a subscriber is “22”.
As the patient is a dependent of the subscriber, then a subordinate HL follows (value = 1).
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37. Subscriber – Primary Payer
HL*2*1*22*1~
SBR*P********CI~
NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~
Identifies payer source of claim.
1 Primary payer code.
2 Indicates that subscriber is not the patient.
3 Commercial insurance.
SLIDE 37 DISCUSSION
The subscriber information segment identifies the primary payer source for the claim.
There must be a primary pay source.
Data elements:
1 “P” indicates primary payer source
2 This element contains the value “18” when the subscriber is also the patient. The field is empty when the subscriber is not the patient. It also signals that a patient HL follows. In this claim, the patient is not the subscriber, thus the field contains no value.
3 Contains a two-digit code for the source of the payment. The valid values are located in the THCIC 837 Technical Specifications manual. In this example the source of payment is commercial insurance.
Although there are other data elements that can be reported, THCIC only needs the above three elements in the SBR segment.
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38. Subscriber – Primary Payer
HL*2*1*22*1~
SBR*P********CI~
NM1*PR*2*ALLWAYS PAYS CLAIM*****PI*HH4504~
1 Payer name
2 Payer ID qualifier
3 Payer ID
In the situation where there is not insurance, then if
self pay: payer name = SELF PAY, payer ID = SELF
indigent: payer name = INDIGENT, payer ID = INDIGENT
charity: payer name = CHARITY, payer ID = CHARITY, and
unknown: payer name = UNKNOWN, payer ID = UNKNOWN.
SLIDE 38 DISCUSSION
Since the subscriber is not the patient, there is no need for any additional subscriber data. The next required segment for this claim is the payer name segment, which identifies the name of the primary insurer and the insurer’s payer ID.
If there is no insurance, then the claim falls into one of the following categories: self-pay, indigent care, charity, or unknown. In these situations, report those values in the payer name field and payer ID field. Note that there is a difference with reporting self pay.
This completes the reporting for the primary payer data.
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39. Patient name, identifiers, demographics.
Patient Info
HL*3*2*23*0~
PAT*19~
NM1*QC*1*WEISS*NATE~
N3*P O BOX 001~
N4*AUSTIN*TX*78701~
DMG*D8* *M**4~
REF*SY* ~
Patient name, identifiers, demographics.
SLIDE 39 DISCUSSION
This next set of segments begins the data for the patient. These segments, beginning with the patient HL, report the patient name and demographic data.
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40. Patient Info HL*3*2*23*0~ 5 PAT*19~
HL*3*2*23*0~ 5
PAT*19~
NM1*QC*1*WEISS*NATE~
N3*P O BOX 001~
N4*AUSTIN*TX*78701~
DMG*D8* *M**4~
REF*SY* ~
HL segment for patient that is subordinate to the previous subscriber
1 HL ID number ID of parent HL
3 HL level code – dependent
4 Child code – no subordinate HLs follow
5 Identifies patient’s relationship to insured.
SLIDE 40 DISCUSSION
The first segment is the patient hierarchical level segment.
Data elements:
This is the identification number of the HL, which is one more than the ID of the previous HL, which is that of the immediately preceding subscriber.
This is the identification number of the parent HL which is the immediately preceding subscriber HL.
HL characteristic is ’23’ – dependent.
There are no subordinate HLs, thus Child Code is ‘0’.
Following the HL segment is the patient information (PAT) segment. This segment identifies the patient’s relationship to the subscriber.
In this example, the patient is the son of the subscriber.
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41. Patient Info 1 2 NM1*QC*1*WEISS*NATE~ 3 N3*P O BOX 001~ 4 5 6
HL*3*2*23*0~
PAT*19~
NM1*QC*1*WEISS*NATE~ 3
N3*P O BOX 001~
N4*AUSTIN*TX*78701~
DMG*D8* *M**4~
REF*SY* ~
1 Patient last name Patient first name
3 Line one of the street address of the patient
4 City State Zip Code
SLIDE 41 DISCUSSION
These next three segments report the patient’s name and address.
