Sita Kapoor Infotech Global Inc. 100 Franklin Square Dr. Somerset, NJ 08873 sk@igiusa
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Transcript of Sita Kapoor Infotech Global Inc. 100 Franklin Square Dr. Somerset, NJ 08873 sk@igiusa
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Sita KapoorSita KapoorInfotech Global Inc.Infotech Global Inc.100 Franklin Square Dr.100 Franklin Square Dr.Somerset, NJ 08873Somerset, NJ [email protected]@igiusa.com
Profession Claim exampleProfession Claim example 837 Professional ASC x12N
(004010x098A1)
September 24, 2003
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SUBSCRIBER/PATIENT: Ted Smith
ADDRESS: 236 N. Main St., Miami, FL 33413
TELEPHONE NUMBER: 305-555-1111
SEX: Male
DOB: 05/01/1948
GROUP#: 12312-A
SSN: 000-22-1111
DESTINATION PAYER: ACS BENEFITS SERVICES
PAYOR ADDRESS: P O Box 2181, Somerset, NJ 08853
PAYER ID NUMBER: 00520
Claim Information, in EnglishClaim Information, in EnglishClaim Information, in EnglishClaim Information, in English
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Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500
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BILLING PROVIDER/SENDER: Michael Brenett
ADDRESS: ASSAD, WASSAD NJ 12121212
TIN: 111753453
RENDERING PROVIDER: Michael Brenett
Payer Provider ID: 52054
UPIN ID C68426
PATIENT ACCOUNT NUMBER: SM-192619
CASE: Office Visit DOS=03/21/2003. POS=Office
SERVICES RENDERED:
Office first visit = $40.00
Next CPT Code = $15.00
Next CPT Code = $35.00
Claim Information, in EnglishClaim Information, in EnglishClaim Information, in EnglishClaim Information, in English
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Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500
V1506
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BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~PER*IC*MNJY*TE*9089463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*1*BERNETT*MICHAEL****24*111753453~N3*ASSAD~N4*WSDSAD*NJ*12121212~REF*1C*52054~
Claim Information, in x12Claim Information, in x12Claim Information, in x12Claim Information, in x12
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HL*2*1*22*0~SBR*P*18**ACS BENEFITS SERVICES*****16~NM1*IL*1*SMITH*TED****MI*000221111~N3*2316 N. MAIN STREET~N4*MIAMI*FL*33413~DMG*D8*19480501*M~REF*1G*12312-A~NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~N3*P O BOX 2181~N4*SOMERSET*NJ*08853~CLM*SM192619*55***22::1*Y*A*Y*A*C~DTP*431*D8*20030321~HI*BF:V1506~NM1*82*1*BERNETT*MICHAEL****ZZ*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~LX*1~SV1*HC:99213*40*UN*1*40**1**Y******0~DTP*472*RD8*20030321-20030321~LX*2~SV1*HC:99214*40*UN*1*15**1**Y******0~DTP*472*D8*20030321~LX*3~SV1*HC:99215*40*UN*1*30**1**Y******0~DTP*472*RD8*20030321-20030323~
Claim Information, in x12Claim Information, in x12Claim Information, in x12Claim Information, in x12
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52054 C68426
HL*1**20*1~
NM1*85*1*BERNETT*MICHAEL****24*111753453~
N3*ASSAD~
N4*WSDSAD*NJ*12121212~
REF*1C*52054~
Provider InformationProvider InformationProvider InformationProvider Information
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HL*2*1*22*0~
SBR*P*18**ACS BENEFITS SERVICES*****16~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*2316 N. MAIN STREET~
N4*MIAMI*FL*33413~
DMG*D8*19480501*M~
NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~
N3*P O BOX 2181~
N4*SOMERSET*NJ*08853~
Subscriber InformationSubscriber InformationSubscriber InformationSubscriber Information
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HL*2*1*22*0~
SBR*P*18**ACS BENEFITS SERVICES*****16~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*2316 N. MAIN STREET~
N4*MIAMI*FL*33413~
DMG*D8*19480501*M~
REF*1G*12312-A~
NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~
N3*P O BOX 2181~
N4*SOMERSET*NJ*08853~
Subscriber InformationSubscriber InformationSubscriber InformationSubscriber Information
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The Subscriber is the Patient
