EDI 5010 Documentation 837 Professional - Loop 2000C Patient Hierarchical Level

LOOP 2000C Patient Hierarchical Level and  and LOOP 2010CA – Patient Name

 

        

Important Note:

This loop required only when the patient is a different person than the subscriber.

 

In this loop, all the information will be taken from Patient demographics.

Take a look of our sample screen here how Patient demographics information are stored in the system.

Now let’s start the detail implementation.

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2000C	HL	Patient Hierarchical Level	ID	2		R	HL
		Element Separator	AN	1			*
	HL01	Hierarchical ID Number	AN	1/12	828	R	Unique alphanumeric number for each occurrence of the HL segment in the transaction set. HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be “1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction
		Element Separator	AN	1			*
	HL02	Hierarchical Parent ID Number	AN	1/12	734	R	HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate
		Element Separator	AN	1			*
	HL03	Hierarchical Level Code	ID	1/2	735	R	23
		Element Separator	AN	1			*
	HL04	Hierarchical Child Code	ID	1/1	736	R	0
		Segment Terminator					~

 

LOOP 2000C  Patient Information

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2000C	PAT	Patient Information	ID	3		R	PAT
		Element Separator	AN	1			*
	PAT01	Individual Relationship Code	ID	2/2	1069	R	See below for more information
		Element Separator	AN	1			*
	PAT02	Patient Location Code	ID	1/1	1384	Not Used
		Element Separator	AN	1			*
	PAT03	Employment Status Code	ID	2/2	584	Not used
		Element Separator	AN	1			*
	PAT04	Student Status Code	AN	1/1	1220	Not used
		Element Separator	AN	1			*
	PAT05	Date Time Period Format Qualifier	ID	2/3	1250	S	D8 if patient is known to be deceased.
		Element Separator	AN	1			*
	PAT06	Date time Period	AN	1/35	1251	S	Print patient death date if patient is known to be deceased. Format CCYYMMDD
		Element Separator	AN	1			*
	PAT07	Unit or Basis for Measurement Code	ID	2/2	355	S	GR – Required when the patient’ age is less than 29 days old.
		Element Separator	AN	1			*
	PAT08	Weight	X	1/10	81	S	Print patient weight. Required when the patient’s age is less than 29 days old.
		Element Separator	AN	1			*
	PAT09	Yes/No Condition	ID	1/1	1073	O	Print “Y” if the patient is pregnant. Leave blank if the patient is not pregnant.
		Segment Terminator					~

PAT01 – Individual Relationship Code

 

Code	Definition
01	Spouse
19	Child
20	Employee
21	Unknown
39	Organ Donor
40	Cadaver Donor
53	Life Partner
G8	Other Relationship

 

LOOP 2010CA Patient Name

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2000CA	NM1	Patient Name	ID	3		R	NM1
		Element Separator	AN	1			*
	NM101	Entity Identifier Code	ID	2/3	98	R	QC
		Element Separator	AN	1			*
	NM102	Entity Type qualifier	ID	1/1	1065	R	1
		Element Separator	AN	1			*
	NM103	Name Last or Organization Name	AN	1/60	1035	R	Patient Last Name
		Element Separator	AN	1			*
	NM104	Name First	AN	1/35	1036	S	Patient First Name
		Element Separator	AN	1			*
	NM105	Name Middle	AN	1/25	1037	S	Patient Middle Name
		Element Separator	AN	1			*
	NM106	Name Prefix	AN	1/10	1038	Not used
		Element Separator	AN	1			*
	NM107	Name Suffix	AN	1/10	1039	S	Patient Suffix
		Element Separator	AN	1			*
	NM108	Identification code Qualifier	ID	1/2	66	R	MI (Required if the patient identifier is different than the subscriber identifier.
		Element Separator	AN	1			*
	NM109	Identification code	AN	2/80	67	R	Print Patient Primary Identification Number or Insured ID or Subscriber ID or Health Insurance claim Number
		Segment Terminator					~

 