The N3 segment allows for two lines in the street address. Only the first is shown.
Notice that, with the exception of the QC qualifier, these segments are just as was with the previous name and address segments for the provider and subscriber.
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42. 1 Patient birth date 2 Gender 3 Race 4 Patient social security number.
Patient Info
HL*3*2*23*0~
PAT*19~
NM1*QC*1*WEISS*NATE~
N3*P O BOX 001~
N4*AUSTIN*TX*78701~
DMG*D8* *M**4~ 4
REF*SY* ~
1 Patient birth date Gender Race
4 Patient social security number.
Use SY qualifier.
Use for patients without social security numbers, who refuse to provide the number, or are covered by 42 USC 290dd-2 and 42 CFR Part 2.1.
SLIDE 42 DISCUSSION
Beginning with the Patient Demographic Information (DMG) segment, we report the patient’s birth date, the patient’s gender and the patient’s race code.
Following the DMG segment is a Patient Secondary Identification number (REF) segment which is used to report the patient’s social security number. The qualifier for social security number is “SY”.
Important change from the UB92:
The UB92 carried a field that allowed reporting the “reason for no SSN” when a SSN was not reported. This was in record 22. The 837 does not have this field. So, in order to ensure that the SSN is not overlooked, if there is no SSN to report or no SSN can be reported or the patient’s identity is protected by law, place all 9’s in this field.
With the exception of the patient’s ethnicity, all of the patient demographic and characteristic data has been reported at this point.
Issues noted during test reviews:
Patient race is usually not reported to payers and many of the test submissions are missing this value.
The social security number is not necessarily reported to payers and many tests have the segment missing.
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43. Claim details: including admission, diagnosis and treatment data.
Claim Info
CLM*100381* ***11:A:1~
DTP*096*TM*1045~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*187~
NTE*UPI*2~
Claim details: including admission, diagnosis and treatment data.
SLIDE 43 DISCUSSION
This next group of segments report the dates for the services.
Also included in this group of segments is the NTE segment that reports the patient ethnicity.
Patient ethnicity is not normally reported to payers. However, THCIC is required to collect patient ethnicity. The Note segment, shown as the last segment above, is used to collect patient ethnicity.
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44. CLM*100381*1000.40***11:A:1~ Claim Info 1 2 3 4
CLM*100381* ***11:A:1~
DTP*096*TM*1045~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*187~
NTE*UPI*2~
1 Patient account number (patient control number).
2 Total claim charges
3 Facility code
4 Claim frequency code
SLIDE 44 DISCUSSION
Each of the data elements in the claim information (CLM) segment provide data key to the patient stay.
Patient account number (aka patient control number)
Total claim charges. The total claim charges must equal to the sum of the charge details reported in the SV2 segments. A decimal point is optional if the amount does not include cents.
This data element eliminates the need for the 0001 revenue code detail, used in the UB92, to report total charges.
3 Facility code. This is the first two digits of the bill type.
4 Claim frequency code. This is the third digit of the bill type.
The facility code and the claim frequency code are reported in a composite data element.
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45. Claim Dates
CLM*100381* ***11:A:1~ 1
DTP*096*TM*1045~ 2
DTP*434*RD8* ~ 3
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*187~
NTE*UPI*2~
1 Discharge time – hhmm format.
2 Statement dates in a range.
3 Admission date and time - ccyymmddhhmm.
SLIDE 45 DISCUSSION
These three segments report the dates and times pertinent to the patient stay.
Dates are reported in a Date or Time or Period (DTP) segment. Each of the three contain an identifier following the DTP that indicates what is reported in the segment. Following the identifier is a qualifier that describes the content and format of the following field.
The discharge time segment will only occur if the claim covers the patient discharge.
Identifier descriptions:
reports the discharge time
reports the dates of the patient stay. This is different from the UB92 in that the statement from and through dates are reported in one data element separated by a hyphen.
reports both the admission date and the time of admission in one data element. Again, this is different from the UB92, where the fields were reported separately.
