(5010) ansi to micromd mapping troubleshooting guide ...€¦ · (5010) ansi to micromd mapping...

760 Boardman-Canfield Rd. Boardman OH 44512 P: 330-758-8832 F: 330-758-0182 micromd.com 1

(5010) ANSI TO MICROMD MAPPING TROUBLESHOOTING GUIDE (PROFESSIONAL)

This document contains a basic reference for those trying to troubleshoot ANSI claim files. We have organized these tables by ANSI loop and element. Users will also find directions for finding the appropriate location within MicroMD® where the system actually pulls information to create the claim file.

NOTE | Use the ANSI Ripper application to help you read the ANSI file in a human-friendly format.

ENVELOPING

Element Location in MicroMD (window and field)

ISA01 EB Setup Screen – Author Information qualifier

ISA02 EB Setup Screen - Author Information

ISA03 “01” if ISA04 contains data, “00” otherwise

ISA04 EB Setup Screen – Password

If EB Type is ALPR, Emdeon Dental or PerSe, MicroMD leaves this element blank

ISA05 EB Setup Screen – Sender ID qualifier

ISA06 EB Setup Screen – Sender ID

ISA07 EB Setup Screen – Interchng Recv ID qualifier

ISA08 EB Setup Screen – Interchng Recv ID

ISA09 Today’s date, “yymmdd”

ISA10 Current time, “hhmm”

ISA11 Defaults to “^”. Can be changed in eb.ini file

ISA12 “00501”

ISA13 EB Setup Screen – Submission Number

ISA14 Claims Processing – EB –

If EB Type is MDWV, MicroMD sets this to 1. Otherwise, the system sends a 0.

ISA15 EB Setup Screen – Submission Test

ISA16 Defaults to “:”. Can be changed in the eb.ini file

GS01 “HC”



GS02 EB Setup Screen – Application Sender ID

If Application Sender ID is blank, MicroMD pulls the value from the EB Setup Screen - Sender ID field

GS03 EB Setup Screen – Application Receiver ID

If Application Receiver ID is blank, MicroMD pulls the value from the EB Setup Screen - Interchng Recv ID

GS04 Today’s date, “yyyymmdd”

GS05 Current time, “hhmm”

GS06 EB Setup Screen – Group Control

GS07 “X”

GS08 EB Setup Screen – Claim File Type

HEADER


ST01 “837”

ST02 Incremental counter, starting at “000000001” for every batch

ST03 EB Setup Screen – Claim File Type

BHT01 “0019”

BHT02 “00”

BHT03 If EB Type is BSLA, BSIL, MDIL, THIN, or MDAR, MicroMD sets this to GS06. Otherwise the build date, version and database ID of MicroMD are used

BHT04 Today’s date, “yyyymmdd”

BHT05 Current time, “hhmm”

BHT06 “CH”

LOOP 1000A


NM1(41)01 “41”

NM1(41)02 If EB Setup Screen – First Name is filled in then this is populated with a “1”, otherwise “2” is entered here.

NM1(41)03 EB Setup Screen – Sub Org/Last Name

If this field is blank, MicroMD uses the practice name



NM1(41)04 EB Setup Screen – First Name

Only if the practice name is not used

NM1(41)05 EB Setup Screen – MI

Only if the practice name is not used

NM1(41)06 Blank

NM1(41)07 Blank

NM1(41)08 “46”

NM1(41)09 EB Setup Screen – Source ID

If it exists. Sender ID otherwise

PER01 “IC”

PER02 EB Setup Screen – Contact

PER03 EB Setup Screen – Primary Contact No. Qualifier (“TE” if it does not exist)

PER04 EB Setup Screen – Primary Contact No. (Uses practice phone if it does not exist)

PER05 EB Setup Screen – Sec. Contact No. Qualifier

PER06 EB Setup Screen – Sec. Contact No.

