Guarantor/Program Billing Defaults - 837 Institutional Section - Cal-PM

Set default 837 Institutional billing file values.

Prerequisites:

• Fields enabled by registry settings.

1. ---

   In the Submitter Name (1000A-NM1-03) field, type the submitter name to populate the 1000A-NM1-03 segment.

2. In the Submitter Contact Name (1000A-PER-02) field, enter the contact name, which will populate the 1000A-PER-02 segment.

3. In the Submitter Telephone Number (1000A-PER-04) field, type the submitter phone number to populate the 1000A-PER-04 segment.

4. In the Submitter Primary Identification # (1000A-NM1-09) field, type the primary identification number to populate the 1000A-NM1-09 segment.

5. In the Receiver Name (1000B-NM1-03) field, type the receiver name to populate the 1000B-NM1-03 segment.

6. In the Receiver Primary Identification # (1000B-NM1-09) field, type the receiver primary identification number to populate the 1000B-NM1-09 segment.

7. In the Billing Provider Name (2010AA-NM1-03) field, type the agency name. This value populates the 2010AA-NM1-03 segment.

8. In the Billing Provider Primary Identification Code Qualifier (2010AA-NM1-08) field, select the qualifier, which populates the 2010AA-NM1-08 segment.

9. In the Billing Provider Primary Identification # (2010AA-NM1-09) field, type the agency Primary Identification number. This value populates the 2010AA-NM1-09 segment.

10. In the Billing Provider Address 1 (2010AA-N3-01) field, type the agency street location information. This value populates the 2010AA-N3-01 segment.

11. In the Billing Provider Address 2 (2010AA-N3-02) field, type any additional street location information. This value populates the 2010AA-N3-02 segment.

12. In the Billing Provider ZIP Code (2010AA-N4-03) field, type the agency ZIP Code information. This value populates the 2010AA-N4-03 segment.

13. In the Billing Provider City (2010AA-N4-01) field, type the agency city information. This value populates the 2010AA-N4-01 segment.

14. In the Billing Provider State (2010AA-N4-01) field, select the state from the list. This value populates the 2010AA-N4-01 segment.

15. In the Billing Provider Secondary Identification Code Qualifier field, select the value from the list. The value selected populates the 2010AA-REF-01 segment.

16. In the Billing Provider Secondary Identification # (2010AA-REF-02) field, type the agency Secondary Identification number. This value populates the 2010AA-REF-02 segment.

17. In the Billing Provider Secondary Identification Code Qualifier - 2 (2010AA-REF-01) field, enter the value that populates the 2010AA-REF-01 segment.

18. In the Billing Provider Secondary Identification # - 2 (2010AA-REF-01) field, type the agency Secondary Identification number. This value populates the 2010AA-REF-01 segment.

19. In the Billing Provider Secondary Identification Code Qualifier - 3 (2010AA-REF-01) field, enter the value that populates the 2010AA-REF-01 segment.

20. In the Billing Provider Secondary Identification # - 3 (2010AA-REF-02) field, type the agency Secondary Identification number. This value populates the 2010AA-REF-02 segment.

21. In the Billing Provider Contact Name (2010AA-PER-02) field, enter the contact name. This value populates the 2010AA-PER-02 segment.

22. In the Billing Provider Phone # (2010AA-PER-04) field, type the contact phone number. This value populates the 2010AA-PER-04 segment.

23. In the Payer Identification Code Qualifier (2010BB/2330B-NM1-08) field, select the value from the list. This value populates the 2010BB/2330B-NM1-08 segments.

24. In the Payer Identification Number (2010BB/2330B-NM1-09) field, type the agency Payer Identification number. This value populates the 2010BB/ 2330B-NM1-09 segments.

25. In the Patient Amount Due Information To Display In 2300-AMT field, select the information to display in the 2300-AMT segment.

26. In the Patient Paid Amount Information To Display In 2300-AMT field, select the information to display in the 2300-AMT segment.

27. In the Suppress AMT Segments When AMT-02 Is Zero field, select Yes to suppress AMT segments when AMT-02 is zero; select No to disable this function.

28. In the Service Authorization Exception Code Reference Identification (2300-REF-02) field, enter the value that populates the 2300-REF-02 segment.