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46. 4 5 Claim Codes 1 2 3 CL1*3*2*01~ REF*EA*187~ NTE*UPI*2~
CLM*100381* ***11:A:1~
DTP*096*TM*1045~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~ 4
REF*EA*187~ 5
NTE*UPI*2~
1 Admission type Admission source Patient status
4 Medical record number Patient ethnicity
SLIDE 46 DISCUSSION
The claim codes (CL1) segment reports the admission and discharge statuses. The code values are the same as used with the UB92.
Admission type
Admission source
Patient status.
This reference identification (REF) segment reports the patient’s medical record number. EA identifies the REF segment as containing the medical record number.
As mentioned in slide 43, the NTE segment is used by THCIC to report the patient ethnicity. The UPI qualifier is used to indicate that the patient ethnicity is being reported.
The segment is actually part of the demographics but because THCIC is using the NTE segment to collect this data, it appears under the claim information and looks to be out of order.
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47. Diagnoses, E-Codes, Treatment Codes
NTE*UPI*2~
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
All reported using HI segment.
Identifiers are key to defining field values.
Can mix and match but best kept in order.
SLIDE 47 DISCUSSION
Following the claim information are the reasons for hospitalization, treatments, and other modifying or qualifying data.
All of this data is reported in HI segments. Only the identifiers distinguish the data content.
To enhance readability, review and problem solving, it is best if the segments are reported in the order listed in the 837 Technical Specifications manual.
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48. Principal, Admitting Diagnoses, E-Codes
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
1 Identifier for principal diagnosis 2 Principal diagnosis
3 Identifier for admitting diagnosis 4 Admitting diagnosis
5 Identifier for external cause of injury E-code
7 Identifier for external cause of injury E-Code
SLIDE 48 DISCUSSION
This first segment must always occur. It reports the principal diagnosis, the admitting diagnosis and any external cause of injury codes that may exist.
There must be a principal diagnosis and an admitting diagnosis.
Each data element consists of two or more components separated by the component separator, which in this example is a colon.
Up to 10 external case of injury codes (e-codes) can be reported. In this example, two e-codes are reported.
Do not include decimal points in codes. Decimal points are implied.
Issues found during test reviews (relative to data elements):
Diagnosis codes contain decimal points. This will cause the diagnosis code to be invalid.
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49. HI*BF:49121*BF:4019~ Other Diagnoses 1 2 3 4
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
1 Identifier for other diagnosis Diagnosis code
3 Identifier for other diagnosis Diagnosis code
SLIDE 49 DISCUSSION
There may or may not be any other diagnoses. If other diagnoses exist, report them in a separate HI segment after the principal diagnosis.
There can be up to 24 other diagnoses.
Each HI segment can hold 12 occurrences of data. If more than 12 other diagnosis are to be reported, a second HI segment would be used.
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50. HI*BR:10012:D8:20040102~ Principal Procedure 1 2 3 4
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
1 Identifier for principal procedure
2 Principal procedure code
3 Qualifier for date type Principal procedure date
SLIDE 50 DISCUSSION
For most hospitalizations, there are procedures that are performed.
This HI segment reports the principal procedure code and the principal procedure date.
Either a HCPCS or an ICD code can be reported. In this example the identifier BR is used to indicate that a HCPCS code is being reported.
Identifiers for Principal Procedures:
BP – ICD procedure code
BR – HCPCS procedure code
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51. HI*BQ:4001:D8:20040102*BO:8853:D8:20040102~ Other Procedure
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853:D8: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
1 Identifier for ICD code 2 Other procedure code
3 Qualifier for date type 4 Other procedure date
5 Identifier for HCPCS code 6 Other procedure code
7 Qualifier for date type Other procedure date
SLIDE 51 DISCUSSION
Other procedures are reported in the same way that other diagnoses are reported. There can be a maximum of 24 other procedures and dates.
A second HI segment is required if there are more than 12 other procedures.
Identifiers for Other Procedures:
BQ – ICD procedure code
BO – HCPCS procedure code
As with diagnosis codes, decimals should not be used with procedure codes.