LOOP 1000B


NM1(40)01 “40”

NM1(40)02 “2”

NM1(40)03 If EB Setup Screen – Batch By Plan is checked, MicroMD pulls the value for this element from the Plan Detail - IDs tab, Org Name (1000B). Otherwise, the system pulls the information from the EB Setup Screen – Receiver Name

NM1(40)04 Blank

NM1(40)05 Blank

NM1(40)06 Blank

NM1(40)07 Blank

NM1(40)08 “46”

NM1(40)09 If EB Setup Screen – Batch By Plan is checked, MicroMD pulls the value for this element from the Plan Detail - IDs tab, Org ID (1000B). Otherwise, the system pulls the information from the EB Setup Screen – Recv ID


LOOP 2000A


HL01 Incremental number, starting with 1 for each batch

HL02 “0”

HL03 “20”

HL04 “1”

PRV01 If EB Setup Screen – Organization is not checked, or if Plan Detail – IDs tab, Taxonomy 2000a drop-down has a selection made then this PRV segment is created. “BI”

PRV02 “PXC”

PRV03 Depending on the choice in the Taxonomy 2000a drop-down, MicroMD pulls the value for this element from Provider Detail – Taxonomy field or from the Taxonomy Code column on the practice Location tab. If the client needs to have Organization checked, they can check the Taxonomy 2000a checkbox on the EB Setup window. You must also turn on Batch by Provider in this case so the loop is created for each provider

LOOP 2010AA


NM1(85)01 “85”

NM1(85)02 If there is a checkmark in the Non-Person Entity checkbox on the provider’s detail window, the system populates this segment with a “2”. The non-person entity whole name must also appear in the Last Name field. (Enter a dummy first name, as this is a required field.) If there is no check mark, the system enters a “1” in this segment

NM1(85)03 If EB Setup Screen – Organization is checked, MicroMD first looks at the name on the Practice Detail – Provider tab, Box 33 Information. If this name exists, the system uses that information. If the Box 33 information is blank, MicroMD uses the Name from the Practice Detail. Otherwise if Organization is not checked, the system uses the Rendering Provider Last Name from the Provider Detail

NM1(85)04 If EB Setup Screen – Organization is not checked, the Rendering Provider First Name will be used from Provider Detail

NM1(85)05 If EB Setup Screen – Organization is not checked, the Rendering Provider MI will be used from Provider Detail

NM1(85)06 Blank

NM1(85)07 Blank



NM1(85)08 If a qualifier is entered on the EB Setup Screen – Provider Qualifier, then that value is entered here. If not, then the value of the Tax Type on the Practice Detail – Practice tab is used to determine the value. If Tax Type = S, a “34” is entered here. If Tax Type = E, a “24” is entered here. If none of the above, an “XX” is entered here

NM1(85)09 If NM1(85)08 = “34”, the SSN from the Provider Detail will be used. If NM1(85)08 = “24”, then the Federal Tax ID from the Provider tab of Practice Detail will be used if it exists, otherwise, the Federal Tax ID from the Practice Detail, Practice tab will be used.

If NM1(85)08 = “XX” and Organization is checked on the EB Setup window, then the value will be pulled from:

Practice Detail – Practice Insurance ID Tab – NPI

Practice Detail - Providers Tab – NPI

Practice Detail - Practice Tab - Practice NPI

Practice Detail - Provider Insurance ID Tab – NPI

Provider Detail - NPI.

If NM1(85)08 = “XX” and Organization is not checked on the EB Setup window, then the value will be pulled from:

Practice Detail – Provider Tab - Provider Insurance ID Tab - NPI

Provider Detail – NPI

Practice Detail – Practice Insurance ID Tab – NPI

Practice Detail – Provider Tab – NPI

Practice Detail – Practice NPI

N301 The Box 33 information on Practice Detail, Provider tab will be used if it exists to send Address line 1, otherwise, the practice address line 1 will be sent

N302 The Box 33 information on Practice Detail, Provider tab will be used if it exists to send Address line 2, otherwise, the practice address line 2 will be sent

N401 The Box 33 information on Practice Detail, Provider tab will be used if it exists to send city, otherwise, the practice city will be sent

N402 The Box 33 information on Practice Detail, Provider tab will be used if it exists to send state, otherwise, the practice state will be sent

N403 The Box 33 information on Practice Detail, Provider tab will be used if it exists to send zip code, otherwise, the practice zip code will be sent

N404 The Box 33 information on Practice Detail, Provider tab will be used if it exists to send country (if other than US), otherwise, the practice country will be sent (if other than US)



N405 Blank

N406 Blank

REF01 If NM1(85)08 = “XX” then this REF segment will be created. This is the value of the Tax Type on the Practice Detail – Practice tab is used to determine the value. If Tax Type = S, then “SY” is entered here. If Tax Type = E, then “EI” is entered here

