| << Previous Appendix | AS, ED, IP X12-837 Input / IP Output / OP Output | Next Appendix >> |
|---|
Appendix NN -Programmers Guide for SPARCS Requirements
| Data Element Name | Segment ID | Data Type | Min./Max. Length | Syntax/Value | Notes |
|---|---|---|---|---|---|
| ISA Interchange Control Header (Header) | Fixed Length required | ||||
| ISA01 | ID | 2/2 | May equal "00" | ||
| ISA02 | AN | 10/10 | May equal Authorization Information | ||
| ISA03 | ID | 2/2 | May equal "0" | ||
| ISA04 | AN | 10/10 | May equal Security Information | ||
| ISA05 | ID | 2/2 | Must equal "ZZ" | ||
| ISA06 | AN | 15/15 | May equal Interchange Sender ID or SPARCS Collector Code | ||
| ISA07 | ID | 2/2 | Must equal "ZZ" | ||
| ISA08 | AN | 15/15 | May equal Interchange Receiver ID or SPARCS Collector Code | ||
| ISA09 | DT | 6/6 | May equal Interchange Date - YYMMDD format | ||
| ISA10 | TM | 4/46 | May equal Interchange Time - HHMM format | ||
| ISA11 | ID | 1/1 | Must equal Repetition Separator, "^" | ||
| ISA12 | ID | 5/5 | Must equal "00405" Must Equal "00501" |
4050 Only 5010 Only |
|
| ISA13 | AN | 9/9 | May equal Interchange Control Number (same value as Interchange Control Trailer, IEA02) | ||
| ISA14 | ID | 1/1 | Must equal "0" or "1" | ||
| ISA15 | ID | 1/1 | Must equal "P" or "T" | ||
| ISA16 | AN | 1/1 | Must equal Component Element Separator, ":" | ||
| GS Functional Group Header | Required | ||||
| GS01 | ID | 2/2 | Must equal "HC" | ||
| GS02 | AN | 2/15 | May equal Application Sender's Code or SPARCS Collector Code | ||
| GS03 | AN | 2/15 | May equal Application Reviewer's Code or "SPARCS" | ||
| GS04 | DT | 8/8 | May equal Functional Group Date (Creation Date - CCYYMMDD format) | ||
| GS05 | TM | 4/8 | May equal Functional Group Time (Creation Time - HHMM format) | ||
| GS06 | AN | 1/9 | May equal Group Control Number (same value as Functional Group Trailer, GE02) | ||
| GS07 | ID | 1/2 | Must equal "X" | ||
| GS08 | AN | 1/12 | Must equal "004050X156" Must Equal "005010X225A1" or "005010X225A2" or "005010X225E1" |
4050 Only 5010 Only |
|
| ST Transaction Set Header (Header) | Required | ||||
| ST01 | ID | 3/3 | May equal "837" | ||
| ST02 | AN | 4/9 | May equal Transaction Set Control Number (same value as SE02) | ||
| BHT Beginning of Hierarchical Transaction (Header) | Required | ||||
| BHT01 | ID | 4/4 | Must equal "0019" | ||
| BHT02 | ID | 2/2 | Must equal "00" or "18" | ||
| BHT03 | AN | 1/7* | May equal File Sequence and Serial Number | ||
| BHT04 | DT | 8/8 | May equal Processing Date - CCYYMMDD format | ||
| BHT05 | TM | 4/8 | May equal Processing Time - HHMM format | ||
| NM1 Submitter Name (1000A) | Required | ||||
| NM101 | ID | 2/3 | Must equal "41" | ||
| NM102 | ID | 1/1 | Must equal "2" | ||
| NM103 | AN | 1/21* | May equal Submitting Organization Name | ||
| NM108 | ID | 1/2 | Must equal "46" | ||
| NM109 | AN | 2/3 | Must equal SPARCS Collector Code | ||
| REF Submitter Secondary Identifcation (1000A) | Not Used by SPARCS | ||||
| PER Submitter EDI Contact Information(1000A) | Not Used by SPARCS | ||||
| PER01 | ID | 2/2 | May equal "IC" | ||
| PER02 | AN | 1/21* | May equal Submitter Contact Person (Name) | ||
| PER03 | ID | 2/2 | May equal "ED", "EM", "FX", or "TE" Must equal "EM", "FX", or "TE" |
4050 Only 5010 Only |
|
| PER04 | AN | 1/256 | May equal Communication Number | ||
| NM1 Receiver Name (1000B) | Not Used by SPARCS | ||||
| NM101 | ID | 2/3 | May equal "40" | ||
| NM102 | ID | 1/1 | May equal "2" | ||
| NM103 | AN | 1/60 | May equal Receiver Organization Name | ||
| NM108 | ID | 1/2 | May equal "46" | ||
| NM109 | AN | 2/80 | May equal Receiver Primary Identification | ||
| HL Service Provider Hierarchical Level (2000A) | Required | ||||
| HL01 | N | 1/12 | Must begin with 1 for the first HL01 in the transaction and be incremented by 1 each time an HL is used within the transaction. Only numeric values are allowed in HL01. The same value should also be reported in every subordinate Subscriber Hierarchical Level HL02. | ||
