EDI 837 Professional. Version 005010X222A1
Example 9: Payer Secondary Identification
Some payer need additional identifiers other than payer ID. Here are those available option in EDI 837 , you can submit additional numbers
2U | Payer Identification Number |
EI | Employer’s Identification Number |
FY | Claim Office Number |
NF | National Association of Insurance Commissioners (NAIC) Code |
MEDICAID IL, required 2U Number, if that is missing, then the following error will be thrown.
MEDICAID IL NON-PRIMARY CLAIMS REQUIRE A 5-DIGIT NUMERIC SECONDARY PAYER NUMBER WITH A 2U TYPE FOR THE OTHER POLICIES. THIS NUMBER SHOULD BE THE 3-DIGIT TPL CODE FOLLOWED BY THE 2-DIGIT STATUS CODE ASSIGNED BY HFS
Here is an example of EDI 837 message which contains Payer secondary information
ISA*00* *00* *ZZ*123123 *ZZ*241232 *210719*0950*^*00501*199509000*1*T*:
GS*HC*123123*241232*20210719*0950*199509*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*199509*20210719*0950*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
REF*2U*412412
REF*EI*124567890
REF*FY*21212
REF*NF*32122222
CLM*10421*100.00***11:B:1*Y*A*Y*Y*P
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:99213*50.00*UN*1.00***1:2
DTP*472*D8*20201204
REF*6R*6001
LX*2
SV1*HC:87070*50.00*UN*1.00***1:2
DTP*472*D8*20201204
REF*6R*6002
SE*39*0001
GE*1*199509
IEA*1*199509000
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 | 07/19/2021 |
InterChange Time (HHMM) | 09:50 |
Repetition Seperator | ^ |
Control Number | 199509000 |
Acknowledgement Requested | 1 |
Usage Indicator | T |
Functional Group Header
Application Sender Code | 123123 |
Application Receiver Code | 241232 |
Group Transaction Date | 07/19/2021 |
Group Transaction Time (HHMM) | 09:50 |
Group Control Number | 199509 |
EDI Version | 005010X222A1 |
Transaction Set Header
Transaction set | 837 |
Transaction Control Number | 0001 |
Hierarchical Transaction
Application Transaction Number | 199509 |
Transaction Date | 07/19/2021 |
Transaction Time (HHMM) | 09:50 |
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 |
Payer Identification Number | 412412 |
Employer’s Identification Number | 124567890 |
Claim Office Number | 21212 |
National Association of Insurance Commissioners (NAIC) Code | 32122222 |
Claim Information
Claim No | 10421 |
Billed Amount | 100.00 |
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 | 6001 |
Procedure Code | 99213 |
Units Code | UN |
Units | 1.00 |
Charges | 50.00 |
ICD Pointers | 1,2 |
Service From Date | 12/04/2020 |
Service To Date | 12/04/2020 |
Line Item : 2
Line Item ID | 6002 |
Procedure Code | 87070 |
Units Code | UN |
Units | 1.00 |
Charges | 50.00 |
ICD Pointers | 1,2 |
Service From Date | 12/04/2020 |
Service To Date | 12/04/2020 |
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