REF02 If NM1(85)08 = XX and if REF01 = SY then the SSN from the Provider Detail will be used. Otherwise, if NM1(85)08 = XX and REF01 = EI then the Federal Tax ID from the Provider tab of Practice Detail will be used if it exists; otherwise, the Federal Tax ID from the Practice Detail, Practice tab will be used

REF01 If EB Setup – Provider Qualifier is set to XX-NPI w/o Insurance ID, then this REF segment will NOT be created. Otherwise, the billing qualifier from the Practice

Insurance ID tab from Practice Detail will be used first. If it does not exist, the billing qualifier from the Provider Insurance ID tab from Practice Detail will be used. If that does not exist, the Source of Payment from Plan Detail will be used to determine what qualifier to send

REF02 If a value is chosen in EB Setup – 2010AA, then the value from that location will be used for the ID. The values for 2010AA are Practice Insurance ID, Plan Practice ID, and Provider Insurance ID.

If none of those are chosen, then MicroMD uses IDs in the following order. If none exists in the field, then the system moves to the next field in this list:

Plan Detail - IDs tab – Plan Practice ID

Practice Detail, Practice Insurance ID tab – Practice Insurance ID

Practice Detail, Provider Insurance ID tab – Provider Insurance No

REF01 A second REF segment will be created in the 2010AA loop if EB Type is BSGA (G5), ALPR (G5), MDNY (LU), ENS for payer ID NYMCD (LU), PRIN for payer ID MCDNY (LU)or PerSe (LU).

REF02 If EB Type is ALPR or PerSe, the value is taken from EB Setup – Password (the value explicitly not put in the ISA segment). If EB Type is BSGA, the value is taken from EB Setup – Contact No. If EB Type is MDNY, the value is taken from Practice Detail – Location tab, Location Code based on the location on the sequence

LOOP 2010AB

MicroMD can create this loop if there is no checkmark in the Suppress 2010AB checkbox on the EB Setup window on the ANSI tab.

STOP | BE CAREFUL: The difference that triggers this loop can be a matter of a


single character, including spaces and punctuation.


NM1(87)01 “87”

NM1(87)02 If EB Setup Screen – Organization is checked, MicroMD enters a “2” here, otherwise a “1” is used

NM1(87)03 First, MicroMD looks at Practice Detail – Provider tab, Pay-To Name and Pay-To Address 1. If these are different than the 2010AA Name and Address 1 and EB Setup – Organization is checked, then the Provider Pay-To Name will be put in this element; if Organization is unchecked, the Provider Last Name will be entered here.

If those items are the same, MicroMD looks at the Practice Detail – Practice tab, Pay-To Name and Pay-To Address 1. If either is different than the 2010AA Name and Address 1 and EB Setup – Organization is checked, then the Practice Pay-To Name will be entered in this element; if Organization is unchecked, the Provider Last Name will be entered here. If both Name and Address 1 match, this loop will not be created

NM1(87)04 If Provider Last Name is entered in NM1(87)03, then Provider First Name will be entered here

NM1(87)05 If Provider Last Name is entered in NM1(87)03, then Provider Middle Initial will be entered here

NM1(87)06 Blank

NM1(87)07 Blank

NM1(87)08 Blank

NM1(87)09 Blank

N301 Address 1 from the corresponding name in NM1(87)03 will be entered here

N302 Address 2 from the corresponding name in NM1(87)03 will be entered here

N401 The city from the corresponding name in NM1(87)03 will be entered here

N402 The state from the corresponding name in NM1(87)03 will be entered here

N403 The zip code from the corresponding name in NM1(87)03 will be entered here

N404 Blank

N405 Blank

N406 Blank


LOOP 2000B


HL01 Incremental number, unique in batch

HL02 Matches preceding HL01

HL03 “22”

HL04 If patient insured relationship is Self for pending payer, this is set to “0”, otherwise, this is set to “1”

SBR01 Pending payer, “P” for Primary, “S” for Secondary, “T” for Tertiary

SBR02 If patient insured relationship is Self for current pending payer, this is set to “18”

SBR03 If pending payer Plan Detail – IDs tab, Suppress sbr03 sbr04 is checked, this element is left blank. If not, then Pending payer – IDs tab, Reset Group Number is checked, and Claim Office ID is set to BNC, then this field is populated with “999999 “, otherwise pending payer Group No from Patient Detail – Plan Sets

