ASC X12N 837 VERSION (4050X156) May 2003
New York State Department of Health
Statewide Planning and Research Cooperative System
Inpatient Addendum - Revised January 2007

TABLE OF CONTENTS


1. INTRODUCTION
2. PURPOSE OF THIS DOCUMENT
3. HOW TO USE THIS DOCUMENT
4. 837 LOOP DIAGRAM FOR SPARCS
5. SEGMENT REVIEW AND SPARCS REQUIREMENTS
5.1 Introduction
5.2 ISA Interchange Control Header Header
5.3 GS Functional Group Header Header
5.4 ST Transaction Set Header Header
5.5 BHT Beginning of Hierarchical Transaction Header
5.6 NM1 Submitter Name Loop 1000A
5.7 REF Submitter Secondary Identification Loop 1000A
5.8 PER Submitter EDI Contact Information Loop 1000A
5.9 NM1 Receiver Name Loop 1000B
5.10 HL Service Provider Hierarchical Level Loop 2000A
5.11 NM1 Service Provider Name Loop 2010AA
5.12 REF Service Provider Secondary Identification Loop 2010AA
5.13 HL Subscriber Hierarchical Level Loop 2000B
5.14 SBR Subscriber Information Loop 2000B
5.15 PAT Patient Information Loop 2000B
5.16 NM1 Subscriber Name Loop 2010BA
5.17 N3 Subscriber Address Loop 2010BA
5.18 N4 Subscriber City/State/Zip Code Loop 2010BA
5.19 DMG Subscriber Demographic Information Loop 2010BA
5.20 REF Subscriber Secondary Identification Loop 2010BA
5.21 NM1 Payer Name Loop 2010BC
5.22 REF Payer Secondary Identification Loop 2010BC
5.23 HL Patient Hierarchical Level Loop 2000C
5.24 PAT Patient Information Loop 2000C
5.25 NM1 Patient Name Loop 2010CA
5.26 N3 Patient Address Loop 2010CA
5.27 N4 Patient City/State/Zip Code Loop 2010CA
5.28 DMG Patient Demographic Information Loop 2010CA
5.29 REF Patient Secondary Identification Number Loop 2010CA
5.30 CLM Claim Information Loop 2300
5.31 DTP Discharge Date/Hour Loop 2300
5.32 DTP Statement Dates Loop 2300
5.33 DTP Admission Date/Hour Loop 2300
5.34 CL1 Institutional Claim Code Loop 2300
5.35 PWK Claim Supplemental Information Loop 2300
5.36 AMT Payer Estimated Amount Due Loop 2300
5.37 AMT Patient Estimated Amount Due Loop 2300
5.38 REF Medical Record Number Loop 2300
5.39 REF Mother's Medical Record Number for Newborns Loop 2300
5.40 K3 File Information Loop 2300
5.41 NTE Claim Note Loop 2300
5.42 HI Principal, Admitting, E-Code, Patient Reason for Visit Loop 2300
5.43 HI Diagnosis Related Group (DRG) Information Loop 2300
5.44 HI Other Diagnosis Information Loop 2300
5.45 HI Principal Procedure Information Loop 2300
5.46 HI Other Procedure Information Loop 2300
5.47 HI Occurrence Span Information Loop 2300
5.48 HI Occurrence Information Loop 2300
5.49 HI Value Information Loop 2300
5.50 HI Condition Information Loop 2300
5.51 QTY Claim Quantity Loop 2300
5.52 NM1 Attending Physician Name Loop 2310A
5.53 REF Attending Physician Secondary ID Loop 2310A
5.54 NM1 Operating Physician Name Loop 2310B
5.55 REF Operating Physician Secondary ID Loop 2310B
5.56 NM1 Other Provider Name Loop 2310C
5.57 REF Other Provider Secondary ID Loop 2310C
5.58 NM1 Referring Provider Name Loop 2310D
5.59 REF Referring Provider Secondary ID Loop 2310D
5.60 SBR Other Subscriber Information Loop 2320
5.61 AMT Payer Prior Payment Loop 2320
5.62 NM1 Other Subscriber Name Loop 2330A
5.63 REF Other Subscriber Secondary Information Loop 2330A
5.64 NM1 Other Payer Name Loop 2330B
5.65 REF Other Payer Secondary ID and Ref Number Loop 2330B
5.66 NM1 Other Payer Patient Information Loop 2330C
5.67 REF Other Payer Patient ID Number Loop 2330C
5.68 LX Service Line Number Loop 2400
5.69 SV2 Institutional Service Line Loop 2400
5.70 DTP Service Line Date Loop 2400
5.71 SE Transaction Set Trailer Trailer
5.72 GE Functional Group Trailer Trailer
5.73 IEA Interchange Control Trailer Trailer

1. INTRODUCTION

The purpose of this document is to provide guidelines for creating an ANSI ASC X12-837 Version 4050 file as it is implemented for the Statewide Planning and Research Cooperative System (SPARCS). The SPARCS implementation of this format is based on the 837 Health Care Service Data Reporting implementation guide (X156).