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52. Occurrence Span 1 Identifier for occurrence span
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853:D8: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
1 Identifier for occurrence span
2 Occurrence span code
3 Qualifier for date type
4 Date range associated with occurrence span code
SLIDE 52 DISCUSSION
If occurrence span codes and dates are to be reported, they are reported using the BI identifier.
The date range for the occurrence span codes is reported in a single data element in the same format as used for the statement dates.
THCIC will collect a maximum for 4 occurrences.
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53. Occurrence 1 Identifier for occurrence code 2 Occurrence code
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853:D8: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
1 Identifier for occurrence code
2 Occurrence code
3 Qualifier for date type
4 Date associated with occurrence code
SLIDE 53 DISCUSSION
The BH identifier is used for occurrence codes and associated dates.
THCIC will collect a maximum of 12 occurrences.
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54. HI*BE:01:::307.65~ HI*BG*17~ Occurrence 1 2 3 4 5
HI*BK:486*BJ:486*BN:E2021*BN:E2022~
HI*BF:49121*BF:4019~
HI*BR:10012:D8: ~
HI*BQ:4001:D8: *BO:8853:D8: ~
HI*BI:71:RD8: ~
HI*BH:06:D8: ~
HI*BE:01:::307.65~
HI*BG*17~
1 Identifier for value code Value code Amount
4 Identifier for condition code Condition code
SLIDE 54 DISCUSSION
The identifier BE is used for value codes and the identifier BG is used for condition codes.
The value codes use component separators. In this example, there are data elements that are not used.
THCIC will collect a maximum of 12 value codes and a maximum of 8 condition codes and dates.
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55. NM1*71*1*RICKSHAW*ROBERT~ REF*1G*C12321~ NM1*72*1*SHAW*RICK~
Practitioners
NM1*71*1*RICKSHAW*ROBERT~
REF*1G*C12321~
NM1*72*1*SHAW*RICK~
REF*0B*C3926~
Attending and operating practitioners
Validate against
license number/ UPIN
first three characters of last name
first character of first name.
SLIDE 55 DISCUSSION
The segments that follow the HI segment identify the attending and operating practitioners (if an operating practitioner is reported).
Both practitioners are reported using the NM1 segment. The attending practitioner is required.
THCIC uses the first 3 characters of the last name and the first character of the first name in its validation audit for practitioners.
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56. NM1*71*1*RICKSHAW*ROBERT~ REF*1G*C12321~
Practitioners
NM1*71*1*RICKSHAW*ROBERT~
REF*1G*C12321~
NM1*72*1*SHAW*RICK~
REF*0B*C3926~
1 Identifier for attending practitioner
2 Last name 3 First name
4 Qualifier for UPIN UPIN
SLIDE 56 DISCUSSION
The identifier 71 is used to identify the attending practitioner.
The last name, first name and middle initial can be reported.
A REF segment must follow a NM1 segment for a practitioner. This segment reports the practitioner state license number or UPIN.
REF identifier code values: 1G - reports the UPIN
0B - reports the state license number.
In this example the practitioner’s UPIN is being reported.
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57. NM1*72*1*SHAW*RICK~ REF*0B*C3926~ Practitioners 1 2 3 4 5
NM1*71*1*RICKSHAW*ROBERT~
REF*1G*C12321~
NM1*72*1*SHAW*RICK~
REF*0B*C3926~
1 Identifier for operating practitioner
2 Last name 3 First name
4 Qualifier for state license State license
SLIDE 57 DISCUSSION
If there is an operating practitioner, use the identifier 72.
In this example, the REF segment is reporting the state license number of the operating practitioner.
Issues found during test review:
The REF segment is being left off.
The qualifiers are sometimes mixed. That is, 1G is used with a state license number and vice versa.
Also, sometimes both the UPIN and the state license number are being reported, each in a separate REF segment. In this situation. the last occurrence of the REF will be used.
IMPORTANT NOTE: THCIC preference is for the state license number as the success rate on validation is higher than with the UPIN. If both the state license number and the UPIN are reported for a practitioner, places the REF segment with the state license number last as this will be the one that THCIC validates.