SBR04 If pending payer Plan Detail – IDs tab, Suppress sbr03 sbr04 is checked, this element is left blank. If not, then if Claim level Documentation contains “*0FILL* then this element will be populated with “0FILL”, otherwise if SBR03 is filled in, this will contain the pending payer Plan Name from Plan Detail – Plan tab

SBR05 If pending payer is not Primary and source of payment on Plan Detail – Plan tab = Medicare, then this element is populated with Claim Modification, Ins Type field

SBR06 Blank

SBR07 Blank

SBR08 Blank

SBR09 Pending payer, Plan Detail, Source of Payment

PAT01 This segment is only created if pending payer patient insured relationship is Self, and there is either a death date or it is a pregnancy related sequence with Injury/LMP populated with no type of accident involved. This element is Blank

PAT02 Blank

PAT03 Blank

PAT04 Blank

PAT05 If Patient Detail, Death Date is filled in, it will populate “D8” in this element

PAT06 If Patient Detail, Death Date is filled in, it will populate that date in this element

PAT07 If there is DME CMN information on the sequence, and weight is filled in on the



case, this element populates with “01”

PAT08 Weight(lbs) from the Patient Detail – Cases tab, case associated with the sequence

PAT09 A “Y” is entered here if Pregnancy indicator is checked and there is no check mark in Auto Accident or Other Accident. Date must also be included in Injury/LMP field to create segment


LOOP 2010BA


NM1(IL)01 “IL”

NM1(IL)02 If there is a checkmark in the NP Entity checkbox on the patient’s plan sets tab (in the Policyholder section if the relation is other than self) for pending payer, the system populates this segment with a “2”. The non-person entity whole name must also appear in the Last Name field. (Enter a dummy first name, as this is a required field.) If there is no check mark, the system enters a “1” in this segment

NM1(IL)03 If patient is self-insured, the last name is pulled from Patient Detail, Detail tab – Last Name for pending payer. If patient is not self-insured, and the insured is a guarantor in the system, the last name is pulled from Patient Detail – Detail tab of the insured account. If the insured is not a patient in the system, then the last name is pulled from the Insured Box on Patient Detail – Plan Sets tab

NM1(IL)04 If NM1(IL)02 = “1”, then pulls the first name from the same place as the last name is pulled for NM1(IL)03, otherwise Blank

NM1(IL)05 If NM1(IL)02 = “1”, then pulls the middle initial from the same place as the last name is pulled for NM1(IL)03, otherwise Blank

NM1(IL)06 Blank

NM1(IL)07 Pulls the generation from the same place as the last name is pulled for NM1(IL)03

NM1(IL)08 Patient Detail, Plan Sets tab – Policy Qualifier for pending payer

NM1(IL)09 If pending payer Plan Detail – IDs tab, NM109 10d is checked, then MicroMD first looks at Claim Transactions – Block 10D; otherwise, it uses the Patient Detail, Plan Sets tab – Policy for pending payer

N301 Segment created if patient insured relation is self, or if pending payer Plan Detail – IDs tab, Insured Address is checked. Address 1 is pulled from the same place as last name is pulled for NM1(IL)03

N302 Blank

N401 This segment is only created when the subscriber is the patient or Plan Detail – IDs tab, Subscriber Address is checked. City is pulled from the same place as last name is pulled for NM1(IL)03

N402 State is pulled from the same place as last name is pulled for NM1(IL)03

N403 Zip code is pulled from the same place as last name is pulled for NM1(IL)03

N404 Country is pulled from the same place as last name is pulled for NM1(IL)03, if set to anything other than US



DMG01 Segment created if patient insured relation is self, or if pending payer Plan Detail – IDs tab, Insured Address is checked. “D8” is entered here

DMG02 DOB is pulled from the same place as last name is pulled for NM1(IL)03

DMG03 Insured sex is pulled from the same place as last name is pulled for NM1(IL)03

REF(SY)01 Segment created if pending payer Plan Detail – IDs tab, SSN Ref is checked and patient is self-insured. “SY” is entered here

REF(SY)02 This is the patient social security number, pulled from Patient Detail – Detail tab

LOOP 2010BB


NM1(PR)01 “PR”

NM1(PR)02 “2”