29. In the Determine Managed Care Authorizations (2300-REF-02) field, select the method by which to determine the managed care authorizations. This value populates the 2300-REF-02 segment.

30. In the Include Un-Authorized Services (2300-REF-02) field, select Yes to include unauthorized services in the 2300-REF-02 segment; select No to exclude unauthorized services.

31. In the Display NTE Segment At Claim Level field, select Yes to display the NTE segment at the claim level; select No to exclude the NTE segment.

32. In the Claim Note Reference Code (837I-2300-NTE-01) field, select the value from the list. This value populates the 2300-NTE-01 segment.

33. In the Claim Note Text (837I-2300-NTE-02) field, type the claim note text. This value populates the 2300-NTE-02 segment.

34. In the Billing Note Reference Code (837I-2300-NTE-01) field, enter the value that populates the 2300-NTE-01 segment.

35. In the Billing Note Text (837I-2300-NTW-02) field, enter the claim note text. This value populates the 2300-NTE-02 segment.

36. In the Include Discharge Date In Occurrence Information (2300-Hi:Occurance Information-01) field, select Coverage Expiration Date - Medicare A to use the Medicare coverage expiration date in the occurrence information; select Discharge Date to instead use the discharge date.

37. In the Include Claim Quantity Segment (QTY) For Covered Days field, select Yes to include the claim quantity segment for covered days.

38. In the Specify Rendering Practitioner As Attending Practitioner In Loop 2310A (Attending Physician Name) field, select Yes to specify the rendering practitioner as the attending physician in loop 2310A.

39. In the Select Type Of Information To Include In Loop 2310C field, select the type of information to include in the 2310 loop.

40. In the Facility Identification Code Qualifier (2310E-NM1-08) field, enter the value that populates the 2310E-NM1-08 segment.

41. In the Facility Identification Code (2310E-NM1-09) field, type the value to populate the 2310E-REF-01 segment.

42. In the Facility Reference Identification Qualifier (2310E-REF-01) field, enter the value that populates the 2310E-REF-01 segment.

43. In the Facility Reference Identification (2310E-REF-02) field, type the agency Facility Reference Identification . This value populates the 2310E-REF-02 segment.

44. In the Facility Reference Identification Qualifier - 2 (2310E-REF-01) field, select the value that populates the 2310E-REF-01 segment.

45. In the Facility Reference Identification - 2 (2310E-REF-02) field, type the agency Facility Reference Identification . This value populates the 2310E-REF-02 segment.

46. In the Facility Reference Identification Qualifier - 3 (2310E-REF-01) field, select the value that populates the 2310E-REF-01 segment.

47. In the Facility Reference Identification - 3 (2310E-REF-02) field, type the agency Facility Reference Identification. This value populates the 2310E-REF-02 segment.

48. In the Include Transfers In Claim Level Adjustments/Service Level Adjustments (2320/2430-CAS) field, select Yes to include transfers within loops 2320 and 2430-CAS.

49. In the Amount To Display (2320-AMT:Payer Paid Amount-02) field, select Zero to allow the display of zeroes in the amount; select Other Payer Patient Paid Amount to display the amount paid by the payer.

50. In the Suppress When Amount is Zero (2320-AMT: Other Payer Patient Paid Amount-02) field, select Yes to exclude zero dollar services.

51. In the Specify Number of Digits for Service Line Revenue Code (2400-SV2-01) field, select the number of digits to use for the service line revenue code. myAvatar will add leading zeroes to shorter codes so that the number of digits meets the required length.

52. In the Authorization Information Qualifier (ISA-01) field, select the value that populates the ISA-01 segment.

53. In the Authorization Information (ISA-02) field, type the authorization information. This field requires 10 digits.

54. In the Security Information Qualifier (ISA-03) field, select the value that populates the ISA-03 segment.

55. In the Security Information (ISA-04) field, type the security information. This value populates the ISA-04 segment and requires 10 digits.

56. In the Interchange Sender ID Qualifier (ISA-05) field, enter the value that populates the ISA-05 segment.

57. In the Interchange Sender ID (ISA-06) field, type the information. This value populates the ISA-06 segment and requires 15 digits.

58. In the Interchange Receiver ID Qualifier (ISA-07) field, select the value that populates the ISA-07 segment.

59. In the Interchange Receiver ID (ISA-08) field, enter the value that populates the ISA-08 segment and requires 15 digits.