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58. Other Subscriber - Payer
SBR*S********ZZ~
NM1*PR*2*CHARITY*****PI*CHARITY~
1 Secondary subscriber
2 Payer source
3 Payer name
4 Payer ID qualifier
5 Payer ID
In the situation where there is not insurance, then if
self pay: payer name = SELF PAY, payer ID = SELF
indigent: payer name = INDIGENT, payer ID = INDIGENT
charity: payer name = CHARITY, payer ID = CHARITY, and
unknown: payer name = UNKNOWN, payer ID = UNKNOWN.
SLIDE 58 DISCUSSION
If there is more than one payer involved, the secondary payer (item 1) is reported.
The segment for the secondary (other) payer is reported after the practitioner data.
The SBR segment contains many data elements that are not required by THCIC.
The only data collected by THCIC from the secondary SBR segment is the payer source code (item 2).
The NM1 segment reports the name of the payer and the payer’s ID.
If there is more than one secondary payer, the last occurrence will be used.
If there is a tertiary payer, that data will be ignored.
In this example, the service is being provided as charity.
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59. Each service is preceded by a line number (LX)
Service Lines
LX*1~
SV2*0120*HC:2034:01:02:03:04* *DA*4*307*200~
LX*2~
SV2*0271**6.30*UN*1~
LX*3~
SV2*0258**285.80*UN*8~
Each service is preceded by a line number (LX)
Sum of charges in service lines must equal the total charges in the CLM segment.
No 0001 revenue code.
SLIDE 59 DISCUSSION
These segments are used to report the service line charges.
Each service is reported via two segments. The first, Assigned Number (LX) segment, is a line number, which begins with one and is incremented by one for each line.
The second segment, the institutional service (SV2) segment, contains the charge details.
The sum of all of the charges of the SV2 segments is reported in the total charges field in the CLM segment.
The LX numbering begins with 1 for each claim.
Issues found during test review:
The sum of the charge details does not equal to the total charges in the CLM segment.
A totaling revenue code 0001 is being included in the SV2 segment charges. The 837 structure does not require (or allow) for a totaling revenue code 0001.
LX counter is not reset to 1 for each claim.
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60. Service Lines 1
LX*1~
SV2*0120*HC:2034:01:02:03:04* *DA*4*307*200~
LX*2~ SV2*0271**6.30*UN*1~ LX*3~ SV2*0258**285.80*UN*8~
1 line number beginning with 1 and incremented by 1
2 Revenue Code 3 Revenue Procedure Code Qualifier
4 Revenue Procedure Code
Revenue Procedure Code Modifiers
SLIDE 60 DISCUSSION
All of the charges are reported in a two-segment set. The first being the line number segment (LX) and the second the Institutional Service Line (SV2). This examples includes three service details. We will discuss the first as it contains all possible elements.
1 The first segment contains the line number. A LX segment must always precede a SV2 segment.   
The first data element in the SV2 segment is the revenue code.
Following the revenue code, if it exists, is the revenue procedure code and up to four modifiers.
Revenue procedure code qualifier. HC indicates the procedure code is a HCPS code.
Revenue procedure code.
5 – 8 Each procedure code can have up to 4 modifiers. In this example, there are four modifiers.
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61. Service Lines 1
LX*1~
SV2*0120*HC:2034:01:02:03:04* *DA*4*307*200~
LX*2~ SV2*0271**6.30*UN*1~ LX*3~ SV2*0258**285.80*UN*8~
9 Charge amount
10 Unit code Quantity
12 Unit rate Non-covered amount
SLIDE 61 DISCUSSION
9 Service Line Charge Amount. This amount can have a negative sign. If there is no decimal, then the amount is assumed to be a whole number.
10 Unit Code – valid values are DA, UN, F2
11 Quantity. This amount can also be negative.
12 Unit rate. This amount can also be negative.
13 Non-Covered Charge Amount.
Note:
Negative amounts include a negative sign at the beginning of the amount.
Amounts can have decimal points. If there are no decimal points, the amount is assumed to be a whole number.
The 837 Technical Specifications manual provides detail instructions regarding the format and content for the SV2 segment. The Technical Specifications Appendices provides direction for the code sets.