NM1(PR)03 Plan Detail, Plan tab – Plan Name for pending payer

NM1(PR)04 Blank

NM1(PR)05 Blank

NM1(PR)06 Blank

NM1(PR)07 Blank

NM1(PR)08 Plan Detail - IDs tab – Payer ID Qualifier for pending payer

NM1(PR)09 Plan Detail - IDs tab – Payer ID

If EB type is MDWV, then the value WV_MMIS_4UNISYS is entered here

N301 Plan Detail, Plan tab – Address line 1 for pending payer

N302 Plan Detail, Plan tab – Address line 2 for pending payer

N401 Plan Detail, Plan tab – City for pending payer

N402 Plan Detail, Plan tab – State for pending payer

N403 Plan Detail, Plan tab – Zip code for pending payer

N404 Plan Detail, Plan tab – Country for pending payer, if set to anything other than US

REF01 Segment is only created if a value exists on Plan Detail - IDs tab, Claim Office ID for pending payer. “FY” is entered here

REF02 Plan Detail - IDs tab – Claim Office ID for pending payer

REF01 Segment is only created if a value is chosen on Plan Detail – IDs tab, item REF



2010BB. “G2” is entered here

REF02 The value selected in the REF 2010BB dropdown will be entered here, Plan Practice ID from the current plan (Plan Detail – IDs tab, Plan Practice ID), Practice Insurance ID (Practice Detail – Practice Insurance ID tab, relative to the current plan insurance class), or Provider Insurance ID (Practice Detail – Provider Insurance ID tab, relative to provider on the claim and the insurance class for the current plan)

LOOP 2000C (Only created if patient is not the insured)


HL01 Incremental number, unique in batch

HL02 Matches preceding HL01

HL03 “23”

HL04 “0”

PAT01 Patient Detail, Plan Sets tab – Relation for pending payer

PAT02 Blank

PAT03 Blank

PAT04 Blank

PAT05 If Patient Detail, Death Date is filled in, it will populate “D8” in this element

PAT06 If Patient Detail, Death Date is filled in, it will populate that date in this element

PAT07 If there is DME CMN information on the sequence, and weight is filled in on the case, this element populates with “01”

PAT08 Weight(lbs) from the Patient Detail – Cases tab, case associated with the sequence

PAT09 A “Y” is entered here if Pregnancy indicator is checked and there is no check mark in Auto Accident or Other Accident. Date must also be included in Injury/LMP field to create segment

LOOP 2010CA

(Only created if patient is not the insured)


NM1(QC)01 “QC”



NM1(QC)02 “1”

NM1(QC)03 Patient Detail, Detail tab – Last Name

NM1(QC)04 Patient Detail, Detail tab – First Name

NM1(QC)05 Patient Detail, Detail tab – MI

NM1(QC)06 Blank

NM1(QC)07 Patient Detail, Detail tab – Generation

NM1(QC)08 Blank

NM1(QC)09 Blank

N301 Patient Detail, Detail tab – Address 1

N302 Patient Detail, Detail tab – Address 2

N401 Patient Detail, Detail tab – City

N402 Patient Detail, Detail tab – State

N403 Patient Detail, Detail tab – Zip code

N404 Patient Detail, Detail tab – Country, if set to anything other than US

DMG01 “D8”

DMG02 Patient Detail, Detail tab – DOB

DMG03 Patient Detail, Detail tab –Sex

REF(Y4)01 “Y4” (Created only for Texas Workers Comp)

REF(Y4)02 Claim Number (on the Extra button on the Texas Workers Comp form)

LOOP 2300


CLM01 Patient Detail, Detail tab – Patient ID in the form of practice security ID-guarantor id.patient no-sequence no. e.g. 2323-1001.0-1 Or, if EB Setup – ANSI tab – Format Ctrl Number is not checked then the control number is entered in the form of: PracticeSecurityID(space)guarantorID(space)patientNo(space)sequenceNo e.g., 2323 1001 0 1

CLM02 Claim Transactions – Fee (Summed for all line items)

CLM03 Blank

CLM04 Blank



CLM05-1 Claim Transactions – POS

CLM05-2 “B”

CLM05-3 Claim Adjustment Information – Claim Frequency Type Code (Claim Level)

CLM06 “Y”

CLM07 Claim Transactions – Assignment

CLM08 Patient Detail, Plan Sets Tab– Assign Benefits for pending payer

CLM09 Patient Detail, Plan Sets tab – Release Code for pending payer

CLM10 If CLM09 does not equal “I”, then Patient Detail, Plan Sets tab – Signature Code