This document is to be used as an addendum document to the ANSI ASC X12 implementation guides and assumes the reader is familiar with the 837 Claim/Encounter Standard.

Note 1:  Although this guide references discharge data as "claims" or "encounters", it must be noted that an X12-837 created with only SPARCS required segments will not be complete enough for payer submissions. Conversely, an X12-837 created with only the payer required segments will not be complete enough for SPARCS submissions. The additional data needed for SPARCS is noted in this document.

Note 2:  Any data included in 837 submissions required by payer systems, but not necessary for SPARCS will be ignored by the SPARCS processing system. Additional data submitted to SPARCS will NOT cause a rejection.

Note 3:  Certain segments of the X12-837 included in this guide are required solely for the certification of the X12-837 format and do not contain any data elements for the SPARCS system. These segments are identified in Section 5. In addition, data reported in these segments is NOT stored on SPARCS master files.

2. PURPOSE OF THIS DOCUMENT

The purpose of this document is to provide technical guidance to the programmer/analyst who needs to implement the X12-837 transaction set as it applies to the SPARCS system.

Note:   It is not the intent of this document to educate the user on X12-837 transactions. This document must be used in conjunction with published ANSI ASC X12 implementation guides and the SPARCS Input Data Dictionary.

3. HOW TO USE THIS DOCUMENT

It is expected that the reader familiarize themselves with the ANSI ASC X12 837 standard and relevant implementation guides, as well as the SPARCS Input Data Dictionary before attempting to use this addendum. Chapters One and Two and Appendices A and B of the ANSI ASC X12 implementation guides should be of particular focus as these chapters provide a detailed discussion regarding the X12-837 and its envelope. These implementation guides are available from the Washington Publishing Company Web site at www.wpc-edi.com.

4. 837 LOOP DIAGRAM FOR SPARCS

The diagram below is an outline representing the hierarchical structure of the X12-837 loops and segments for the SPARCS Inpatient implementation. If you are not familiar with the hierarchical looping structure, we strongly suggest you study Appendix A in any of the published 837 implementation guides before proceeding further. Included below are the primary and secondary loop descriptions and the segment IDs. Note included are the Interchange Control and Functional Group segments. The indentations in the outline are intended to represent hierarchical relationships. The numbers in parenthesis in the right hand margin represent permissible repeats of that loop.

HEADER
ISA Interchange Control Header
GS Functional Group Header
ST Transaction Set Header
BHT Beginning of Hierarchical Transaction
LOOP ID 1000A SUBMITTER NAME (1)
NM1 Submitter Name
PER Submitter EDI Contact Information

LOOP ID 1000B RECEIVER NAME (1)
NM1 Receiver name

Detail - Provider
LOOP ID

2000A SERVICE PROVIDER HIERARCHICAL LEVEL

(>1)
HL Service Provider Hierarchical Level

LOOP ID 2010AA SERVICE PROVIDER NAME (1)
NM1 Service Provider Name
REF Service Provider Secondary Identification

Detail - Subscriber
LOOP ID

2000B SUBSCRIBER HIERARCHICAL LEVEL

(>1)
HL Service Hierarchical Level
SBR Subscriber Information

LOOP ID 2010BA SUBSCRIBER NAME (1)
NM1 Subscriber Name
N3 Subscriber Address
N4 Subscriber City/State/Zip Code
DMG Subscriber Demographic Information
REF Subscriber Secondary Identification

LOOP ID 2010BC PAYER NAME (1)
NM1 Payer Name
REF Payer Secondary Identification

Detail - Subscriber 
LOOP ID

2000C PATIENT HIERARCHICAL LEVEL

(>1)
HL Patient Hierarchical Level

LOOP ID 2010CA PATIENT NAME (1)
NM1 Patient Name
N3 Patient Address
N4 Patient City/State/Zip Code
DMG Patient Demographic Information
REF Patient Secondary Identification Number