| HL03 | ID | 1/2 | Must equal "20" | ||
| HL04 | ID | 1/1 | Must equal "1" | ||
| NM1 Service Provider Name (2010AA) | Required | ||||
| NM101 | ID | 2/3 | Must equal "SJ" | ||
| NM102 | ID | 1/1 | Must equal "2" | ||
| NM103 | AN | 1/60 | May equal Service Provider Organization Name | ||
| NM108 | ID | 1/2 | Must equal "XX" | ||
| NM109 | AN | 2/13 | Must equal Billing National Provider Identification (when available) | ||
| REF Service Provider Secondary Identification (2010AA) | Required | ||||
| REPEAT 1 | |||||
| REF01 | ID | 2/3 | Must equal "1J" | ||
| REF02 | N | 5/5* | Must equal appropriate SPARCS Facility Identification Number | ||
| HL Subscriber Hierarchial Level (2000B) Note: If the subscriber is not the same as the patient, Loop 2000C must be used for the patient information. If the subscriber is the same as the patient, Loop 2000C is not sent. |
|||||
| HL01 | AN | 1/12 | Must begin with 1 for the first HL01 in the transaction and be incremented by 1 each time an HL is used within the transaction. Only numeric values are allowed in HL01. The same value should also be reported in every subordinate Patient Hierarchical Level HL02. | ||
| HL02 | AN | 1/12 | Must contain the same value as the parent Service Provider Hierarchical Level HL01. | ||
| HL03 | ID | 1/2 | Must equal "22" | ||
| HL04 | ID | 1/1 | Must equal "0" or "1" | ||
| SBR Subscriber Information (2000B) Note: SPARCS only processes and stores the subscriber information when the subscriber IS the patient |
Required | ||||
| SBR01 | ID | 1/1 | Must equal "P" | ||
| SBR02 | ID | 2/2 | Must equal "18" if the subscriber IS the patient, otherwise not required. | ||
| SBR09 | ID | 1/2 | Must equal Claim Filing Indicator Code | ||
| PAT Patient Information (2000B) | Not Used by SPARCS | ||||
| NM1 Subscriber Name (2010BA) - The following are SPARCS data values for this segment if the subscriber IS the patient. The subscriber's name will not be stored on the SPARCS master files. |
Required if the subscriber IS the patient | ||||
| NM101 | ID | 2/3 | Must equal "IL" | ||
| NM102 | ID | 1/1 | Must equal "1" | ||
| NM103 | AN | 1/60 | May equal Subscriber's Last name or masked | ||
| NM104 | AN | 1/35 | May equal subscriber's First Name or masked | ||
| NM105 | AN | 1/25 | May equal Subscriber's Middle Name or masked | ||
| NM108 | ID | 1/2 | Must equal "MI" Must Equal "MI" or "II" (when HIPAA Individual Patient Identifier is mandated) |
4050 Only 5010 Only |
|
| NM109 | AN | 2/19* | Must equal Insurance Policy Number | IP Only | |
| N3 Subscriber Address (2010BA) | Required if subscriber IS the patient | ||||
| N301 | AN | 1/18* | Must equal Subscriber's Street Address | ||
| N302 | AN | 1/18* | Must equal Subscriber's Street Address Line 2, if applicable | ||
| N4 Subscriber City/State/Zip Code (2010BA) | Required if subscriber IS the patient | ||||
| N401 | AN | 2/15* | Must equal Subscriber's City | ||
| N402 | ID | 2/2 | Must equal Subscriber's State | ||
| N403 | ID | 3/9* | Must equal Subscriber's Postal Code | ||
| N405 | ID | 1/2 | Must equal "CO" | ||
| N406 | N | 1/2* | Must equal County Code | ||
| DMG Subscriber Demographic Information (2010BA) | Required if subscriber IS the patient | ||||
| DMG01 | ID | 2/3 | Must equal "D8" | ||
| DMG02 | AN | 1/8* | Must equal Birthdate in CCYYMMDD format | ||
| DMG03 | ID | 1/1 | Must equal Patient Sex ("F", "M", or "U") | ||
| DMG05-2 | ID | 1/3 | Must equal "RET" | IP, AS, ED, only | |
| DMG05-3 | ID | 1/2* | Race must equal: "R1", "R2", "R3", "R4", "R5", "R9" Ethnicity must equal: "E1" or "E2" See example on page in Data Specifications. |
IP, AS, ED, only Optional for OP |
|
| REF Subscriber Secondary Identification(2010BA) | Required if subscriber IS the patient | ||||
| REF01 | ID | 2/3 | Must equal "ABB" | ||
| REF02 | AN | 1/10* | Must equal Unique Personal Identification Number | ||