60. In the Acknowledgement Requested (ISA-14) field, designate whether acknowledgement will be requested.

61. In the Usage Indicator (ISA-15) field, select the value that populates the ISA-15 segment.

62. In the Application Sender's Code (GS-02) field, enter the value that populates the GS-02 segment. This field requires between 2 and 15 digits.

63. In the Application Receiver's Code (GS-03) field, enter the value that populates the GS-03 segment. This field requires between 2 and 15 digits.

64. In the Maximum Claim Information Per Subscriber Information (Maximum CLM Per Subscriber HL) field, enter the maximum number of claims that can be sent for each subscriber.

65. In the Maximum Service Information Per Claim Information (Maximum LX Per CLM) field, enter the maximum number of services that can be sent for each claim.

66. In the Maximum Subscriber Information Per Transaction (Maximum Subscriber SBR Per ST/SE) field, enter the maximum number of subscribers that can be sent with each transaction.

67. In the Include Zero Dollar Services field, select Yes to include zero dollar services. Select No to exclude zero dollar services.

68. In the Allow Periods In Diagnosis Codes (837I) field, select Yes to allow periods in diagnosis codes.

69. In the 'If the Loop/Segment Information At The Service Level...' field, choose Yes to exclude the Loop/Segment information at the service level. Choose No to include the Loop/Segment information at the service level.

70. In the 'If The Begin/From Date Is The Same As The End/To Date...' field, choose Yes to use the D8 format when the begin and end dates are the same. Choose No to use the RD8 format when the begin and end dates are the same.

71. In the 'Additional Sort To LX Segment Based On...' field, choose how to employ an additional sort in the LX segment.

72. In the 'Only Include HCPCS For The Following Revenue' field, select the revenue codes.

► Registry Settings

• Allow Extended Character Set In File
• Allow For Inpatient Bill To Compile As Outpatient
• Allow Policy Number By Date Sort
• Bill Component Services When A Roll Up Service Is Found
• Claim Statement Dates
• Claim Statement Dates Format (RD8)
• Cost Avoidance Override/Zero Fill Logic
• Enable Claim Frequency Code Override
• Enable Contract Information
• Enable Coordination Of Benefits Allowed Amount
• Enable Coordination Of Benefits Total Medicare Paid Amount (2320-AMT)
• Enable Drug Identification (2410)
• Enable Patient Status Code And Service Line Revenue Code Override
• Enable Pay-To Address Name (2010AB)
• Enable PPS Billing
• Enable Pricing/Re-Pricing Information
• Enable Service Suppression For 837 File
• Enable Subscriber Policy Number Override
• Enable Support For Crossover Claims
• Include Billing Guarantor In Other Subscriber Information
• Include Claim Level Adjustment Info
• Include CLIA Numbers
• Include First Billing Date
• Include Payer Secondary Id
• Include Present On Admission Indicator
• Include Service Level Adjudication Info
• Include Subscriber Secondary ID Info
• Include Svc Line Non-Covered Charge Amt
• Limit Number of Claim Numbers Generated
• Maximum Allowed Diagnosis Per HI-6
• Modify Occurrence Span Through Date For Leaves
• Other Payer Name Information Override (2300B)
• Referring Provider Determination Method
• Sort Claim By Medicaid Rate Code
• Specify A Prefix Value For Patient Account Number
• Specify Claim or Encounter Indicator (BHT-06)
• Specify Claim Sorting Parameters
• Specify Default Discharge Hour (2300-DTP)
• Specify Default Patient Status Code
• Specify Functional Group Time Format
• Specify Loops/Segments To Suppress/Include
• Specify Number Of Digits For Service Line Revenue Code (2400-SV2-01)
• Specify Occurrence Span Code For Leaves
• Specify Other Subscriber Primary ID
• Specify Rendering/Attending Provider At Guarantor/Program Level
• Specify Revenue Code For Leaves
• Suppress Non-Billable Leaves
• Suppress Service Facility Name
• Suppress Service Line Date (2400-DTP)
• Use Admission Program For Bill Sorting
• Use Per Diem Rate For Outpatient Billing

► SQL Tables

• SYSTEM.file_import_gpbdt_i837
• SYSTEM.table_837_i_facility_prov_num