Claim
LOOP ID

2300 CLAIM INFORMATION

(100)
CLM Claim Information
DTP Discharge Date/Hour
DTP Statement Dates
DTP Admission Date/Hour
CL1 Institutional Claim Code
REF Medical Record Number
REF Mother's Medical Record Number for Newborns
NTE Claim Note
HI Principal, Admitting, E-Code, Patient Reason for Visit
HI Other Diagnosis Information
HI Principal Procedure Information
HI Other Procedure Information
HI Occurrence Span Information
HI Occurrence Information
HI Value Information
HI Condition Information
QTY Claim Quantity

LOOP ID 2310A ATTENDING PHYSICIAN NAME (1)
NM1 Attending Physician Name
REF Attending Physician Secondary ID

LOOP ID 2310B OPERATING PHYSICIAN NAME (1)
NM1 Operating Physician Name
REF Operating Physician Secondary ID

LOOP ID 2310C OTHER PROVIDER NAME (1)
NM1 Other Provider Name
REF Other Provider Secondary ID

LOOP ID 2320 OTHER SUBSCRIBER INFO (10)
SBR Other Subscriber Information

LOOP ID 2330A OTHER SUBSCRIBER NAME (1)
NM1 Other Subscriber Name
REF Other Subscriber Secondary Information

LOOP ID 2330B OTHER PAYER NAME (1)
NM1 Other Payer Name
REF Other Payer Secondary ID and Ref Number

LOOP ID 2400 SERVICE LINE NUMBER (1)
LX Service Line Number
SV2 Institutional Service Line
TRAILER
SE Transaction Set Trailer
GE Functional Group Trailer
IEA Interchange Control Trailer

5. SEGMENT REVIEW AND SPARCS REQUIREMENTS

5.1  Introduction

The Segment Review Section should be used in conjunction with ANSI ASC X12 implementation guides and the SPARCS Input Data Dictionary. The segments are listed in the order they must appear in the X12-837 submission file.

The segment section includes instructions on how to implement the data elements that will make up the segment. The data element instructions will either:

  • Tell the reader to implement the segment data elements as indicated in the ANSI ASC X12 Implementation Guides

  • Supply the reader with format (length/type) and/or data values specific to the data elements required for the SPARCS implementation.

Note:  The Data Type column will be an AN, N, R, ID, DT, or TM (Alpha Numeric, Numeric, Decimal, Identifier, Date, or Time) and carry the following meanings.

  • AN data type allows all alpha numeric characters and is left justified

  • N data type allows only numeric characters (no decimals) and is right justified

  • R data type allows only numeric characters (with decimals) and is right justified

  • ID data type allows all alpha numeric characters and is left justified

  • DT data type allows only eight (8) digital dates as CCYYMMDD

  • TM data type allows only four (4) digital times as HHMM

Generic Segment Note:   This document does not list all data elements in each segment if they are not required for X12 syntax or for SPARCS. Any data reported in unlisted data elements will not be processed or stored by SPARCS.

5.2  ISA Interchange Control Header (Header) - Required

ISA01 ID 2/2 Must equal "00"
ISA02 AN 10/10 Must equal Authorization Information
ISA03 ID 2/2 Must equal "00"
ISA04 AN 10/10 Must equal Security Information
ISA05 ID 2/2 Must equal "ZZ"
ISA06 AN 15/15 Must equal SPARCS Collector Code
ISA07 ID 2/2 Must equal "ZZ"
ISA08 AN 15/15 Must equal SPARCS Collector Code
ISA09 DT 6/6 Must equal Interchange Date - YYMMDD format
ISA10 TM 4/4 Must equal Interchange Time - HHMM format
ISA11 ID 1/1 Must equal Repetition Separator, "^"
ISA12 ID 5/5 Must equal "00405"
ISA13 AN 9/9 Must 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, ":"

5.3  GS Functional Group Header (Header) - Required

GS01 ID 2/2 Must equal "HC"
GS02 AN 2/15 Must equal SPARCS Collector Code
GS03 AN 2/15 Must equal "SPARCS"
GS04 DT 8/8 Must equal Creation Date - CCYYMMDD format
GS05 TM 4/8 Must equal Creation Time - HHMM format
GS06 AN 1/9 Must 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"

5.4  ST Transaction Set Header (Header) - Required

ST01 ID   3/3 Must equal "837"
ST02 AN 4/9 Must equal Transaction Set Control Number (same value as SE02)

5.5  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 1/50 Must equal File Sequence and Serial Number
BHT04 DT 8/8 Must equal Processing Date - CCYYMMDD format
BHT05 TM 4/8 Must equal Processing Time - HHMM format

5.6  NM1 Submitter Name (1000A) - Required

NM101 ID 2/3 Must equal "41"
NM102 ID 1/1 Must equal "2"
NM103 AN 1/60 Must equal Submitter Organization Name
NM108 ID 1/2 Must equal "46"
NM109 AN 2/80 Must equal SPARCS Collector Code

5.7  REF Submitter Secondary Identification (1000A) - Not Used by SPARCS

5.8  PER Submitter EDI Contact Information (1000A) - Required

Data elements below are required for X12 syntax, but are not required for SPARCS data collection.

