Guarantor/Program Billing Defaults - 837 Professional Section - PM
Set the default 837 Professional billing file values.
- Certain fields on this form depend on the version of 837 Professional Billing used. These fields will be noted and designated with the corresponding version number.
- Fields enabled by registry settings.
| Field Name | 837 Segment | Description |
|---|---|---|
| Submitter Name | 1000A-NM1-03 | this is the agency or provider submitting the billing file |
| Submitter Contact Name | 1000A-PER-02 | |
| Submitter Telephone Number | 1000A-PER-04 | |
| Submitter Primary Identification # | 1000A-NM1-09 | |
| Receiver Name | 1000B-NM1-03 | this is the payor or entity receiving the billing file |
| Receiver Primary Identification # | 1000B-NM1-09 | |
| Provider Code | 2000A-PRV-01 | |
| Reference Identification | 2000A-PRV-03 | this is the agency taxonomy code |
| Billing Provider Entity Type Qualifier | 2010AA-NM1-02 | |
| Billing Provider Last Or Organization Name | 2010AA-NM1-03 | this is the agency name or the last name of the billing provider |
| Billing Provider First Name | 2010AA-NM1-04 | |
| Billing Provider Middle Name | 2010AA-NM1-05 | |
| Billing Provider Name Suffix | 2010AA-NM1-07 | |
| Billing Provider Primary Identification Code Qualifier | 2010AA-NM1-08 | |
| Billing Provider Primary Identification # | 2010AA-NM1-09 | |
| Billing Provider Address 1 | 2010AA-N3-01 | agency or billing provider street location |
| Billing Provider Address 2 | 2010AA-N3-02 | additional agency or billing provider street location information |
| Billing Provider ZIP Code | 2010AA-N4-03 | agency or billing provider ZIP Code |
| Billing Provider City | 2010AA-N4-01 | agency or billing provider city |
| Billing Provider State | 2010AA-N4-02 | agency or billing provider state |
| Billing Provider Tax Identification Code Qualifier | version 5010 only | type of the agency or billing provider tax ID number |
| Billing Provider Tax Identification Number | version 5010 only | agency or billing provider tax ID number |
| Billing Provider UPIN/License Information Code Qualifier | version 5010 only | type of the agency or billing provider UPIN/License code |
| Billing Provider UPIN/License Information | version 5010 only | agency or billing provider UPIN/License code |
| Billing Provider UPIN/License Information Code Qualifier - 2 | version 5010 only | type of the agency or billing provider secondary UPIN/License code |
| Billing Provider UPIN/License Information - 2 | version 5010 only | agency or billing provider secondary UPIN/License code |
| Billing Provider Secondary Identification Code Qualifier | 2010AA-REF-01 (version 4010 only) | |
| Billing Provider Secondary Identification # | 2010AA-REF-02 (version 4010 only) | |
| Billing Provider Secondary Identification Code Qualifier - 2 | 2010AA-REF-01 (version 4010 only) | |
| Billing Provider Secondary Identification # - 2 | 2010AA-REF-02 (version 4010 only) | |
| Billing Provider Secondary Identification Code Qualifier - 3 | 2010AA-REF-01 (version 4010 only) | |
| Billing Provider Secondary Identification # - 3 | 2010AA-REF-02 (version 4010 only) | |
| Billing Provider Contact Name | 2010AA-PER-02 | contact person's name from the agency or or billing provider |
| Billing Provider Phone # | 2010AA-PER-04 | agency or or billing provider phone number |
| Pay-to Address Entity Type Qualifier | 2010AB-NM1-02 | |
| Pay-to Address Last Or Organization Name | 2010AB-NM1-03 | last name or the organization name of the pay-to provider |
| Pay-to Address First Name | 2010AB-NM1-04 | |
| Pay-to Address Middle Name | 2010AB-NM1-05 | |
| Pay-to Address Suffix | 2010AB-NM1-07 | |
| Pay-to Address Identification Code Qualifier | 2010AB-NM1-08 | |
| Pay-to Address Identifier | 2010AB-NM1-09 | |
| Pay-to Address Line 1 | 2010AB-N3-01 | |
| Pay-to Address Line 2 | 2010AB-N3-02 | |
| Pay-to Address ZIP Code | 2010AB-N4-03 | |
| Pay-to Address City | 2010AB-N4-01 | |
| Pay-to Address State | 2010AB-N4-02 | |
| Pay-to Address Reference Identification Qualifier | 2010AB-REF-01 | |
| Pay-to Address Additional Identifier | 2010AB-REF-02 | |
| Payer Identification Code Qualifier | 2010BB/2330B-NM1-08 | |
| Payer Identification # | 2010BB/ 2330B-NM1-09 | agency payer identification number |