The Patient Loop will not be mapped
Patient InformationPatient InformationPatient InformationPatient Information
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HL*2*1*22*0~
SBR*P*18**ACS BENEFITS SERVICES*****16~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*2316 N. MAIN STREET~
N4*MIAMI*FL*33413~
DMG*D8*19480501*M~
REF*1G*12312-A~
NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~
N3*P O BOX 2181~
N4*SOMERSET*NJ*08853~
Subscriber Payer InformationSubscriber Payer InformationSubscriber Payer InformationSubscriber Payer Information
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CLM*SM192619*85***11::1*Y*A*Y*A*C~
DTP*431*D8*20030321~
HI*BF:V1506~
NM1*82*1*BERNETT*MICHAEL****24*52054~
PRV*PE*ZZ*282N00000X~
REF*1G*C68426~
Original
Claim InformationClaim InformationClaim InformationClaim Information
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CLM*SM192619*85***11::1*Y*A*Y*A*C~
DTP*431*D8*20030321~
HI*BF:V1506~
NM1*82*1*BERNETT*MICHAEL****24*52054~
PRV*PE*ZZ*282N00000X~
REF*1G*C68426~
Original
OfficeVisit
Original
Claim InformationClaim InformationClaim InformationClaim Information
V1506
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LX*1~
SV1*HC:99213*40*UN*1*06**1**Y******0~
DTP*472*RD8*20030321-20030321~
LX*2~
SV1*HC:99214*40*UN*1*06**1**Y******0~
DTP*472*D8*20030321~
LX*3~
SV1*HC:99215*40*UN*2*06**1**Y******0~
DTP*472*RD8*20030321-20030323~
Service Line InformationService Line InformationService Line InformationService Line Information
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BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~PER*IC*MNJY*TE*9089463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*1*BERNETT*MICHAEL****24*111753453~N3*ASSAD~N4*WSDSAD*NJ*12121212~REF*1C*52054~HL*2*1*22*0~SBR*P*18*000221111*ACS BENEFITS SERVICES*****MB~NM1*IL*1*SMITH*TEX*S***MI*000221111~N3*2316 N. MAIN STREET~N4*MIAMI*FL*33413~REF*87*3053331111~DMG*D8*19480501*M~NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~N3*P O BOX 1181~N4*SOMERSET*NJ*08853~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030321~HI*BF:V1506~NM1*82*1*BERNETT*MICHAEL****24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~LX*1~SV1*HC:99213*40*UN*1*40**1**Y******0~DTP*472*RD8*20030321-20030321~LX*2~SV1*HC:99214*40*UN*1*15**1**Y******0~DTP*472*D8*20030321~LX*3~SV1*HC:99215*40*UN*1*30**1**Y******0~DTP*472*RD8*20030321-20030323~
EDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N format
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EDI TransactionEDI Transaction
Control SegmentsControl Segments
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Control EnvelopesControl EnvelopesControl EnvelopesControl Envelopes
Control Envelopes – ISA / IEAISA / IEA
• Interchange envelope
– GS / GEGS / GE• Functional group envelope
– ST / SEST / SE• Transaction set envelope
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(One Business Document)(One Business Document)
EQUALSEQUALS
HCFA1500
Functions of the Transaction Set Functions of the Transaction Set (ST/SE) Control Envelope(ST/SE) Control Envelope
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SE *SE *
0101 0202
**
~~
EDI Data - Claim #1EDI Data - Claim #1Transaction SetTransaction Set
ST *ST *
0101 0202
**
~~
EDI Transaction Set with Control Envelope
Control EnvelopeControl Envelope
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ST*837*1234~BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~HL*1**20*1~NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~
{cont}
SE*14*1234~ST*837*1235~
BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~HL*1**20*1~NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~
{cont}
SE*14*1235~
Transaction Set (ST/SE) Transaction Set (ST/SE) Control EnvelopeControl Envelope
Transaction Set (ST/SE) Transaction Set (ST/SE) Control EnvelopeControl Envelope
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Functional Groups
HCFA15001500
HCFA15001500
HCFA1500
Transaction Sets
To
: : Pa
yer A
Cla
ims P
ay a