| NM1 Payer Name(2010BC) | 4050 Only moved to 2010BB in 5010 | ||||
| NM101 | ID | 2/3 | Must equal "PR" | 4050 only | |
| NM102 | ID | 1/1 | Must equal "2" | 4050 only | |
| NM103 | AN | 1/60 | Must equal Payer Name | 4050 only | |
| NM108 | ID | 1/2 | Must equal "PI" or "XV" | 4050 only | |
| NM109 | AN | 2/80 | Must equal Payer Identification Number | 4050 only | |
| NM1 Payer Name(2010BB) | 5010 ONLY | ||||
| NM101 | ID | 2/3 | Must equal "PR" | 5010 only | |
| NM102 | ID | 1/1 | Must equal "2" | 5010 only | |
| NM103 | AN | 1/60 | Must equal Payer Name | 5010 only | |
| NM108 | ID | 1/2 | Must equal "PI" or "XV" | 5010 only | |
| NM109 | AN | 2/8* | Must equal Payer Identification Number | 5010 only | |
| REF Payer Secondary Identification (2010BC)1 | |||||
| REF01 | ID | 2/3 | May equal "2U", "NF" | ||
| REF02 | AN | 1/8* | May equal Payer Identification Number | ||
| HL Patient Hierarchical Level (2000C) Note: If the subscriber is not the same as the patient, Loop 2000C must be used for the patient information. If the subscriber is the same as the patient, Loop 2000C is not sent. |
Required if the patient is NOT the subscriber | ||||
| HL01 | AN | 1/12 | Must begin with 1 for the first HL01 in the transaction and be incremented by 1 each time an HL is used within the transaction. Only numeric values are allowed in HL01. | ||
| HL02 | AN | 1/12 | Must contain the same value as the parent Subscriber Hierarchical Level HL01 | ||
| HL03 | ID | 1/2 | Must equal "PT" Must equal "23" |
4050 Only 5010 Only | |
| HL04 | ID | 1/1 | Must equal "0" | ||
| PAT Patient Information (2000C) | Not required for SPARCS | ||||
| NM1 Patient Name(2010CA) The following are SPARCS data values for this segment if the subscriber IS NOT the patient. The patient's name will not be stored on the SPARCS master files. |
Required if subscriber IS NOT the patient | ||||
| NM101 | ID | 2/3 | Must equal "QC" | 4050 Only. Not needed in 5010 | |
| NM102 | ID | 1/1 | Must equal "1" | 4050 Only. Not needed in 5010 | |
| NM103 | AN | 1/60 | May equal Patient's Last Name or masked | 4050 Only. Not needed in 5010 | |
| NM104 | AN | 1/35 | May equal Patient's First Name or masked | 4050 Only. Not needed in 5010 | |
| NM105 | AN | 1/25 | May equal Patient's Middle Name or masked | 4050 Only. Not needed in 5010 | |
| NM108 | ID | 1/2 | Must equal "MI" Removed 34,ZZ |
4050 Only | |
| NM109 | AN | 2/19* | Must equal Insurance Policy Number | 4050 Only | |
| N3 Patient Address (2010CA) | Required if subscriber IS NOT the patient | ||||
| N301 | AN | 1/18* | Must equal Patient's Street Address | ||
| N302 | AN | 1/18* | Must equal Patient's Street Address Line 2, if applicable | ||
| N4 Patient City/State/Zip Code (2010CA) | Required if subscriber IS NOT the patient | ||||
| N401 | AN | 2/15* | Must equal Patient's City | ||
| N402 | ID | 2/2 | Must equal Patient's State | ||
| N403 | ID | 3/9* | Must equal Patient's Postal Code | ||
| N405 | ID | 1/2 | Must equal "CO" | ||
| N406 | N | 1/2* | Must equal County Code | ||
| DMG Patient Demographic Information(2010CA) | Required if subscriber IS NOT the patient | ||||
| DMG01 | ID | 2/3 | Must equal "D8" | ||
| DMG02 | N | 1/8* | Must equal Birth Date in CCYYMMDD format | ||
| DMG03 | AN | 1/1 | Must equal Patient Sex ("F", "M", or "U") | ||
| DMG05 is a composite data element. The Component Element Separator (ISA16) must be used before and after the composite data element DMG05-2, "RET". In addition, the Repetition Separator (ISA11) must be used between race and ethnicity. | |||||
| DMG05-2 | ID | 1/3 | Must equal "RET" | IP, AS, ED only | |
| DMG05-3 | ID | 1/2* | Race must equal: "R1", "R2", "R3", "R4", "R5", "R9" Ethnicity must equal: "E1" or "E2" See example on page in Data Specifications. |
IP, AS, ED only Optional for OP | |
| REF Patient Secondary Identification(2010CA) | Required if subscriber IS NOT the patient | ||||