NM102 - Entity Type Qualifier

Code qualifying the type of entity

 

Code	Definition
1	Person
2	Non-Person Entity

 

2010CA Patient Address

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2010CA	N3	Patient Address	AN	2		R	N3
		Element Separator	AN	1			*
	N301	Address Line 1	AN	1/55	166	R	Patient Address Line 1
		Element Separator	AN	1			*
	N302	Address Line 2	AN	1/55	1065	S	Patient Address Line 2 if exists
		Segment Terminator					~

2010CA  Patient City/State/Zip code

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2010CA	N4	Patient City / State / Zip Code	AN	2		R	N4
		Element Separator	AN	1			*
	N401	City Name	AN	2/30	19	R	Patient City Name
		Element Separator	AN	1			*
	N402	State or Province Code	ID	2/2	156	R	Patient State Code
		Element Separator	AN	1			*
	N403	Postal Code	ID	3/15	116	R	Patient Zip Code
		Segment Terminator					~

2010CA Patient Demographic Information.

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2010CA	DMG	Patient Demographic information	ID	3		R	DMG
		Element Separator	AN	1			*
	DMG01	Date time Period Format Qualifier	ID	2/3	1250	R	D8
		Element Separator	AN	1			*
	DMG02	Date time Period	AN	1/35	1251	R	Patient Date of birth in the Format CCYYMMDD
		Element Separator	AN	1			*
	DMG03	Gender Code	ID	1	1068	R	Print M for Male Print F for Female Print U for unknown
		Segment Terminator					~

Loop 2000C and 2010CA  Sample

Patient Demographic Information

 

Field	Value
Patient Last Name	Marvin
Patient First Name	White
Insured ID	86J353
Patient Address Line 1	2832 Linden Blvd
Patient Address Line 2	NA
Patient City	Southern View
Patient State	NY
Patient Zip Code	11234
Patient DOB (mm/dd/yyyy)	10/05/2002
Patient Gender	Female

 

PAT*19~
NM1*QC*1*MARVIN*WHITE****MI*86J353~
N3*2832 LINDEN BLVD~
N4*Southern View*NY*11234~
DMG*D8*20021005*F

Complete Example :

The conditions are follows

1. Bill with Group and Individual NPI
2. Provider Bill with Tax ID
3. Patient is NOT same as the Insurer (Self). Son is the patient and father is the insurer.
4. Bill to Patient Primary Insurance
5. ICD Version 9
6. Number of Line Items 1
7. No of Claims : 1

Clearing House Settings



Practice Setup

Patient Demographics Information



Patient Insurance Information

Claim Header Information




Claim Line items

EDI Content
Note : For Understanding, segments are shown as one line. In the actual file, there should not be any line separator.

ISA*00*          *00*          *ZZ*S32433         *01*Zirmed         *140423*1258*^*00501*999      *0*P*:
GS*HC*S32433*Zirmed*20140423*1258*999*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20140423*1258*CH
NM1*41*2*Demo Practice*****46*S32433
PER*IC*STEVEN RONALD*TE*3523412412*FX*3453241234
NM1*40*2*Zirmed*****46*Zirmed
HL*1**20*1
NM1*85*2*Demo Practice*****XX*3232323232
N3*1186 East 58TH Street
N4*Richmond Hill*NJ*114191232
REF*EI*432323232
HL*2*1*22*1
SBR*P********CI
NM1*IL*1*CAROL*AUGUSTIN****MI*YU13224
N3*5411 FILMORE AVENUE
N4*Fort Leavenwort*FL*323231212
DMG*D8*19560101*M
NM1*PR*2*WESTFIELD INSURANCE*****PI*10874
N3*7221 Engle Road*Suite 220
N4*Fort Wayne*IN*468042233
HL*3*2*23*0
PAT*19
NM1*QC*1*ADAMS*JACKIE
N3*18 HUBERT PLACE
N4*South Dayton*NY*11238
DMG*D8*19921111*M
CLM*100071*15712.25***11:B:1*Y*A*Y*Y
HI*BK:49
NM1*82*1*MOON*BRIAN****XX*1003018342
NM1*77*2*Pepin Office*****XX*3423423535
N3*668-2204 Non Rd.
N4*White Plains*NY*809051232
REF*LU*484345
LX*1
SV1*HC:99213*120.00*UN*1.00*11**1
DTP*472*RD8*20142304-20142304
REF*6R*186
SE*37*0001
GE*1*999
IEA*1*999     