ble
To
: Pa
yer A
Cla
ims R
ep
ortin
g
EQUALS
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
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FFUUNNCCTTIIOONNAALL
EDI Data – Claims (charges)EDI Data – Claims (charges)
EDI Data – Claims (reporting) EDI Data – Claims (reporting)
GS *GS *
GE *GE *
0101
0101
0505 0606 0707 0808
040403030202
0202
Trans SetTrans Set
Trans SetTrans Set
STST
STST
SESE
SESE
** ** ** **
** ** **
****
~~
~~~~
Control EnvelopeControl EnvelopeControl EnvelopeControl Envelope
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GS*HC*ZZ576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~
BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*1000*1234~ ST*837*1235~
BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*26*1234~GE*2*20030923~
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
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HCFA15001500
HCFA15001500
EligibilityInformation
EXPRESS DELIVERY
Sender:
Dr Jones345 laneNJ 99893
Receiver:
BSBC OF CA232 LNCA 09393
Tracking #: 000000000177975 021760 7
Transaction Sets
Functional Groups
Interchange
To
: : Pa
yer A
Cla
ims P
ay a
ble
To
: : Pa
yer A
Me
mb
er E
nro
l lme
nt
Interchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control Envelope
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FFUUNNCCTTIIOONNAALL
GGRROOUUPP
GE GE
EDI Data – HCFA SET #1EDI Data – HCFA SET #1Trans SetTrans Set
STST
SESE
GS GS
IEA *IEA * 0101 0202** ~~
ISAISA 0101 040403030202** ** ** ** 0505 06 07 08** ** **
~0909 121211111010** ** ** ** 13 14 15 16** ** ****
**
Control EnvelopeControl EnvelopeControl EnvelopeControl Envelope
EDI Data – HCFA SET #2EDI Data – HCFA SET #2Trans SetTrans Set
STST
SESE
EDI Data Eligibility Info #1EDI Data Eligibility Info #1Trans SetTrans Set
STST
SESE
GS GS
GE GE
IINNTTEERRCCHHAANNGGEE
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ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~
Interchange (ISA/IEA) Interchange (ISA/IEA) Control EnvelopeControl Envelope
Interchange (ISA/IEA) Interchange (ISA/IEA) Control EnvelopeControl Envelope
IEA*1*000000001~
GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~
BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*1000*1234~ ST*837*1235~
BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*26*1234~GE*2*20030923~
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ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ST*837*00001~BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*DEWITT HOSPITAL & NURSING HOME*****46*E1576~PER*IC*SUSAN*TE*8709463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*2*DEWITT HOSPITAL & NURSING HOME*****24*57237~N3*P.O. BOX 32~N4*DE WITT*AR*72042~REF*1C*57237~HL*2*1*22*0~SBR*P*18*XCAV71748*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*DEBERRY*WILLIAM*S***MI*XCAV71748~N3*90 SAM DEBERRY RD~N4*DEWITT*AR*720420000~DMG*D8*19530817*M~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:9895*BF:72981*BF:E9053*BF:V1506~NM1*DN*1*BURLESON*STAN*W***24*D04410~REF*1B*X~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2:3:4**Y******0~DTP*472*RD8*20030726-20030726~HL*3*1*22*0~SBR*P*18*431356390*AMCO/AHA-1ST SOURCE REPRICI*****MB~PAT*~NM1*IL*1*JAMES*KELLY****MI*431356390~N3*813 W GIBSON~N4*DEWITT*AR*72042~DMG*D8*19721113*F~NM1*PR*2*AMCO/AHA-1ST SOURCE REPRICI*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722032181~CLM*1154754*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:7840*BF:78701~NM1*DN*1*GUSTAVUS*JOHN*L***24*C68426~REF*1B*52054~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2**Y******0~DTP*472*RD8*20030726-20030726~HL*4*1*22*0~SBR*P*18*HIP431310803-00*BLUE ADVANTAGE ADMINISTRATO*****MB~PAT*~NM1*IL*1*PADGETT*DELORES****MI*HIP431310803-00~N3*P.O.BOX 56~N4*ETHEL*AR*72048~DMG*D8*19400405*F~NM1*PR*2*BLUE ADVANTAGE ADMINISTRATO*****PI*00520~N3*P.O. 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EDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N format
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