| In 5010R, REF section is used to report two data elements. | REF01 | ID | 2/3 | "ABB" - Use this qualifier for Unique Personal Identifier "IG" - Use this qualifier for Insured's Policy Number |
4050R and 5010R 5010R only |
| REF02 | AN | 1/10* (Unique Personal ID) 1/19* (Insured's Policy #) |
Must equal Unique Personal Identification Number when qualifier is "ABB" In 5010R only, when qualifier is "IG", REF02 must equal Insurance Policy Number |
||
| CLM Claim Information (2300) | Required | ||||
| CLM01 | AN | 1/20* | Must equal Patient Control Number | ||
| CLM02 | N | 1/12* | Must equal Total Claim Charges | ||
| CLM05 is a composite data element. The Component Element Separator(ISA16) must be used before and after the composite data element CLM05-2, "A" | |||||
| CLM05-1 | AN | 1/2 | Must equal Bill Type Facility Code Value | ||
| CLM05-2 | ID | 1/2 | Must equal "A" | ||
| CLM05-3 | ID | 1/1 | Must equal Bill Type Frequency Code | ||
| DTP Discharge Hour(2300) - Required | Required | ||||
| DTP01 | ID | 3/3 | Must equal "096" | ||
| DTP02 | ID | 2/3 | Must equal "TM" | ||
| DTP03 | AN | 1/2* | Must equal Discharge Hour (HHMM format used. SPARCS currently edits the first two characters) | ||
| DTP Statement Dates(2300) | Required | ||||
| DTP01 | ID | 3/3 | Must equal "434" | ||
| DTP02 | ID | 2/3 | Must equal "RD8" | ||
| DTP03 | N | 16/16 where: 8/8 for Statement From and 8/8 for Statement Through |
Must equal Statement Period From and Through Dates(CCYYMMDD-CCYYMMDD format) | ||
| DTP Admission Date/Hour(2300) | Required | ||||
| DTP01 | ID | 3/3 | Must equal "435" | ||
| DTP02 | ID | 2/3 | Must equal "DT" | ||
| DTP03 | DT | 1/12* where: 8/8 for Admission Date and 2/4 for Admission Hour |
Must equal Admission Date/Hour (CCYYMMDDHHMM format) | ||
| CL1 Institutional Claim Code(2300) | Required | ||||
| CL101 | AN | 1/1 | Must equal Type of Admission Code | IP Only | |
| CL102 | AN | 1/1 | Must equal Point of Origin | IP Only | |
| CL103 | AN | 1/2 | Must equal Patient Status Code | ||
| PWK Claim Supplemental Information(2300) | Not Required by SPARCS | ||||
| AMT Payer Estimated Amount Due(2300) | Not Required by SPARCS | ||||
| AMT Patient Estimated Amount Due(2300) | Not Required by SPARCS | ||||
| REF Medical Record Number(2300) | Required | ||||
| REF01 | ID | 2/3 | Must equal "EA" | ||
| REF02 | AN | 1/17* | Must equal Medical Record Number | ||
| REF Mother's Medical Record Number for Newborns(2300) | Required | ||||
| REF01 | ID | 2/3 | Must equal "MRN" | IP Only | |
| REF02 | AN | 1/17* | Must equal Mother's Medical Record Number | IP Only | |
| K3 File Information(2300) | Not Required by SPARCS | ||||
| NTE Claim Note - Required(2300) | Required | ||||
| NTE01 | ID | 3/3 | Must equal "UPI" | ||
| NTE02 | AN | 1/80 | See below for SPARCS NTE requirements | ||
| SPARCS 2300 NTE SEGMENT LAYOUT | |||||
| Description | Inpatient Position |
Outpatient Position |
Length/Format | |
|---|---|---|---|---|
| Expected Principal Reimbursement | 1-2 | 1-2 | 2 A/N | IP, AS, ED only |
| Expected Principal Reimbursement Other 1 | 3-4 | Not Required | 2 A/N | IP only |
| Expected Reimbursement Other 2 | 5-6 | Not Required | 2 A/N | IP only |
| Method of Anesthesia | 7-8 | 3-4 | 2 A/N | IP, AS only |
| Exempt Unit Indicator | 9-11 | Not Required | 3 A/N | IP only |
| Filler | 12-14 | 5-7 | - --- | Removed Patient Race and Ethnicity to DMG. |
| Heart Rate | 15-17 | 8-10 | 3 AN | Removed Patient Race and Ethnicity to DMG. |
| Blood Pressure - Systolic | 18-20 | 11-13 | 2 AN | IP, ED only. |
| Blood Pressure - Diastolic | 21-23 | 14-16 | 3 AN | IP, ED only. |
| Procedure Time | IP not required | 17-19 | 3 AN | AS only. |
| Source of Payment Typology I | 24-28 | 20-24 | 5 AN | |
| Source of Payment Typology II | 29-33 | 25-29 | 5 AN | |
| Source of Payment Typology III | 34-38 | 30-34 | 5 AN | |
| End of Segment Indicator~ | 39 | 35 | 1 AN | |
| Note:Spaces equaling the data element length must be used if a data element cannot be supplied. | ||||
