Monday, 10 September 2012

EDI 5010 Documentation 837 Professional - LOOP 2000B Subscriber Hierarchical Level

2000B Subscriber Hierarchical Level

        

For this Loop, Take the information from Patient Insurance and Insurance Master details.

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Loop Seg ID Segment Name Format Length Ref# Req Value
2000B HL Subscriber Hierarchical Level ID 2 R HL
Element Separator AN 1 *
HL01 Subscriber ID Number AN 1/12 628 R 2
Element Separator AN 1 *
HL02 Hierarchical Parent ID Number AN 1/12 734 R 1
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 22
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1/1 736 R 0
Segment Terminator ~
               
 
 
2000B Subscriber Information
Loop Seg ID Segment Name Format Length Ref# Req Value
2000B SBR Subscriber Information ID 3 R SBR
Element Separator AN 1 *
SBR01 Payer Responsibility Code ID 1/1 1138 R See below for more information
Element Separator AN 1 *
SBR02 Individual Relationship code ID 2/2 1069 S If Subscriber is same person as of the patient, then Print 18, else do not print , just append element separator.
Element Separator AN 1 *
SBR03 Reference Identification AN 1/50 127 S Print Patient –> Insurance –> Group Number
Element Separator AN 1 *
SBR04 Name AN 1/60 93 S Print Patient-> Insurance-> Group Name
Element Separator AN 1 *
SBR05 Insurance Type Code ID 1/3 1336 S See below for more information
Element Separator AN 1 *
SBR06 Coordination of Benefit code Not Used *
SBR07 Yes/No Condition Not Used *
SBR08 Employment Status Code Not Used *
SBR09 Claim filling Indicator Code ID 1/2 1032 S See below for more information
Segment Terminator ~
               

SBR01 – Payer Responsibility Sequence Number Code
Code Definition
P Primary
S Secondary
T Tertiary
A Code for the 4th Insurance
B Code for the 5th Insurance
C Code for the 6th Insurance
D Code for the 7th Insurance
E Code for the 8th Insurance
F Code for the 9th Insurance
G Code for the 10th Insurance
H Code for the 11th Insurance
 
 
SBR05 –  Insurance Type Code
2000B SBR05 is required when Medicare is the destination payer but not the primary payer i.e Medicare would be the second or third payer. We should capture this field either in the Patient Insurance Policy information or at the claim level.

 
Code Definition
12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13 Medicare Secondary End Stage Renal Disease
14 Medicare Secondary , No Fault Insurance including Auto is Primary
15 Medicare Secondary Worker’s Compensation
16 Medicare Secondary Public Health Service (PHS) or other Federal Agency
16 Medicare Secondary Public Health Service
41 Medicare Secondary Black Lung
42 Medicare Secondary Veteran’s Administration
43 Medicare Secondary Veteran’s Administration
47 Medicare Secondary, Other Liability Insurance is Primary

 


SBR09 – Claim Filling indicator code

 

We should capture this field (single selection drop down) in the insurance master screen for each insurance.
Code Definition
11 Other Non-Federal Programs
12 Preferred Provider Organizations
13 Point of Service
14 Exclusive Provider Organization
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Risk
17 Dental Maintenance Organization
AM Automobile Medical
BL Blue Cross/Blue Shield
CH Champus
CI Commercial Insurance Co
DS Disability
HM Health Maintenance Organization
LM Liability Medical
MB Medicare Part B
MC Medicaid
MA Medicare Part A
OF Other Federal Program
TV Title V
VA Veteran Administration Plan
WC Worker’s Compensation Health Claim
FI Federal Employees Program
ZZ Mutually Defined.
 
2000B Subscriber Information – Sample
Test data  -  Use case 1:
 
Insurance Master Setup
Field Value
Insurance Name Cigna
Insurance Program ZZ  (Mutually Defined). Drop down. Values should be from this list
 
Test data – Patient Insurance Policy Setup
Field Value
Insurance Plan Cigna Prim Plan
Patient Relation Self
Group Name XYZ
Group Number 492929
 
Destination payer is Cigna and patient is same as the subscriber.
SBR*P*18*492929*XYZ*****ZZ~
****************************************************************************************************************
 
 
Test data - Use case 2:
Insurance Master Setup
Field Value
Insurance Name Medicare
Insurance Program MB  ( Medicare Part B). Drop down. Values should be from this list
Test data – Patient Insurance Policy Setup
Field Value
Insurance Plan Medicare Plan
Patient Relation Child
Group Name Premium Plus
Group Number ABC34F3
Destination payer is Medicare and patient is NOT same as the subscriber.
SBR*P**ABC34F3*Premium Plus*****MB~
 
Test data - Use case 3:
Insurance Master Setup
Field Value
Insurance Name Medicare
Insurance Program MB ( Medicare Part B). Drop down. Values should be from this list
 
Test data – Patient Insurance Policy Setup
Field Value
Insurance Plan Medicare Plan
Patient Relation Child
Group Name Premium Plus
Group Number ABC34F3
Secondary Type 41 Drop down. Values should be from this list .
 
Destination payer is Medicare WHICH IS AT THE 5TH Level and patient is NOT same as the subscriber.
SBR*B**ABC34F3*Premium Plus*41****MB~
 
        

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com. 

1 comment:

  1. use case 7 has 1 in HL04? This says only 0?

    ReplyDelete