PER01 ID 2/2 Must equal "IC"
PER02 AN 1/60 Must equal Submitter Contact Name
PER03 ID 2/2 Must equal "ED", "EM", "FX", or "TE"
PER04 AN 1/256 Must equal Communication Number

5.9  NM1 Receiver Name (1000B) - Required

Data elements below are required for X12 syntax, but are not required for SPARCS data collection.

NM101 ID 2/3 Must equal "40"
NM102 ID 1/1 Must equal "2"
NM103 AN 1/60 Must equal Receiver Organization Name
NM108 ID 1/2 Must equal "46"
NM109 AN 2/80 Must equal Receiver Primary Identification

5.10  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"

5.11  NM1 Service Provider Name (2010AA) - Required

NM101 ID 2/3 Must equal "SJ"
NM102 ID 1/1 Must equal "2"
NM103 AN 1/60 Must equal Service Provider Organization Name
NM108 ID 1/2 Must equal "XX"
NM109 AN 2/80 Must equal National Provider Identification (when available)

5.12  REF Service Provider Secondary Identification (2010AA) - Required

REPEAT 1
REF01 ID 2/3 Must equal "1J"
REF02 AN 1/50 Must equal appropriate SPARCS Identification Number

5.13  HL Subscriber Hierarchical Level (2000B) - Required

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"

5.14  SBR Subscriber Information (2000B) - Required

Note:   SPARCS only processes and stores the subscriber information when the subscriber IS the patient.

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 Source of Payment

5.15  PAT Patient Information (2000B) - Not Used by SPARCS

5.16  NM1 Subscriber Name (2010BA) - Required if subscriber IS the patient

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.

NM101 ID 2/3 Must equal "IL"
NM102 ID 1/1 Must equal "1"
NM103 AN 1/60 Must equal Subscriber's Last Name or masked
NM104 AN 1/35 Must equal Subscriber's First Name or masked
NM105 AN 1/25 Must equal Subscriber's Middle Name or masked
NM108 ID 1/2 Must equal "MI"
NM109 AN 2/80 Must equal Insurance Policy Number

5.17  N3 Subscriber Address (2010BA) - Required if subscriber IS the patient

N301 AN 1/55 Must equal Subscriber's Street Address
N302 AN 1/55 Must equal Subscriber's Street Address Line 2, if applicable

5.18  N4 Subscriber City/State/Zip Code (2010BA) - Required if subscriber IS the patient

N401 AN 2/30 Must equal Subscriber's City
N402 ID 2/2 Must equal Subscriber's State
N403 ID 3/15 Must equal Subscriber's Postal Code
N405 ID 1/2 Must equal "CO"
N406 AN 1/30 Must equal County Code

5.19  DMG Subscriber Demographic Information (2010BA) - Required if subscriber IS the patient

DMG01 ID 2/3 Must equal "D8"
DMG02 AN 1/35 Must equal Birth Date in CCYYMMDD format
DMG03 ID 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. Below is a DMG segment example.

DMG05-2 ID 1/3 Must equal "RET"
DMG05-3 ID 1/30 Must equal Race or Ethnicity ("R1", "R2", "R3", "R4", "R5", "R9", "E1", or "E2")

Example: DMG*D8*19880208*F**:RET:R5^:RET:E2******~

5.20  REF Subscriber Secondary Identification (2010BA) - Required if subscriber IS the patient

REF01 ID 2/3 Must equal "ABB"
REF02 AN 1/50 Must equal Unique Personal Identification Number

5.21  NM1 Payer Name (2010BC) - Required

NM101 ID 2/3 Must equal "PR"
NM102 ID 1/1 Must equal "2"
NM103 AN 1/60 Must equal Payer Name
NM108 ID 1/2 Must equal "PI" or "XV"
NM109 AN 2/80 Must equal Payer Identification Number

5.22  REF Payer Secondary Identification (2010BC) - Situational

REF01 ID 2/3 Must equal "2U", "NF"
REF02 AN 1/50 Must equal Payer Identification Number

5.23  HL Patient Hierarchical Level (2000C) - Required if the patient is NOT the subscriber

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.
HL02 AN 1/12 Must contain the same value as the parent Subscriber Hierarchical Level HL01
HL03 ID 1/2 Must equal "PT"
HL04 ID 1/1 Must equal "0"

5.24  PAT Patient Information (2000C) - Not required for SPARCS

5.25  NM1 Patient Name (2010CA) - Required if subscriber IS NOT the patient

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.