| HI Principal, Admitting, and External Cause of Injury Codes (2300) HI101-HI12 is required composite data elements. HI05-HI12 is used for claims that have a third through tenth E-code, respectively. Component Element Separator (ISA16) must be used between segment data elements. This section is repeated to clarify the difference between the 4050 and the 5010. |
Required | ||||
| This HI Section applies to the 4050 ONLY: | |||||
| Data Element Name | Segment ID | Data Type | Min./Max. Length | Syntax/Value | Notes |
|---|---|---|---|---|---|
| HI01-1 | ID | 1/3 | Must equal "BK" | ||
| HI01-1 | ID | 1/3 | Must equal "BK" | ||
| HI01-2 | AN | 1/30 | Must equal Principal Diagnosis Code | ||
| HI02-1 | ID | 1/3 | Must equal "BJ" | IP Only | |
| HI02-2 | AN | 1/30 | Must equal Admitting Diagnosis Code | ||
| HI02-1 | ID | 1/3 | Must equal "PR" | AS, ED Only | |
| HI02-2 | AN | 1/30 | Must equal Patient Reason for Visit | ||
| HI03-1 | ID | 1/3 | Must equal "BN" | External Cause-of-Injury Code in the range of E850.0-E869.9 or E880.0-E928.9 is reported, then a "Place of Occurrence" code must also be reported. | |
| HI03-2 | AN | 1/30 | Must equal External Cause of Injury Code | ||
| HI04-1 | ID | 1/3 | Must equal "BN" | ||
| HI04-2 | AN | 1/30 | Must equal Place of Injury Code | ||
| HI05-1 thru HI12-1 | ID | 1/3 | Must equal "BN" | External Cause-of-Injury Code in the range of E850.0-E869.9 or E880.0-E928.9 is reported, then a "Place of Occurrence" code must also be reported. | |
| HI05-2 thru HI12-2 | AN | 1/30 | Must equal External Cause of Injury Code | ||
| This HI Section applies to the 5010 ONLY: | |||||
| HI01-1 | ID | 1/3 | Must equal "BK" (for ICD-9-CM) Must equal "ABK" (for ICD-10-CM reporting) |
||
| HI01-2 | AN | 1/30 | Must equal Principal Diagnosis Code | ||
| HI01-1 | ID | 1/3 | Must equal "BJ" (for ICD-9-CM) Must equal "ABJ" (for ICD-10-CM reporting) |
IP Only | |
| HI01-2 | AN | 1/30 | Must equal Admitting Diagnosis Code | ||
| HI01-1 | ID | 1/3 | Must equal "PR" (for ICD-9-CM) Must equal "APR" (for ICD-10-CM reporting) |
AS, ED Only Up to three reasons for visit can be reported. First reason in HI01. | |
| HI01-2 | AN | 1/30 | Must equal Patient's Reason for Visit Code | ||
| HI02-1 | ID | 1/3 | Must equal "PR" (for ICD-9-CM) Must equal "APR" (for ICD-10-CM reporting) |
AS, ED Only Up to three reasons for visit can be reported. Second reason in HI02. | |
| HI02-2 | AN | 1/30 | Must equal Patient's Reason for Visit Code | ||
| HI03-1 | ID | 1/3 | Must equal "PR" (for ICD-9-CM) Must equal "APR" (for ICD-10-CM reporting) |
AS, ED Only Up to three reasons for visit can be reported. Third reason in HI03. |
|
| HI03-2 | AN | 1/30 | Must equal Patient's Reason for Visit Code | ||
| HI01-1 thru HI12-1 | ID | 1/3 | Must equal "BN"(for ICD-9-CM) Must equal "ABN"(for ICD-10-CM reporting) |
Up to twelve external causes of injury can be reported. External Cause-of-Injury Code in the range of E850.0-E869.9 or E880.0-E928.9 is reported, then a "Place of Occurrence" code must also be reported. | |
| HI01-2 thru HI12-2 | AN | 1/30 | Must equal External Cause of Injury Code | ||
| HI Diagnosis Related Group (DRG) Information(2300) | Not Required by SPARCS | ||||
| HI Other Diagnosis Information (2300) HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have a second through twelfth Other Diagnosis Code, repspectively. Component Element Separator (ISA16) must be used between segment data elements. Note: A second repeat of these segments may be used to report Other Diagnosis Codes 13 through 24. |
Situational | ||||
| HI01-1 thru HI12-1 | ID | 1/3 | Must equal "BF" (for ICD-9-CM) Must equal "ABF" (for ICD-10-CM reporting) |
||
| HI01-2 thru HI12-2 | AN | 1/6* | Must equal Other Diagnosis Code | ||
| HI01-9 thru HI12-9 | ID | 1/1 | Must equal Present on Admission Indicator("N", "U", "Y", or "W") | IP Only | |
| HI Principal Procedure Information (2300) HI01 is a required composite data element. Component Element Separator (ISA16) must be used between segment data elements. |