CLM11-1 Claim Transactions – Accident Related

CLM11-2 Claim Transactions – Accident Related (if more than 1 type)

CLM11-3 Claim Transactions – Accident Related (if more than 2 types)

CLM11-4 Claim Transactions – State

CLM12 Blank

CLM13 Blank

CLM14 Blank

CLM15 Blank

CLM16 Blank

CLM17 Blank

CLM18 Blank

CLM19 Blank

CLM20 If a Delay Reason Code is selected from Claim Transactions, More screen, that code is entered here

DTP(431)01 If Claim Transaction – Consult Date is different than the Service Date From, this segment will be created. “431” entered here

DTP(431)02 “D8”

DTP(431)03 Claim Transaction – Consult Date

DTP(454)01 Segment only created if EB Setup – Claim Indicator is set to Chiropractic or if Claim Transactions – Pregnancy is not checked, and claim is not accident-related. “454” entered here

DTP(454)02 “D8”



DTP(454)03 If Claim Indicator is Chiropractic, then the date is pulled from Chiropractic Information Screen – Treatment. If not pregnancy-related, the date is pulled from Claim Transactions – Injury/LMP (if dates exists)

DTP(304)01 “304”

DTP(304)02 “D8”

DTP(304)03 Claim Transaction – Lst Seen (if a date exists)

DTP(453)01 Segment only created if EB Setup – Claim Indicator is set to Chiropractic and Chiropractic Information Screen – Nature of Condition is set to A or M. “453” entered here

DTP(453)02 “D8”

DTP(453)03 Chiropractic Information Screen – Manifestation Date (if a date exists)

DTP(439)01 Segment only created if accident-related. “439” entered here

DTP(439)02 “D8”

DTP(439)03 Claim Transactions – Injury/LMP (if a date exists)

DTP(484)01 Segment only created if Claim Transactions – Pregnancy is checked, and the sequence is not accident-related. “484” entered here

DTP(484)02 “D8”

DTP(484)03 Claim Transactions – Injury/LMP (if a date exists)

DTP(455)01 Segment only created if EB Setup – Claim Indicator is set to Chiropractic. “455” entered here

DTP(455)02 “D8”

DTP(455)03 Chiropractic Information Screen – X-Ray Date (if a date exists)

DTP(435)01 “435”

DTP(435)02 “D8”

DTP(435)03 Claim Transactions – Admission (if a date exists)

DTP(096)01 “096”

DTP(096)02 “D8”

DTP(096)03 Claim Transactions – Discharge (if a date exists)



PWK01 Segment only created if it is a Texas Workers Compensation claim, or if there is Claim Attachment Information. Segment may be repeated up to 10 times with information from the preceding sources. Attachment Code from Texas Workers Compensation window, or Report Type Code from Claim Attachment Information window

PWK02 Transmission Method Code from Texas Workers Compensation window, or Report Trans Code from Claim Attachment Information window

PWK03 Blank

PWK04 Blank

PWK05 If PWK02 = “BM”, “EL”, “EM”, “FX”, or “FT”, this element will be populated with “AC”

PWK06 Attachment Control Number from Texas Workers Compensation window, or Attach Control No from Claim Attachment Information window

CN101 Segment created if information exists on Claim Adjustment Information window, Contract Info section, with a minimum of Code and one of (Amount, Percent, Reference ID, Discount %, Version). Populated with Code from Claim Adjustment Information window, Contract Info section

CN102 Amount from Claim Adjustment Information window, Contract Info section (if exists)

CN103 Percent from Claim Adjustment Information window, Contract Info section (if exists)

CN104 Reference ID from Claim Adjustment Information window, Contract Info section (if exists)

CN105 Discount % from Claim Adjustment Information window, Contract Info section (if exists)

CN106 Version from Claim Adjustment Information window, Contract Info section (if exists)

AMT(F5)01 Segment only created if Practice Preferences – Billing Preferences, Show Patient Payment is checked and Patient Paid amount is non-zero. “F5” is entered here

AMT(F5)02 Patient Paid amount from Sequence

REF(4N)01 “4N”

REF(4N)02 Claim Adjustment Information – Service Authorization Exception Code

REF(EW)01 Segment only created if Plan Detail – Plan tab for pending payer, Source of Payment is set to Medicare. “EW” is entered here