NM101 ID 2/3 Must equal "QC"
NM102 ID 1/1 Must equal "1"
NM103 AN 1/60 Must equal Patient's Last Name or masked
NM104 AN 1/35 Must equal Patient's First Name or masked
NM105 AN 1/25 Must equal Patient's Middle Name or masked
NM108 ID 1/2 Must equal "34", "MI" or "ZZ"
NM109 AN 2/80 Must equal Insurance Policy Number

5.26  N3 Patient Address (2010CA) - Required if subscriber IS Not the patient

N301 AN 1/55 Must equal Patient's Street Address
N302 AN 1/55 Must equal Patient's Street Address Line 2, if applicable

5.27   N4 Patient City/State/Zip Code (2010CA) - Required if subscriber IS NOT the patient

N401   AN 2/30 Must equal Patient's City
N402 ID 2/2 Must equal Patient's State
N403 ID 3/15 Must equal Patient's Postal Code
N405 ID 1/2 Must equal "CO"
N406 AN 1/30 Must equal County Code

5.28   DMG Patient Demographic Information (2010CA) - Required if subscriber IS NOT the patient.

DMG01 ID 2/3 Must equal "D8"
DMG02 AN 1/35 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. Below is a DMG segment example.

DMG05-2 ID 1/3 Must equal "RET"
DMG05-3 ID 1/30 Must equal Race or Ethnicity ("R1", "R2", "R3", "R4", "R5", "R9", "E1", or "E2")

Example: DMG*D8*19880208*F**:RET:R5^:RET:E2******~

5.29  REF Patient Secondary Identification (2010CA)- Required if subscriber IS NOT the patient

REF01 ID 2/3 Must equal "ABB"
REF02 AN 1/50 Must equal Unique Personal Identification Number

5.30  CLM Claim Information (2300) - Required

CLM01 AN 1/38 Must equal Patient Control Number
CLM02 R 1/18 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". Below is a CLM segment example.

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

Example: CLM*2745331203128112806*0.00***13:A:1~

5.31  DTP Discharge Hour (2300) - Required

DTP01 ID 3/3 Must equal "096"
DTP02 ID 2/3 Must equal "TM"
DTP03 AN 1/35 Must equal Discharge Hour (HHMM format)

5.32  DTP Statement Dates (2300) - Required

DTP01   ID 3/3 Must equal "434"
DTP02 ID 2/3 Must equal "RD8"
DTP03 AN 1/35 Must equal Statement Period From and Through Dates (CCYYMMDD-CCYYMMDD format)

5.33  DTP Admission Date/Hour (2300) - Required

DTP01 ID 3/3 Must equal "435"
DTP02 ID 2/3 Must equal "DT"
DTP03 AN 1/35 Must equal Admission Date/Hour (CCYYMMDDHHMM format)

5.34  CL1 Institutional Claim Code (2300) - Required

CL101 ID 1/1 Must equal Type of Admission Code
CL102 ID 1/1 Must equal Source of Admission Code
CL103 ID 1/2 Must equal Patient Status / Disposition Code

5.35  PWK Claim Supplemental Information (2300) - Not Required for SPARCS

5.36  AMT Payer Estimated Amount Due (2300) - Not Required for SPARCS

5.37  AMT Patient Estimated Amount Due (2300) - Not Required for SPARCS

5.38  REF Medical Record Number (2300) - Required

REF01 ID 2/3 Must equal "EA"
REF02 AN 1/50 Must equal Medical Record Number

5.39  REF Mother's Medical Record Number for Newborns (2300) - Required

REF01 ID 2/3 Must equal "MRN"
REF02 AN 1/50 Must equal Mother's Medical Record Number

5.40  K3 File Information (2300) - Not Required by SPARCS

5.41  NTE Claim Note (2300) - Required

NTE01 ID 3/3 Must equal "UPI"
NTE02 AN 1/80 See below for SPARCS NTE requirements