Situational | ||||
| HI01-1 | ID | 1/3 | Must equal "BR"(for ICD-9-CM) Must equal "BBR" (for ICD-10-CM reporting) |
IP Only | |
| HI01-2 | AN | 1/7* | Must equal Principal Procedure Code | IP Only | |
| HI01-3 | ID | 2/3 | Must equal "D8" | IP Only | |
| HI01-4 | N | 8/8* | Must equal Principal Procedure Date (CCYYMMDD format) | IP Only | |
| HI Other Procedure Information (2300) HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have a second through twelfth Other Procedure Code, repspectively. Component Element Separator (ISA16) must be used between segment data elements. |
Situational | ||||
| HI01-1 thru HI12-1 | ID | 1/3 | Must equal "BQ"(for ICD-9-CM) Must equal "BBQ" (for ICD-10-CM reporting) |
IP Only | |
| HI01-2 thru HI12-2 | AN | 1/7* | Must equal Other Procedure Code | IP Only | |
| HI01-3 thru HI12-3 | ID | 2/3 | Must equal "D8" | IP Only | |
| HI01-4 thru HI12-4 | N | 8/8* | Must equal Other Procedure Date (CCYYMMDD format) | IP Only | |
| Note: A second repeat of these segments may be used to report Other Procedure Codes 12 through 24. Although all other procedure codes for a claim may be entered on two iterations of this composite segment, SPARCS currently only processes the first fourteen (14) Other Procedure Codes. | |||||
| HI Occurence Span Information (2300) HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Occurrence Span Code conditions. Component Element Separator (ISA16) must be used between segment data elements. SPARCS allows a maximum of 30 Occurrence Spans. |
Situational | ||||
| HI01-1 thru HI12-1 | ID | 1/3 | Must equal "BI" | IP Only | |
| HI01-2 thru HI12-2 | AN | 1/2* | Must equal "74" or "75" (Removed "81" and "82") | IP Only | |
| HI01-3 thru HI12-3 | ID | 2/3 | Must equal "RD8" | IP Only | |
| HI01-4 thru HI12-4 | AN | 1/35 | Must equal Occurrence Span Date range (CCYYMMDD-CCYYMMDD format) | IP Only | |
| Note: Reportable Occurrence Span Code conditions may be coded in any order, and may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides. | |||||
| HI Occurence Information (2300) HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Occurrence Code conditions. Component Element Separator (ISA16) must be used between segment data elements. |
Situational | ||||
| HI01-1 thru HI12-1 | ID | 1/3 | Must equal "BH" | ||
| HI01-2 thru HI12-2 | AN | 1/30 | Must equal "01", "02", "03", "04", "05", or "06" | ||
| HI01-3 thru HI12-3 | ID | 2/3 | Must equal "D8" | ||
| HI01-4 thru HI12-4 | AN | 1/35 | Must equal Occurrence Associated Date(CCYYMMDD format) | IP Only | |
| Note: Reportable Occurrence Code conditions may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides. | |||||
| HI Value Information (2300) HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Value Code conditions. Component Element Separator (ISA16) must be used between segment data elements. |
Situational | ||||
| HI01-1 thru HI12-1 | ID | 1/3 | Must equal "BE" | ||
| HI01-2 thru HI12-2 | AN | 1/2* | Must equal: Inpatient (IP) Only: "14"- No Fault, Incl. Auto/other "15"- Worker's Comp. "21"- Catastrophic "22"- Surplus "23"- Recurring Monthly Income "37"- Units of Blood "54"- Newborn Weight in Grams "80"- Covered Days "81"- Non-covered Days Ambulatory Surgery(AS) and Emergency Dept (ED) only: "45"- Accident Hour Outpatient (OP) Only: "24"- Medicaid Rate Code |
Use of codes for specific type of data: example - Code 45 is AS, ED Only 5010 Only 5010 Only | |
| HI01-5 thru HI12-5 | R | 1/19* | Must equal Value Information | ||
| Note: Reportable Value Code conditions may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides. | |||||
| HI Condition Information (2300) HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have additional reportable Condition Codes. Component Element Separator (ISA16) must be used between segment data elements. |
Situational | ||||
| HI01-1 thru HI12-1 | ID | 1/3 | Must equal "BG" | ||