With these segments, this completes the dependent claim.
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62. Subscriber is Patient Claim
HL*4*1*22*0~
SBR*P*18*******MA~
NM1*QC*1*SMITH*JOSEPH~
N3*54 TRAILS END~
N4*AUSTIN*TX*78755~
DMG*D8* *M**4~
REF*SY* ~
NM1*PR*2*MEDICARE PART A*****PI*HH300~
HL segment for subscriber where subscriber is the patient
1 HL ID number 2 ID of parent HL 3 HL level code – 22 for subscriber
4 Child code – no subordinate HL follows
SLIDE 62 DISCUSSION
The next set of segments reports the second of the two claims, this being the one for the subscriber where the subscriber is also the patient.
Like the previous claim, the segments begin with the HL for the subscriber. Except this time there will be no patient HL as all of the claim data will be reported directly under the subscriber HL.
1 The HL identification number, 4, is the next sequential number.
2 The parent HL is the provider (1).
3 This is a HL for a subscriber.
4 And, there are no subordinate HLs.
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63. Subscriber 1 2 3 SBR*P*18*******MA~
HL*4*1*22*0~
SBR*P*18*******MA~
NM1*QC*1*SMITH*JOSEPH~
N3*54 TRAILS END~
N4*AUSTIN*TX*78755~
DMG*D8* *M**4~
REF*SY* ~
NM1*PR*2*MEDICARE PART A*****PI*HH300~
SBR identifies payer source of claim.
1 Primary payer 2 Subscriber is the patient Payer source
SLIDE 63 DISCUSSION
This next segment, identifies that the subscriber is the patient. And, also identifies the primary source of payment.
1 Identifier “P” which identifies this SBR segment as being for the primary payer.
2 The key to this segment is this item. The value 18 indicates that the subscriber is also the patient.
3 In this example, the SBR segment reports the primary payer source to be Medicare Part A.
So, via the 0 at the end of the HL segment and the 18 in the SBR segment we know that there will be no subordinate HLs.
Issues noted during test reviews:
The SBR*P segment is not the second segment.
A value other than 18 is placed in element 2. This element can only be empty or contain the value “18”.
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64. NM1*IL*1*SMITH*JOSEPH~ 3 N3*54 TRAILS END~ 4 5 6 N4*AUSTIN*TX*78755~
Patient Info
HL*4*1*22*0~
SBR*P*18*******MA~
NM1*IL*1*SMITH*JOSEPH~ 3
N3*54 TRAILS END~
N4*AUSTIN*TX*78755~
DMG*D8* *M**4~
REF*SY* ~
NM1*PR*2*MEDICARE PART A*****PI*HH300~
1 Patient last name Patient first name
3 Line 1 - Street Address City State Zip.
SLIDE 64 DISCUSSION
Since the subscriber is the patient, the name, identifiers and demographics are reported under the subscriber.
Three segments are used to report the patient name and address – NM1, N3 and N4.
The “IL” identifier in the NM1 distinguishes this name as being the name of the subscriber.
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65. 1 Patient birth date 2 Gender 3 Race 4 Social security number
Patient Info
HL*4*1*22*0~
SBR*P*18*******MA~
NM1*QC*1*SMITH*JOSEPH~
N3*54 TRAILS END~
N4*AUSTIN*TX*78755~
DMG*D8* *M**4~ 4
REF*SY* ~
NM1*PR*2*MEDICARE PART A*****PI*HH300~
1 Patient birth date Gender Race
4 Social security number
SLIDE 65 DISCUSSION
The DMG segment is used to report the
subscriber’s birth date,
gender, and
Race.
The REF segment is used to report the
4 social security number using the SY identifier.
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66. 1 2 Primary Payer NM1*PR*2*MEDICARE PART A*****PI*HH300~
HL*4*1*22*0~
SBR*P*18*******MA~
NM1*QC*1*SMITH*JOSEPH~
N3*54 TRAILS END~
N4*AUSTIN*TX*78755~
DMG*D8* *M**4~
REF*SY* ~
NM1*PR*2*MEDICARE PART A*****PI*HH300~
1 Payer name Payer ID
SLIDE 66 DISCUSSION
This next segment, while reported under the subscriber HL, identifies the primary payer.