| Special Program Indicator Code | 2300-CLM-12 | |
| Enable Demonstration Project Identifier | 2300-REF | select whether or not to populate the 2300-REF segment in both the 837P |
| Demonstration Project Identifier | 2300-REF-02 | if enabled, enter the identifier |
| Claim Note Reference Code | 2300-NTE-01 | |
| Claim Note Text | 2300-NTE-02 | |
| Select Type Of Information To Include In Referring Provider Name | 2310A and 2420F | |
| Suppress Rendering Provider Name if Practitioner is Not Required to be Enrolled With Guarantor | Suppress 2310B to suppress all non-required rendering practitioners from the CLM loop, segment 2310B Suppress 2420A to suppress all non-required rendering practitioners from the SV1 loop, segment 2420A |
Required rendering practitioners are defined by the selections made in the Practitioner Categories for Coverage Needing Enrollment with Guarantor field on the 837 section of the Guarantors/Payors form. |
| Facility Identification Code Qualifier | 2310D-NM1-08 | |
| Facility Identification Code | 2310D-NM1-09 | |
| Facility Reference Identification Qualifier | 2310D-REF-01 | |
| Facility Reference Identification | 2310D-REF-02 | |
| Include Transfers In Claim Level Adjustments/Service Level Adjustments | 2320/2430-CAS | Yes to include transfers within loops 2320 and 2430-CAS |
| Suppress Claim Level Adjustments/Service Level Adjustments When Total is Zero | 2320-CAS/2430-CAS | select whether or not to remove from 2320-CAS/2430-CAS any claim adjustment group/reason code pairs that have a total of zero |
| Amount To Display | 2320-AMT:Payer Paid Amount-02 |
|
| Suppress Payer Paid Amount | 2320-AMT |
|
| Other Subscriber Secondary Identification Qualifier | 2330A-REF-01 | |
| Use Roll-Up Component First And Last Dates Of Service | 2400-DTP | select Yes to use the first and last dates of a roll-up component service; select No to disable this function |
| Service Note Reference Code | 837P-2400-NTE-01 | |
| Service Note Text | 837P-2400-NTE-02 | |
| Populate 2400-NTE-02 With Start and End Times? | 2400-NTE-02 | |
| Populate 2400-NTE-02 With EBP Information | 2400-NTE-02 | elect whether or not to enable functionality to format the 2400-NTE-02 field with the following eight components delimited by a vertical bar: Component 1 = spaces Component 2 = 'C' (for CCBHC service lines) Component 3 = Medicaid Provider ID from Program Maintenance Component 4 = First Evidence Based Practice code associated with the service Component 5 = Second Evidence Based Practice code associated with the service Component 6 = Third Evidence Based Practice code associated with the service Component 7 = Fourth Evidence Based Practice code associated with the service Component 8 = Fifth Evidence Based Practice code associated with the service |
| Use Claim Original Reference Number for Reference Identification on Re-Bills | 2400-REF-02 | |
| Authorization Information Qualifier | ISA-01 | |
| Authorization Information | ISA-02 | |
| Security Information Qualifier | ISA-03 | |
| Security Information | ISA-04 | this value must consist of 10 digits |
| Interchange Sender ID Qualifier | ISA-05 | |
| Interchange Sender ID | ISA-06 | this field requires a 15 character entry, and is a free-text data element |
| Interchange Receiver ID Qualifier | ISA-07 | |
| Interchange Receiver ID | ISA-08 | this value must consist of 15 digit |
| Repetition Separator | ISA-11 | enter a character to serve as a separator for the ISA-11 segment Note: The pipe/vertical bar character [ | ] is not permitted as a value in this field. To enable the vertical bar as the separator character, enter another character and then select Vertical Bar in the Repetition Separator Override field. |
| Acknowledgement Requested | ISA-14 | choose whether acknowledgement will be requested from the interchange receiver |
| Usage Indicator | ISA-15 | |
| Application Sender's Code | GS-02 | This field requires between 2 and 15 digits, and is a free-text data element |
| Application Receiver's Code | GS-03 | This field requires between 2 and 15 digits, and is a free-text data element |
| Include Zero Dollar Services | select Yes to include zero dollar services; select No to disable this function | |
| Allow Periods In Diagnosis Codes (837P) | select Yes to allow periods in the diagnosis codes; select No to disable this function | |