REF(EW)02 Service Facility Detail, Service Facility tab – Mammo. Cert (If a value exists)



REF(9F)01 Segment created if pending payer Plan Detail – IDs tab, Referral Ref is populated. “9F” is entered here

REF(9F)02 If pending payer Plan Detail – IDs tab, Referral Ref is set to Block 19, then Block 19 from Claim Transactions window is used. If it is set to Block 10D, then Block 10d is used from Claim Transactions. If Referral is chosen, then the Referring Doctor Insurance ID is entered here

REF(G1)01 “G1”

REF(G1)02 Claim Transactions – Prior Authorization # (If a value exists)

REF(F8)01 “F8”

REF(F8)02 Claim Modification – Original-Ref No/CRN. If, however, there is data in the Override ICN field (click Adj. Codes button), the system uses this data instead for this segment

REF(X4)01 Segment only created if Plan Detail – Plan tab, Source of Payment is set to Medicare or Medicaid and Procedure Detail – Detail tab, CLIA Flag is checked. “X4” is entered here

REF(X4)02 Order of CLIA priority:

Provider Detail – CLIA No

Practice Detail, Location Tab

Practice Detail, Practice Tab

REF(P4)01 Segment only created if Claim Adjustment Information window has a value in Clinical Trial Reg. Number. “P4” is entered here

REF(P4)02 Claim Adjustment Information window, Clinical Trial reg. Number

REF(1J)01 Segment only created if Plan Detail – IDs tab for current plan has 2300 Ref Hospice checked and a value exists on Patient Detail – Cases tab for Hospice NPI. “1J” is entered here

REF(1J)02 Patient Detail – Cases tab, Hospice NPI

K301 Resubmission Condition Indicator (when sending a bill that is a duplicate or an appeal) (Created for Texas Workers Comp)

NTE01 Claim Transactions – Document Claim Level qualifier

NTE02 Claim Transactions – Document Claim Level note

CR101 Segment created if Ambulance Addtl Info is populated. If Weight (lbs) is populated on Ambulance Addtl Info, this element populates with “LB”

CR102 Weight (lbs) from Ambulance Addtl Info

CR103 Transport Code from Ambulance Addtl Info



CR104 Transport Reason Code from Ambulance Addtl Info

CR105 “DH”

CR106 Miles from Ambulance Addtl Info

CR107 Blank

CR108 Blank

CR109 If Transport Code = “X”, then Round Trip Description from Ambulance Addtl Info

CR110 Stretcher Description from Ambulance Addtl Info

CR201 Segment only created if EB Setup – Claim Indicator is set to Chiropractic. This element is Blank

CR202 Blank

CR203 Blank

CR204 Blank

CR205 Blank

CR206 Blank

CR207 Blank

CR208 Chiropractic Information – Nature of Condition

CR209 Blank

CR210 Chiropractic Information – Symptoms Description

CR211 Chiropractic Information – Symptoms Description

CRC(07)01 Segment only created if the CR1 segment exists and Condition Codes exist. “07” is entered here

CRC(07)02 Ambulance Addtl Info, Condition Codes Apply

CRC(07)03 Ambulance Addtl Info, Condition Code 1





CRC(ZZ)01 Segment only created if Claim Transactions – EPSDT is checked. “ZZ” is entered here

CRC(ZZ)02 If Claim Transactions – More Screen, Visit Code 2 (first row only) is empty, or has a value of NU, then an “N” is entered here; otherwise, a “Y” is entered



CRC(ZZ)03 If Claim Transactions – More Screen, Visit Code 2 (first row only) is empty, an “NU” is entered here, otherwise, the code in the field is entered

HI01-1 “BK”

HI01-2 Claim Transactions – Diagnosis 1

HI02-1 “BF”


HI03-1 “BF”


HI04-1 “BF”


HI05-1 “BF”


HI06-1 “BF”


HI07-1 “BF”


HI08-1 “BF”


LOOP 2310A

(Only created if a referring doctor is on the sequence and if Plan Detail – IDs tab for pending payer does not have Suppress 2310a checked)


NM1(DN)01 “DN”

NM1(DN)02 “1”