The NM1 segment with a PR identifier is used to report
1 the primary payer name, and
2 the payer ID.
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67. Claim details: including admission, diagnosis and treatment data.
Claim Info
CLM*PAN1043*400***11:A:1~
DTP*096*TM*0900~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*MRN2211~
NTE*UPI*2~
Claim details: including admission, diagnosis and treatment data.
SLIDE 67 DISCUSSION
Because this claim is for a subscriber that also is the patient, there is no patient HL. Thus the patient HL hierarchical level and all related segments are skipped.
These segments begin the claim information.
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68. CLM*PAN1043*400***11:A:1~ Claim Info 1 2 3
CLM*PAN1043*400***11:A:1~
DTP*096*TM*0900~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*MRN2211~
NTE*UPI*2~
1 Patient account number (patient control number).
2 Total claim charges
3 Bill Type
SLIDE 68 DISCUSSION
This CLM segment reports
The patient account number
The total charges for the claim
The bill type.
Note that element 2 contains This is interpreted to be $
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69. DTP*435*DT*200410050700~ Discharge Time 1 2 3 DTP*096*TM*0900~
CLM*PAN1043*400***11:A:1~
DTP*096*TM*0900~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*MRN2211~
NTE*UPI*2~
1 Identifies DTP as for discharge data.
2 Qualifies next element as time in format of hhmm.
3 Discharge time.
SLIDE 69 DISCUSSION
The DTP segments immediately following the CLM segment are used to report the discharge time, statement dates, and admit date and time.
The first DTP segment is for the discharge time.
096 identifies the segment as being for discharge.
Qualifies element 3 as being time in hhmm format.
Reports the time.
The reporting formats of both the statement dates and admit date and time are different from that used in the UB92 claim.
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70. DTP*434*RD8*20041005-20041010~ Statement Dates 1 2 3
CLM*PAN1043*400***11:A:1~
DTP*096*TM*0900~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*MRN2211~
NTE*UPI*2~
1 Identifies DTP as for statement dates.
2 Qualifies next element as being a date range.
3 Statement dates.
SLIDE 70 DISCUSSION
The next DTP segment reports the statement from and through dates.
434 identifies the segment as reporting the statement dates.
Qualifies element 3 as being a date range containing two 8 digit dates.
Reports the statement from and through dates separated by a hyphen.
The reporting formats of both the statement dates are different from that used in the UB92 claim.
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71. Admission Date and Time
CLM*PAN1043*400***11:A:1~
DTP*096*TM*0900~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~
REF*EA*MRN2211~
NTE*UPI*2~
1 Identifies DTP as for admission date and time.
2 Qualifies next element as being a date/time combination.
3 Admission date and admission time (hhmm).
SLIDE 71 DISCUSSION
The next DTP segment reports the admission date and admission time.
435 identifies the segment as reporting admission data.
Qualifies element 3 as being a date – time combination.
Reports the admission date and the admission time. The date is 8 digits followed by a 4 digits for the hhmm.
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72. Claim Codes 1 Admission type 2 Admission source
CLM*PAN1043*400***11:A:1~
DTP*096*TM*0900~
DTP*434*RD8* ~
DTP*435*DT* ~
CL1*3*2*01~ 4
REF*EA*MRN2211~ 5
NTE*UPI*2~
1 Admission type
2 Admission source
3 Patient status (discharge status)
4 Medical record number
5 Ethnicity of patient.
SLIDE 72 DISCUSSION
The CLM segment reports the
admission type,
admission source, and
discharge status code.
The REF segment, using the EA identifier, reports the
medical record number.
The NTE segment completes the patient demographics by reporting the
5 ethnicity of the patient. The NTE segment requires the UPI qualifier.
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73. HI Segments Diagnoses, E-Codes, Treatment Codes
NTE*UPI*2~
HI*BK:100*BJ:100~
All reported using HI segment.