| If The Begin/From Date Is The Same As The End/To Date... | select Yes to use the D8 format when the begin and end dates are the same; select No to use the RD8 format instead | |
| Sort Billing Pay To Provider Group By Rendering Practitioner | select Yes to sort the billing pay-to provider by rendering practitioner; select No to disable this function | |
| Select Segments To Suppress |
- ► Dictionary Values
-
- Acknowledgement Requested (ISA-14)
- Authorization Information Qualifier (ISA-01)
- Billing Provider Entity Type Qualifier (2100AA-NM1-02)
- Billing Provider Primary Identification Code Qualifier (2010AA-NM1-08)
- Billing Provider Tax Identification Code Qualifier
- Billing Provider UPIN/License Information Code Qualifier
- Billing Provider UPIN/License Information Code Qualifier - 2
- Billing Provider Secondary Identification Code Qualifier (2010AA-REF-01)
- Billing Provider Secondary Identification Code Qualifier - 2 (2010AA-REF-01)
- Billing Provider Secondary Identification Code Qualifier - 3 (2010AA-REF-01)
- Claim Note Reference Code (837P-2300-NTE-01)
- Facility Identification Code Qualifier
- Facility Reference Identification Qualifier
- Interchange Receiver ID Qualifier (ISA-07)
- Interchange Sender ID Qualifier (ISA-05)
- Other Subscriber Secondary Identification Qualifier (2330A-REF-01)
- Pay-to Address Entity Type Qualifier (2010AB-NM1-02)
- Pay-to Address Reference Identification Qualifier (2010AB-REF-01)
- Payer Identification Code Qualifier (2010BB/2330B-NM1-08)
- Provider Code (2000A-PRV-01)
- Security Information Qualifier (ISA-03)
- Service Note Reference Code (837P-2400-NTE-01)
- Special Program Indicator Code (2300-CLM-12)
- Usage Indicator (ISA-15)
- ► Registry Settings
-
- 837P Loops/Segments To Suppress
- Allow Extended Character Set In File
- Allow Policy Number By Date Sort
- Bill Component Services When A Roll Up Service Is Found
- Enable Ambulance Pick-Up/Drop Off Location
- Enable Contract Information
- Enable Contract Information (2300-CN1) Report Only
- Enable Coordination Of Benefits Allowed Amount
- Enable Coordination Of Benefits Total Medicare Paid Amount (2320-AMT)
- Enable Coordination of Benefits Patient Responsibility Amount
- Enable Drug Identification (2410)
- Enable EPSDT Referral (2300-CRC)
- Enable Pricing/Re-Pricing Information
- Enable Subscriber Group Number (2000B-SBR-03)
- Enable Subscriber Policy Number Override
- Enable Supervising Practitioner Based On Rendering Practitioner (2310B)
- Enable Support For Crossover Claims
- Facility Entity ID Code (2310D/2420C)
- Fields to Include in Client Charge Input
- File Information (Loop 2400)
- Include Billing Guarantor In Other Subscriber Information
- Include CLIA Numbers
- Include First Billing Date
- Include Patient Remaining Liability
- Include Payer Secondary Id
- Include Secondary Submitter EDI Contact Information (1000A-PER)
- Include Service Level Adjudication Info
- Include Special Program Indicator Code (2300-CLM-12)
- Include Subscriber Secondary ID Info (2010BA-REF)
- Maximum Allowed Diagnosis Per HI
- Other Payer Name Information Override (2300B)
- Other Subscriber Secondary ID
- Other Subscriber Secondary ID Logic
- Override Claim Submitter Identifier
- Override Payer Name (2010BB)
- Override Subscriber Policy Number Using Social Security Number
- Patient Amount Paid (2300-AMT)
- Principal Medical Diagnosis In HI When Max LX Per CLM Is Set To 1 Logic
- Referring Provider Determination Method
- Rendering Provider Name (2420A)
- Rendering Provider Name (Loop 2310B)
- Select A Suffix Value For Patient Account Number
- Service Facility Location 2310D/2420C
- Service Panel Charge Input - Fields To Include
- Sort 'Claim Information' By Treatment String Values
- Specify A Prefix Value For Patient Account Number
- Specify Claim or Encounter Indicator (BHT-06)
- Specify Functional Group Time Format
- Specify Loops/Segments To Suppress/Include (834)
- Specify Loops/Segments To Suppress/Include (837)
- Specify Other Subscriber Primary ID
- Specify Rendering/Attending Provider At Guarantor/Program Level
- Suppress Rendering Provider Name (2310B/2420A)
- Suppress Service Facility Location (2310D/2420C)
- Svc Level Adjudication Logic (Ohio MRDD)
- Use Component First And Last Dates Of Service For Billing