SPARCS 2300 NTE SEGMENT INPATIENT LAYOUT

      Description Position Length Format
Expected Principal Reimbursement 1 - 2 2 A/N
Expected Reimbursement Other 1 3 - 4 2 A/N
Expected Reimbursement Other 2 5 - 6 2 A/N
Method of Anesthesia 7 - 8 2 A/N
Exempt Unit Indicator 9 - 11 3 A/N
Patient's Race 12 - 13 2 A/N  (These positions should contain spaces if reporting
Patient's Ethnicity 14 - 14 1 A/N   Patient Race and Ethnicity in the DMG05 segment.)
Heart Rate 15 - 17 3 A/N
Blood Pressure - Systolic 18 - 20 3 A/N
Blood Pressure - Diastolic 21 - 23 3 A/N
Source of Payment Typology I 24 - 28 5 A/N
Source of Payment Typology II 29 - 33 5 A/N
Source of Payment Typology III 34 - 38 5 A/N

Note:  Spaces equaling the data element length must be used if a data element cannot be supplied. Below are NTE segments examples:

All data elements reported: NTE*UPI*06100120ALR012072125080211  22   00000~

Patient Race and Ethinicity not reported:  NTE*UPI*06100120ALR   072125080211  22   00000~

5.42  HI Principal, Admitting, and E-Codes (2300) - Required

HI01-HI12 are required composite data elements. HI05-HI12 are used for claims that have a third through tenth E-code, respectively. Component Element Separator (ISA16) must be used between segment data elements. See HI segment example below.

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"
HI02-2 AN 1/30 Must equal Admitting Diagnosis Code

HI03-1   ID 1/3 Must equal "BN"
HI03-2 AN 1/30   Must equal External Cause of Injury Code (E-Code)

HI04-1 ID 1/3 Must equal "BN"
HI04-2 AN 1/30   Must equal Place of Injury Code (E-Code)

HI05-1 thru HI12-1 ID 1/3 Must equal "BN"
HI05-2 thru HI12-2 AN 1/30   Must equal External Cause of Injury Code (E-Code)

Example: HI*BK:63491*BJ:63491~

5.43  HI Diagnosis Related Group (DRG) Information (2300) - Not Required by SPARCS

5.44  HI Other Diagnosis Information (2300) - Situational

HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have a second through twelfth Other Diagnosis Code, respectively. Component Element Separator (ISA16) must be used between segment data elements. See HI segment example below.

HI01-1 ID 1/3 Must equal "BF"
HI01-2 AN 1/30 Must equal Other Diagnosis Code
HI01-9 ID 1/1 Must equal Onset of Diagnosis Indicator ("N", "U", "Y" or "W")

HI02-1 thru HI12-1 ID 1/3 Must equal "BF"
HI02-2 thru HI12-2 AN 1/30 Must equal Other Diagnosis Code
HI02-9 thru HI12-9 ID 1/1 Must equal Onset of Diagnosis Indicator ("N", "U", "Y" or "W")

Note:  A second repeat of these segments may be used to report Other Diagnosis Codes 13 through 24. Although all other diagnosis codes for a claim may be entered on two iterations of this composite segment, SPARCS currently only processes the first fourteen (14) Other Diagnosis Codes

Example reporting HI01 thru HI06:   HI*BF:99591:::::::N*BF:5789:::::::N*BF:2851:::::::N*BF:5849:::::::N*BF:40391:::::::Y*BF:4538:::::::Y~

5.45  HI Principal Procedure Information (2300) - Situational

HI01 is a required composite data element. Component Element Separator (ISA16) must be used between segment data elements. See HI segment example below.

HI01-1 ID 1/3 Must equal "BR"
HI01-2 AN 1/30 Must equal Principal Procedure Code
HI01-3 ID 2/3 Must equal "D8"
HI01-4 AN 1/35 Must equal Principal Procedure Date (CCYYMMDD format)

Example:  HI*BR:3614:D8:20060413~

5.46  HI Other Procedure Information (2300) - Situational

HI01-HI12 are required composite data elements. HI02-HI12 are used for claims that have a second through twelfth Other Procedure Code, respectively. Component Element Separator (ISA16) must be used between segment data elements. See HI segment example below.

HI01-1 ID 1/3 Must equal "BQ"
HI01-2 AN 1/30 Must equal Other Procedure Code
HI01-3 ID 2/3 Must equal "D8"
HI01-4 AN 1/35 Must equal Other Procedure Date (CCYYMMDD format)

HI02-1 thru HI12-1 ID 1/3 Must equal "BQ"
HI02-2 thru HI12-2 AN 1/30 Must equal Other Procedure Code
HI02-3 thru HI12-3 ID 2/3 Must equal "D8"
HI02-4 thru HI12-4 AN 1/35 Must equal Other Procedure Date (CCYYMMDD format)

Note:   A second repeat of these segments may be used to report Other Procedure Codes 13 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.

Example:  HI*BQ:3963:D8:20060413*BQ:3964:D8:20060413~

5.47  HI Occurrence Span Information (2300) - Situational

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. See HI segment example below.