Qualifier is key to defining field values.
SLIDE 73 DISCUSSION
As with the previous claim, the HI segments report the reasons for hospitalization, the treatment provided and qualifying data.
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74. Principal, Admitting Diagnoses, E-Codes
HI*BK:100*BJ:100~
1 Identifier for principal diagnosis
2 Principal diagnosis
3 Identifier for admitting diagnosis
4 Admitting diagnosis
SLIDE 74 DISCUSSION
In this example only a
identifier for principal diagnosis,
principal diagnosis,
identifier for admitting diagnosis, and
admitting diagnosis
are reported.
This is the minimum that has to be reported.
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75. Attending practitioners Validate against license number/ UPIN
NM1*71*1*RICHARDS*SAM~
REF*1G*C96522~
REF*0B*C9312~
Attending practitioners
Validate against
license number/ UPIN
first three characters of last name
first character of first name.
SLIDE 75 DISCUSSION
Following the HI segments are the segments reporting the practitioner data.
The THCIC validation audit uses the reported practitioner ID (license number or UPIN), the first three characters of the last name and the first character of the first name to validate the practitioner.
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76. NM1*71*1*RICHARDS*SAM~ REF*1G*C96522~ REF*0B*C9312~ Practitioners
NM1*71*1*RICHARDS*SAM~
REF*1G*C96522~
REF*0B*C9312~
1 Identifier for attending practitioner
2 Last name 3 First name
4 Identifier for UPIN 5 UPIN
6 Identifier for state license 7 State license
SLIDE 76 DISCUSSION
In this example both the attending practitioner’s UPIN and state license number are reported.
If two REF segments are listed after a practitioner name segment, the last will be used. In this example the state license number will be used.
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77. Other Subscriber - Payer
SBR*S********BL~
NM1*PR*2*BLUE CROSS OF TEXAS*****PI*BL0325~
SBR*T********CI~
NM1*PR*2*WELLNESS HEALTH*****PI*WELLHLT~
Secondary and tertiary subscriber - payers.
Only secondary subscriber - payer will be used.
SLIDE 77 DISCUSSION
If there is more than one payer for this claim, the segments reporting the other payer(s) occur after the practitioner data.
As seen with the first claim, two segments are required to report the payer data; the SBR and the NM1*PR.
The SBR segment is requires as it identifies the position of the payer in the payment hierarchy and also identifies the source of the payment.
The NM1*PR segment names the payer and reports the payer ID.
In this example secondary and tertiary payers are reported. The tertiary payer will be ignored.
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78. Other Subscriber - Payer
SBR*S********BL~
NM1*PR*2*BLUE CROSS OF TEXAS*****PI*BL0325~
SBR*T********CI~
NM1*PR*2*WELLNESS HEALTH*****PI*WELLHLT~
1 Identifier for secondary subscriber
2 Payer source code
3 Payer name
4 Payer ID
SLIDE 78 DISCUSSION
The SBR segment is reporting the
Secondary payer as having
A payer source code of BL, Blue Cross/Blue Shield.
The NM1 segment is reporting
The name of the payer, and
The payer ID.
The next SBR*T segment is skipped as only the primary and first secondary payer are collected.
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79. Each service is preceded by a line number (LX)
Service Lines
LX*1~ SV2*0120**1000*DA*2*500.00~
Each service is preceded by a line number (LX)
Sum of charges in service lines must equal the total charges in the CLM segment.
No 0001 revenue code.
SLIDE 79 DISCUSSION
Following the secondary payer data are the charges data. At least one service detail is required -- even if the amount is zero.
In this example there is only one service charge detail.
These are the last segments required for the claim where the subscriber also is the patient.
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80. 6453 www.dshs.state.tx.us/thcic Questions ? Ron Weiss
Bruce Burns
6453
SLIDE 80 DISCUSSION
There are details that were not addressed as this was intended to be a introductory level technical session.
The technical specification manual on the website contains the THCIC 837 specifications and can provide answers to many of your questions.
For questions that aren’t answered by the 837 Technical Specifications, please feel free to those questions and any comments or suggestions to either person.
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