EDI 837 Professional. Version 005010X222A1
Example 10: Billing Laboratory Claims Electronically
When laboratory claims are billed electronically the Clinical Laboratory Improvement Act (CLIA) Number must be included in the claims. For reference laboratory claims, Modifier 90 is required as well.
The ANSI Implementation Guide requires the CLIA number on all laboratory claims billed to Medicare.
Example: REF*X4*12D4567890
• The CLIA number is required on all laboratory claims billed to Medicare.
• The CLIA number is submitted in Loop 2300 (Claim Information) and/or Loop 2400 (Service Line Information).
• The CLIA number is submitted in a REF (Reference Identification) segment.
• The Reference Identification Qualifier must be submitted as X4.
Note:
For reference laboratory claims, two CLIA numbers must be submitted. The billing laboratory CLIA number must be submitted in a REF segment in the 2300 loop with an X4 qualifier and the reference laboratory CLIA number
(the CLIA number for the lab who performed the service) must be submitted in a REF segment in the 2400 loop with an F4 qualifier. The billing laboratory CLIA number must be different than the CLIA number of the reference laboratory since they are two separate entities. If these two numbers are the same, claims will be denied.
Here is an example of EDI 837 with referring and referring Laboratory claims.
ISA*00* *00* *ZZ*123123 *ZZ*241232 *210628*1045*^*00501*283181800*1*T*:
GS*HC*123123*241232*20210628*1045*2831818*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*2831818*20210628*1045*CH
NM1*41*2*ABC Submitter*****46*7342343
PER*IC*John Mike*TE*1214151617
NM1*40*2*Zirmed*****46*12345
HL*1**20*1
PRV*BI*PXC*208500000X
NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692
N3*3937 Kenwood Place
N4*Orlando*FL*32801
REF*EI*81-3777631
HL*2*1*22*0
SBR*P*18*92291223*AED12342*****ZZ
NM1*IL*1*BAKER*Alyssa****MI*723223232
N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St
N4*HOUSTON*TX*77833
DMG*D8*20201204*M
NM1*PR*2*CIGNA*****PI*81400
N3*PO BOX 660044
N4*DALLAS*TX*75266
CLM*10421*100.00***11:B:1*Y*A*Y*Y*P
REF*X4*X562123232
HI*ABK:R1013*ABF:E860
NM1*82*1*Nelson*Romer****XX*1023555349
NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059
N3*6100 W CREEK RD SUITE 35
N4*Independence*OH*44131
LX*1
SV1*HC:U0003*60.00*UN*1.00***1
DTP*472*D8*20190517
REF*6R*111
REF*F4*X13412312
SE*33*0001
GE*1*2831818
IEA*1*283181800
HTML Version
Interchange Control Header
| Authorization Qualifier | 00 |
| Security Qualifier | 00 |
| Interchange ID Qualifier Sender | ZZ |
| Submitter ID | 123123 |
| Interchange ID Qualifier Receiver | ZZ |
| Receiver ID | 241232 |
| Interchange Date | 06/28/2021 |
| InterChange Time (HHMM) | 10:45 |
| Repetition Seperator | ^ |
| Control Number | 283181800 |
| Acknowledgement Requested | 1 |
| Usage Indicator | T |
Functional Group Header
| Application Sender Code | 123123 |
| Application Receiver Code | 241232 |
| Group Transaction Date | 06/28/2021 |
| Group Transaction Time (HHMM) | 10:45 |
| Group Control Number | 2831818 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 0001 |
Hierarchical Transaction
| Application Transaction Number | 2831818 |
| Transaction Date | 06/28/2021 |
| Transaction Time (HHMM) | 10:45 |
| Submitter Entity | Organization |
| Organization Name | ABC Submitter |
| Etin Number | 7342343 |
| Contact Name | John Mike |
| Contact Phone | 1214151617 |
| Receiver Name | Zirmed |
| Receiver Etin Number | 12345 |
Billing Provider
| Entity Type | 2 |
| Last or Organization Name | Get Well Family Clinic LLC |
| Address1 | 3937 Kenwood Place |
| City | Orlando |
| State | FL |
| Zip | 32801 |
| NPI | 1740713692 |
| Tax ID | 81-3777631 |
| Taxonomy Code | 208500000X |
Subscriber information
| Payer Responsbility | P |
| Insured Relationship | 18 |
| Group Number | 92291223 |
| Group Name | AED12342 |
| Claim Filling Indicator | ZZ |
Subscriber Name
| Entity Type | 1 |
| Last or Organization Name | BAKER |
| First Name | Alyssa |
| DOB | 12/04/2020 |
| Gender | M |
| Policy No | 723223232 |
| Address1 | 197800 Atascocita Shores Dr |
| Address2 | 302 12 N. Mcgraw St |
| City | HOUSTON |
| State | TX |
| Zip | 77833 |
Payer
| Name | CIGNA |
| Address1 | PO BOX 660044 |
| City | DALLAS |
| State | TX |
| Zip | 75266 |
| Payer ID | 81400 |
Claim Information
| Claim No | 10421 |
| Billed Amount | 100.00 |
| Clia Number | X562123232 |
| Claim Type | 1 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
ICD Information
| ICD Code 1 | R1013 |
| ICD Code 2 | E860 |
Rendering Provider
| Entity Type | 1 |
| Last or Organization Name | Nelson |
| First Name | Romer |
| NPI | 1023555349 |
Facility
| Name | Clinic For Pain And Anxiety |
| Address1 | 6100 W CREEK RD SUITE 35 |
| City | Independence |
| State | OH |
| Zip | 44131 |
| NPI | 1396885059 |
Line Item : 1
| Line Item ID | 111 |
| Procedure Code | U0003 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 60.00 |
| ICD Pointers | 1 |
| Service From Date | 05/17/2019 |
| Service To Date | 05/17/2019 |
| Referring Clia Number | X13412312 |
