2300 Claim information
| Loop | Seg ID | Segment Name | Format | Length | Ref# | Req | Value |
| 2300 | CLM | Claim information | ID | 3 | R | CLM | |
| Element Separator | AN | 1 | * | ||||
| CLM01 | Claim Submitter Identifier | AN | 1/38 | 1028 | R | Unique Claim Number | |
| Element Separator | AN | 1 | * | ||||
| CLM02 | Monetary Amount | R | 1/18 | 782 | R | Total Charges | |
| Element Separator | AN | 1 | * | ||||
| CLM03 | Claim Filling Indicator | Not Used | |||||
| Element Separator | AN | 1 | * | ||||
| CLM04 | Non Institutional Claim Type | Not Used | |||||
| Element Separator | AN | 1 | * | ||||
| CLM05-1 | Facility Code Value | AN | 1/2 | 1331 | R | Place of Service Code | |
| Component Element Separator | : | ||||||
| CLM05-2 | Facility Code Qualifier | ID | 1/2 | R | B | ||
| Component Element Separator | : | ||||||
| CLM05-3 | Claim Frequency Type Code | ID | 1 | 1325 | R | 1 = Original 7 = Replacement 8 = Void | |
| Element Separator | AN | 1 | * | ||||
| CLM06 | Yes/No Provider Signature on File | ID | 1 | 1073 | R | Y | |
| Element Separator | AN | 1 | * | ||||
| CLM07 | Provider Accept Assignment Code | ID | 1 | 1359 | R | A = Assigned B = Assignment Accepted on Clinical Lab Services Only C = Not Assigned | |
| Element Separator | AN | 1 | * | ||||
| CLM08 | Yes/No Assignments of Benefit | ID | 1 | 1073 | R | Y | |
| Element Separator | AN | 1 | * | ||||
| CLM09 | Yes/No Release of Information | ID | 1 | 1363 | R | Y | |
| Element Separator | AN | 1 | * | ||||
| CLM10 | Patient signature source code | ID | 1 | 1351 | S | P | |
| Element Separator | AN | 1 | * | ||||
Examples:
CLM*249*60***11:B:1*Y*A*Y*Y
CLM*250*38***11:B:1*Y*A*Y*Y
********************************************************************************
| Code | Definition |
| 1 | Indicates the claim is an original claim |
| 7 | Indicates the new claim is a replacement or corrected claim. The information present on this bill represents a complete replacement of the previously issued bill. |
| 8 | Indicates the claim is a voided/cancelled claim |
Replacement claims submitted electronically will reduce the potential for a claim to deny as a duplicate. If a replacement claim needs to be submitted, you may submit the correction electronically with the appropriate frequency code (7).
An example of the ANSI 837P file containing a replacement claim, along with the required REF segment and Qualifier in Loop ID 2300 – Claim Information, is provided below.
CLM*12345678*500***11::7*Y*A*Y*I*P~
REF*F8*(Enter the Claim Original Reference Number)
The first two digits (“11”) in the example above indicate the place of service on a professional claim. The colons (“::”) between the place of service and frequency code are known as Sub element Separators (indicates that this field is currently not used).
The replacement claim will replace the entire previously processed claim. Therefore, when submitting a correction, send the claim with all changes exactly how the claim should be processed.
Examples:
1. A claim was previously submitted with procedure codes 99213, 88003 and 77090. The 88003 should have been 88004. An electronic replacement claim should be submitted for the line that needs to be corrected, along with the appropriate frequency code: 7, 99213, 88004 and 77090. This indicates to BCBSIL that all charges need to be deleted, and the claim will then be processed with 99213, 88004 and 77090.
2. A claim was previously submitted with procedure codes 99214, 70052 and 99213. Procedure codes 70052 and 99213 were submitted in error and need to be removed. An electronic replacement claim should be submitted with frequency code 7 and procedure code 99214. This claim will then be adjusted to remove 70052 and 99213, and it will be processed with 99214.
Example : 2
| Field | Value |
| Claim No | 252 |
| Claim Location | NY Office |
| Place of Service | 11 - Office |
| Rendering Provider | David Mark |
| ICD Code | 410,415, 368.34, 522.3 |
Line items
| Procedure Code | Mod1 | Mod2 | Mod3 | Mod4 | ICD | FromDOS | ToDOS | Units | Unit Charges |
| 99214 | 1,2,3,4 | 01/09/2012 | 01/09/2012 | 1 | 40 | ||||
| 92570 | 1 | 01/09/2012 | 01/09/2012 | 1 | 180.04 | ||||
| 90371 | 3,4 | 01/09/2012 | 01/09/2012 | 1 | 83 |
CLM*252*303.04***11:B:1*Y*A*Y*Y~
By Loop
| 2300 - Claim Information | CLM | CLM*252*303.04***11:B:1*Y*A*Y*Y~ |
| 2300 - Claim Information - Clia Number | REF | REF*X4*CL324234~ |
| 2300 - Claim Information - ICDs | HI | HI*BK:410*BF:415*BF:36834*BF:5223~ |
| 2310B - Rendering Provider Name | NM1 | NM1*82*1*Mark*David****XX*1111111111~ |
| 2310D - Service Facility Location | NM1 | NM1*77*2*NY Office*****XX*1336177328~ |
| 2310D - Service Facility Location | N3 | N3*5081 Tellus. Avenue*668-2204 Non Rd.~ |
| 2310D - Service Facility Location | N4 | N4*White Plains*NY*809051232~ |
| 2310D - Service Facility Location | REF | REF*LU*484345~ |
| 2400 - Service Line | LX | LX*1~ |
| 2400 - Service Line | SV1 | SV1*HC:99214*40*UN*1*11**1:2:3:4~ |
| 2400 - Service Line | DTP | DTP*472*RD8*20120109-20120109~ |
| 2400 - Service Line | REF | REF*6R*1140~ |
| 2400 - Service Line | LX | LX*2~ |
| 2400 - Service Line | SV1 | SV1*HC:92570*180.04*UN*1*11**1~ |
| 2400 - Service Line | DTP | DTP*472*RD8*20120109-20120109~ |
| 2400 - Service Line | REF | REF*6R*1141~ |
| 2400 - Service Line | LX | LX*3~ |
| 2400 - Service Line | SV1 | SV1*HC:90371*83*UN*1*11**3:4~ |
| 2400 - Service Line | DTP | DTP*472*RD8*20120109-20120109~ |
| 2400 - Service Line | REF | REF*6R*1142~ |