| HI01-2 thru HI12-2 | AN | 1/2* | Must equal "17", "25", "A2", "A3", "A4", "A5" or "P7" Note: P7 new for state reporting |
Use of codes for specific type of data: i.e., Code 17 is all data types, all others codes for IP only. | |
| Note:Condition Codes may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides. | |||||
| QTY Claim Quantity | Required | ||||
| Loop 1 | IP ONLY | ||||
| QTY01 | ID | 2/2 | Must equal "CA" | 4050 only | |
| QTY02 | R | 1/15 | Must equal Covered Days | 4050 only | |
| QTY03-1 | ID | 2/2 | Must equal "DA" | 4050 only | |
| Loop 2 | IP ONLY | ||||
| QTY01 | ID | 2/2 | Must equal "NA" | 4050 only | |
| QTY02 | R | 1/15 | Must equal Non-Covered Days | 4050 only | |
| QTY03-1 | ID | 2/2 | Must equal "DA" | 4050 only | |
| Note: Loop 2 of the QTY segment is NOT required for claims with no reportable non-covered days. | |||||
| NM1 Attending Physician Name (2310A) | Not Required by SPARCS | ||||
| NM101 | ID | 2/3 | May equal "71" | ||
| NM102 | ID | 1/1 | May equal "1" | ||
| The following data elements in this segment are required for X12 syntax, but are not required for the SPARCS data collection system. The Attending Physician's name will not be stored on the SPARCS master files. | |||||
| NM103 | AN | 1/60 | May equal Attending Physician Last Name | ||
| NM104 | AN | 1/35 | May equal Attending Physician First Name | ||
| NM105 | AN | 1/25 | May equal Attending Physician Middle Name | ||
| REF Attending Physician Secondary Identification (2310A) SPARCS is collecting the State License Number. |
Required | ||||
| REF01 | ID | 2/3 | Must equal "OB" | ED, IP, OP only | |
| REF02 | AN | 1/50 | Must equal Attending Physician State License Number |
ED, IP, OP only | |
| NM1 Operating Physician Name (2310B) | Not Required by SPARCS | ||||
| NM101 | ID | 2/3 | May equal "72" | ||
| NM102 | ID | 1/1 | May equal "1" | ||
| The following data elements in this segment are required for X12 syntax, but are not required for the SPARCS data collection system. The Operating Physician's name will not be stored on the SPARCS master files. | |||||
| NM103 | AN | 1/60 | May equal Operating Physician Last Name | ||
| NM104 | AN | 1/35 | May equal Operating Physician First Name | ||
| NM105 | AN | 1/25 | May equal Operating Physician Middle Name | ||
| REF Operating Physician Secondary IDentification (2310B) SPARCS is collecting the State License Number. |
Required | ||||
| REF01 | ID | 2/3 | Must equal "0B" | AS, ED, IP only | |
| REF02 | AN | 1/50 | Must equal Operating Physician State License Number | AS, ED, IP only | |
| NM1 Other Operating Physician Name (2310C) | Not Required By SPARCS | ||||
| NM101 | ID | 2/3 | May equal "73" in 4050R May equal "ZZ" in 5010R |
4050R 5010R |
|
| NM102 | ID | 1/1 | May equal "1" | ||
| The following data elements in this segment are required for X12 syntax, but are not required for the SPARCS data collection system. The Operating Provider's name will not be stored on the SPARCS master files. | |||||
| NM103 | AN | 1/60 | May equal Other Provider Last Name | ||
| NM104 | AN | 1/35 | May equal Other Provider First Name | ||
| NM105 | AN | 1/25 | May equal Other Provider Middle Name | ||
| REF Other Provider Secondary Identification (2310C) SPARCS is collecting the State License Number. |
Required | ||||
| REF01 | ID | 2/3 | May equal "OB" | ED, IP only | |
| REF02 | AN | 1/50 | May equal Other Provider State License Number | ED, IP only | |
| NM1 Referring Provider Name (2310D) | Not Required for SPARCS | ||||
| REF Referring Provider Secondary Identification (2310D) | Not Required for SPARCS | ||||
| SBR Other Subscriber Information (2320) | Situational | ||||
| SBR01 | ID | 1/1 | May equal "S", or "T" | IP only | |
| SBR02 | ID | 1/2 | May equal Individual Relationship Code "01", "18", "19", "20", "21", "39", "40", "53", "G8" | IP only | |
| SBR09 | ID | 1/2 | Claim Filing Indicator Code | ||
| AMT Payer Prior Payment (2320) | Not Required by SPARCS | ||||