HI01-1 ID 1/3 Must equal "BI"
HI01-2 AN 1/30 Must equal "74", "75", "81", or "82"
HI01-3 ID 2/3 Must equal "RD8"
HI01-4 AN 1/35 Must equal Occurrence Span date range (CCYYMMDD-CCYYMMDD format)

HI02-1 thru HI12-1 ID 1/3 Must equal "BI"
HI02-2 thru HI12-2 AN 1/30 Must equal "74", "75", "81", or "82
HI02-3 thru HI12-3 ID 2/3 Must equal "RD8"
HI02-4 thru HI12-4 AN 1/35 Must equal Occurrence Span date range (CCYYMMDD-CCYYMMDD format)

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.

Example:  HI*BI:74:RD8:20060413-20060414~

5.48  HI Occurrence Information (2300) - Situational

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. See HI segment example below.

HI01-1 ID 1/3 Must equal "BH"
HI01-2 AN 1/30 Must equal "01", "02", "03", "04", "05", or "06"
HI01-3 ID 2/3 Must equal "D8"
HI01-4 AN 1/35 Must equal Occurrence Associated Date (CCYYMMDD format)

HI02-1 thru HI12-1 ID 1/3 Must equal "BH"
HI02-2 thru HI12-2 AN 1/30 Must equal "01", "02", "03", "04", "05", or "06"
HI02-3 thru HI12-3 ID 2/3 Must equal "D8"
HI02-4 thru HI12-4 AN 1/35 Must equal Occurrence Associated Date (CCYYMMDD format)

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.

Example:  HI*BH:01:D8:20061124~

5.49  HI Value Information (2300) - Situational

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. See HI segment example below.

HI01-1 ID 1/3 Must equal "BE"
HI01-2 AN 1/30 Must equal "14", "15", "21", "22", "23", "37", "45" or "54"
HI01-5 R 1/18 Must equal Value Information

HI02-1 thru HI12-1 ID 1/3 Must equal "BE"
HI02-2 thru HI12-2 AN 1/30 Must equal "14", "15", "21", "22", "23", "37", "45" or "54"
HI02-5 thru HI12-5 R 1/18 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.

Example:  HI*BE:45:::6.00~

5.50  HI Condition Information (2300) - Situational

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. See HI segment example below.

HI01-1 ID 1/3 Must equal "BG"
HI01-2 AN 1/30 Must equal "17", "25", "A2", "A3", "A4", or "A5"

HI02-1 thru HI12-1 ID 1/3 Must equal "BG"
HI02-2 thru HI12-2 AN 1/30 Must equal "17", "25", "A2", "A3", "A4", or "A5"

Note:  Condition Codes may be reported multiple times. This HI segment may be reported 2 times as indicated in the 837 Implementation Guides.

Example:  HI*BG:17~

5.51  QTY Claim Quantity (2300) - Required

Loop 1
QYT01 ID 2/2 Must equal "CA"
QTY02 R 1/15 Must equal Covered Days
QTY03-1 ID 2/2 Must equal "DA"

Loop 2
QTY01 ID 2/2 Must equal "NA"
QTY02 R 1/15 Must equal Non-Covered Days
QTY3-1 ID 2/2 Must equal "DA"

Note:   Loop 2 of the QTY segment is NOT required for claims with no reportable non-covered days.

5.52  NM1 Attending Physician Name (2310A) - Required

NM101 ID 2/3 Must equal "71"
NM102 ID 1/1 Must 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 Must equal Attending Physician Last Name
NM104 AN 1/35 Must equal Attending Physician First Name
NM105 AN 1/25 Must equal Attending Physician Middle Name

5.53  REF Attending Physician Secondary Identification (2310A) - Required

The following SPARCS data values for this segment may be repeated two times. One will be for the Attending Physician State License Number. The other will be used for the Attending Physician UPIN number.

Repeat 1
REF01 ID 2/3 Must equal "0B"
REF02 AN 1/50 Must equal Attending Physician State License Number

Repeat 2
REF01 ID 2/3 Must equal "1G"
REF02 AN 1/50 Must equal Attending Physician UPIN Number

5.54  NM1 Operating Physician Name (2310B) - Required

NM101   ID   2/3   Must equal "72"
NM102 ID 1/1 Must 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 Must equal Operating Physician Last Name
NM104 AN 1/35 Must equal Operating Physician First Name
NM105 AN 1/25 Must equal Operating Physician Middle Name

5.55  REF Operating Physician Secondary Identification (2310B) - Required

The following SPARCS data values for this segment may be repeated two times. One will be for the Operating Physician State License Number. The other will be used for the Operating Physician UPIN number.