EDI Content by Loop

LOOP	Segment	EDI
ISA	Header	ISA*00*          *00*          *ZZ*S32433         *01*Zirmed         *140423*1245*^*00501*999      *0*P*:~
GS	Header	GS*HC*S32433*Zirmed*20140423*1245*999*X*005010X222A1~
ST	Header	ST*837*0001*005010X222A1~
BHT	Header	BHT*0019*00*0001*20140423*1245*CH~
1000A - Submitter Name	NM1	NM1*41*2*Demo Practice*****46*S32433~
1000A - Submitter Name EDI Contact	PER	PER*IC*STEVEN RONALD*TE*3523412412*FX*3453241234~
1000B - Receiver Name	NM1	NM1*40*2*Zirmed*****46*Zirmed~
2000A - BILLING/PAY-TO PROVIDER HIERARCHICAL	HL	HL*1**20*1~
2010AA - Billing Provider Name	NM1	NM1*85*2*Demo Practice*****XX*3232323232~
2010AA - Billing Provider Address	N3	N3*1186 East 58TH Street~
2010AA - Billing Provider City/State/ZipCode	N4	N4*Richmond Hill*NJ*114191232~
Billing Provider Secondary Identification 1	Ref	REF*EI*432323232~
2000B - Subscriber Hierarchical Level	HL	HL*2*1*22*1~
2000B - Subscriber Hierarchical Level	SBR	SBR*P********CI~
2010BA - Subscriber Name	NM1	NM1*IL*1*CAROL*AUGUSTIN****MI*YU13224~
2010BA - Subscriber Address	N3	N3*5411 FILMORE AVENUE~
2010BA - Subscriber City/State/Zipcode	N4	N4*Fort Leavenwort*FL*323231212~
2010BA - Subscriber DOB and Gender	DMG	DMG*D8*19560101*M~
2010BB - Payer Name	NM1	NM1*PR*2*WESTFIELD INSURANCE*****PI*10874~
2010BB - Payer Name Address	N3	N3*7221 Engle Road*Suite 220~
2010BB - Payer City/State/ZipCode	N4	N4*Fort Wayne*IN*468042233~
Loop 2000C Patient Hierarchical Level	HL	HL*3*2*23*0~
Loop 2000C Patient Hierarchical Level	PAT	PAT*19~
Loop 2000C Patient Hierarchical Level	NM1	NM1*QC*1*ADAMS*JACKIE~
Loop 2000C Patient Hierarchical Level	N3	N3*18 HUBERT PLACE~
Loop 2000C Patient Hierarchical Level	N4	N4*South Dayton*NY*11238~
Loop 2000C Patient Hierarchical Level	DMG	DMG*D8*19921111*M~
2300 - Claim Information	CLM	CLM*100071*15712.25***11:B:1*Y*A*Y*Y~
2300 - Claim Information - ICDs	HI	HI*BK:49~
Loop 2310B Rendering Provider	NM1	NM1*82*1*MOON*BRIAN****XX*1003018342~
2310D - Service Facility Location	NM1	NM1*77*2*Pepin Office*****XX*3423423535~
2310D - Service Facility Location	N3	N3*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:99213*120.00*UN*1.00*11**1~
2400 - SERVICE LINE	DTP	DTP*472*RD8*20142304-20142304~
2400 - SERVICE LINE	REF	REF*6R*186~
SE	Trailer	SE*37*0001~
GE	Trailer	GE*1*999~
IEA	Trailer	IEA*1*999      ~

That's all.

 

        

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