| NM1 Other Subscriber Name (2330A) The following are SPARCS data values for this segement if other subscriber information is reportable. The Other Subscriber name will not be stored on the SPARCS master files. |
Situational | ||||
| NM101 | ID | 2/3 | May equal "1L" | IP only | |
| NM102 | ID | 1/1 | May equal "1" | IP only | |
| NM103 | AN | 1/60 | May equal Other Subscriber Last Name or "XXXXX" | IP only | |
| NM108 | ID | 1/2 | May equal "MI" (removed "ZZ") May equal "MI" or "II" (when HIPPA Individual Patient Identifier is mandated) |
4050 Only 5010 Only |
|
| NM109 | AN | 1/19* | May equal Other Subscriber Policy Number | IP Only | |
| REF Other Subscriber Secondary Information (2330A) The following are SPARCS data values for this segment if other subscriber information is reportable. |
Situational | ||||
| REF01 | ID | 2/3 | May equal "1W" or "1G" | 4050R only IP only |
|
| REF02 | AN | 1/19* | May equal Other Subscriber Policy Number | 4050R only IP only |
|
| NM1 Other Payer Name (2330B) The following are SPARCS data values for this segment if other payer information is reportable. The Other Payer name will not be stored on the SPARCS master files |
Situational | ||||
| NM101 | ID | 2/3 | Must equal "PR" | IP only | |
| NM102 | ID | 1/1 | Must equal "2" | IP only | |
| NM103 | AN | 1/60 | Must equal Other Payer Name | IP only | |
| NM108 | AN | 2/8* | Must equal "PI" or "XV" | IP only | |
| NM109 | AN | 1/2 | Must equal "PI" or "XV" | IP only | |
| REF Other Payer Secondary Information (2330B) The following SPARCS data values for this segment if other subscriber information is reportable. |
Situational | ||||
| REF01 | ID | 2/3 | Must equal "2U" or "NF" | IP only | |
| REF02 | AN | 1/50 | Must equal Other Payer Identification Number | IP only | |
| NM1 Other Payer Patient Information (2330C) | Not Required by SPARCS | ||||
| REF Other Payer Identification Number (2330C) | Not Required by SPARCS | ||||
| LX Service Line Number (2400) | Not Required by SPARCS | ||||
| LX01 | N | 1/6 | This is the service line number. Begin with 1 and increment by 1 for each new LX segment within a claim. | ||
| SV2 Institutional Service Line (2400) Note: SPARCS allows for a maximum of 999 service lines to be reported. |
Required | ||||
| SV201 | AN | 1/4* | Must equal Revenue Code | ||
| SV202-1 | AN | 2/2 | Must equal HCPCS Procedure Code Qualifier | ||
| SV202-2 | AN | 1/5* | Must equal HCPCS Procedure Code | ||
| SV203 | AN | 2/2 | Must equal Procedure Modifier 1 | ||
| SV202-4 | AN | 2/2 | Must equal Procedure Modifier 2 | ||
| SV202-3 | R | 1/18* | Must equal Line Item Charge Amount | ||
| SV204 | ID | 2/2 | Must equal "DA" = Days "UN" = Units |
"UN" for 5010 reporting. | |
| SV205 | N | 1/4* | Must equal quantity of days or units. | Number of Units added for 5010. IP and OP only. | |
| SV206 | N | 1/9* | Must equal rate | 4050 only. Removed in 5010 | |
| SV207 | R | 1/10* | Must equal Non-Covered Charge Amount | ||
| DTP Service Line Date (2400) | Required | ||||
| DTP01 | ID | 3/3 | Must equal "472" | OP only | |
| DTP02 | ID | 2/3 | Must equal "D8" | OP only | |
| DTP03 | AN | 1/35 | Service Date (or Range of dates) | OP only | |
| SE Transaction Set Trailer (Trailer) | |||||
| SE01 | N | 1/10 | May equal Total number of segments included in a transaction set including ST and SE segments | ||
| SE02 | AN | 4/9 | May equal Transaction Set Control Number (same value as ST02) | ||
| GE Functional Group Trailer (Trailer) | |||||
| GE01 | AN | 1/6 | May equal Number of Transaction Sets | ||
| GE02 | AN | 1/9 | May equal Group Control Number (same value as Functional Group Header, GS06) | ||
| IEA Interchange Control Trailer (Trailer) | |||||
| IEA01 | N | 1/5 | May equal Number of Included Functional Groups | ||
| IEA02 | N | 9/9 | May equal Interchange Control Number (same value as Interchange Control Header, ISA13) | ||
| << Previous Appendix | AS, ED, IP X12-837 Input / IP Output / OP Output | Next Appendix >> |
|---|