Repeat 1
REF01 ID 2/3 Must equal "0B"
REF02 AN 1/50 Must equal Operating Physician State License Number

Repeat 2
REF01 ID 2/3 Must equal "1G"
REF02 AN 1/50 Must equal Operating Physician UPIN Number

5.56  NM1 Other Provider Name (2310C) - Required

NM101 ID 2/3 Must equal "73"
NM102 ID 1/1 Must 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 Must equal Other Provider Last Name
NM104 AN 1/35 Must equal Other Provider First Name
NM105 AN 1/25 Must equal Other Provider Middle Name

5.57  REF Other Provider Secondary Identification (2310C) - Required

The following SPARCS data values for this segment may be repeated two times. One will be for the Other Provider State License Number. The other will be used for the Other Provider UPIN number.

Repeat 1
REF01 ID 2/3 Must equal "0B"
REF02 AN 1/50 Must equal Other Provider State License Number

Repeat 2
REF01 ID 2/3 Must equal "1G"
REF02 AN 1/50 Must equal Other Provider UPIN Number

5.58  NM1 Referring Provider Name (2310D) - Not Required for SPARCS

5.59  REF Referring Provider Secondary Identification (2310D) - Not Required for SPARCS

5.60  SBR Other Subscriber Information (2320) - Situational

SBR01     ID    1/1   Must equal "S", or "T"
SBR02 ID 1/2 Must equal Individual Relationship Code

5.61  AMT Payer Prior Payment (2320) - Not Required by SPARCS

5.62  NM1 Other Subscriber Name (2330A) - Situational

The following are SPARCS data values for this segment if other subscriber information is reportable. The Other Subscriber name will not be stored on the SPARCS master files.

NM101 ID 2/3    Must equal "IL"
NM102 ID 1/1 Must equal "1"
NM103 AN 1/60 Must equal Other Subscriber Last Name or "XXXXX"
NM108 ID 1/2 Must equal "MI" or "ZZ"
NM109 AN 1/80 Must equal Other Subscriber Policy Number

5.63  REF Other Subscriber Secondary Information (2330A) - Situational

The following are SPARCS data values for this segment if other subscriber information is reportable.

REF01 ID 2/3 Must equal "1W" or "IG"
REF02 AN 1/50 Must equal Other Subscriber Policy Number

5.64  NM1 Other Payer Name (2330B) - Situational

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

NM101 ID 2/3     Must equal "PR"
NM102 ID 1/1 Must equal "2"
NM103 AN 1/60 Must equal Other Payer Name
NM108 ID 1/2 Must equal "PI" or "XV"
NM109 AN 2/80 Must equal Other Payer Identification Number

5.65  REF Other Payer Secondary Information (2330B) - Situational

The following SPARCS data values for this segment if other subscriber information is reportable.

REF01 ID 2/3 Must equal "2U" or "NF"
REF02 AN 1/50 Must equal Other Payer Identification Number

5.66  NM1 Other Payer Patient Information (2330C) - Not Required by SPARCS

5.67  REF Other Payer Patient Identification Number (2330C) - Not Required by SPARCS

5.68  LX Service Line Number (2400) - Required

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.

5.69  SV2 Institutional Service Line (2400) - Required

Note: SPARCS allows a maximum of 50 Accommodations and 200 Ancillaries.

SV201 AN 1/48 Must equal UB Revenue Code
SV203 R 1/18 Must equal Revenue Total Charges
SV204 ID 2/2 Must equal "DA" (When accommodation charges are reported)
SV205 R 1/15 Must equal days (When accommodation charges are reported)
SV206 R 1/10 Must equal rate (When accommodation charges are reported)
SV207 R 1/18 Must equal Revenue Total Non-Covered Charges

5.70  DTP Service Line Date (2400) - Not Required by SPARCS

5.71  SE Transaction Set Trailer (Trailer) - Required

SE01 N   1/10 Must equal Total number of segments included in a transaction set including ST and SE segments
SE02 AN 4/9 Must equal Transaction Set Control Number (same value as ST02)

5.72  GE Functional Group Trailer (Trailer) - Required

GE01 AN 1/6 Must equal Number of Transaction Sets
GE02 AN 1/9 Must equal Group Control Number (same value as Functional Group Header, GS06)

5.72   IEA Interchange Control Trailer (Trailer) - Required

IEA01 AN 1/5 Must equal Number of Included Functional Groups
IEA02 AN 9/9 Must equal Interchange Control Number (same value as Interchange Control Header, ISA13)