NM1(DN)03 Referring Doctor Detail, Detail tab – Last Name

NM1(DN)04 Referring Doctor Detail, Detail tab – First Name

NM1(DN)05 Referring Doctor Detail, Detail tab – MI

NM1(DN)06 Blank

NM1(DN)07 Blank



NM1(DN)08 If EB Setup – ANSI tab, Provider Qualifier is set to XX – NPI then this element gets populated with “XX”. If no NPI exists for the referring doctor, then Referral Detail, Detail tab – SSN/FID Qualifier

NM1(DN)09 Referral Detail – Detail tab, NPI if NM1(DN)08 is set to XX, otherwise Referring Doctor Detail, Detail tab – SSN/FID

REF01 Segment created if NM1(DN)08 is set to XX – NPI w/ Insurance ID. Referring Doctor Detail, Insurance ID tab – Qualifier

(If it doesn’t exist, the UPIN qualifier will be sent)

REF02 Referring Doctor Detail, Insurance ID tab – Referring Insurance No

(If it doesn’t exist, UPIN from Detail tab will be sent)

If “Remove Tax ID” is chosen from the 2310A drop-down in EB Setup, the system does not create this REF segment

LOOP 2310B

(Only created if Plan Detail – IDs tab for pending payer does not have Suppress 2310b checked)


NM1(82)01 “82”

NM1(82)02 If there is a checkmark in the Non-Person Entity checkbox on the provider’s detail window, the system populates this segment with a “2”. The non-person entity whole name must also appear in the Last Name field. (Enter a dummy first name, as this is a required field.) If there is no check mark, the system enters a “1” in this segment

NM1(82)03 Provider Detail – Last Name

NM1(82)04 If NM1(82)02 equals “1” then Provider Detail – First Name, otherwise Blank

NM1(82)05 If NM1(82)02 equals “1” then Provider Detail – MI, otherwise Blank

NM1(82)06 Blank

NM1(82)07 Blank

NM1(82)08 If a value exists on EB Setup – Provider Qualifier, it will be entered here. If it does not exist, Practice Detail – Practice tab, Tax Type will determine the value. If Tax Type is E, a 24 will be entered here. If Tax Type is S, a 34 will be entered here. In all other cases, an XX will be entered here



NM1(82)09 If NM1(82)08 = 24, The Federal Tax ID will be entered. First from Practice Detail – Provider tab, then from Practice Detail – Practice tab. If NM1(82)08 = 34, the SSN from Provider Detail will be entered. If NM1(82)08 = XX, then the NPI from Practice Detail, Provider Insurance ID Tab, then from Provider Detail, then from Practice Detail, Practice Insurance ID Tab, NPI column, then from Practice Detail, Providers Tab, NPI field, then from Practice Detail, Practice Tab, Practice NPI

PRV01 “PE”

PRV02 “PXC”

PRV03 Provider Detail – Taxonomy Code

REF01 Segment created if NM1(82)08 is set to XX – NPI w/ Insurance ID. Practice Detail, Provider Insurance ID tab – Rend Qual

Practice Detail, Practice Insurance ID tab – Rend Qual

REF02 If a value is chosen in EB Setup – 2310B, then the value from that location will be used for the ID. The values for 2310B are Practice Insurance ID, Plan Practice ID, and Provider Insurance ID.

If none of those are chosen, then MicroMD uses IDs in the following order. If none exists in the field, then the system moves to the next field in this list:

Practice Detail, Provider Insurance ID tab – Provider Insurance No

Plan Detail - IDs tab – Plan Practice ID

Practice Detail, Practice Insurance ID tab – Practice Insurance ID

If “Remove Tax ID” is chosen from the 2310B drop-down, the system does not create this REF segment

REF01 A second REF segment will be created if there is an ID under Maint, Practice, Provider Network ID tab – Network ID for the plan attached to the patient. “N5” is entered here

REF02 Practice Detail, Provider Network ID tab – Network ID

LOOP 2310C

(Only created if a service facility is on the sequence)


NM1(77)01 “77”

NM1(77)02 “2”

NM1(77)03 Service Facility Detail, Detail tab – Description

NM1(77)04 Blank



NM1(77)05 Blank

NM1(77)06 Blank

NM1(77)07 Blank

NM1(77)08 If EB Setup – ANSI tab, Provider Qualifier is set to XX – NPI then this element gets populated with “XX”, otherwise it is Blank

NM1(77)09 Service Facility Detail – Detail tab, NPI

N301 Service Facility Detail – Detail tab, Address1

N302 Service Facility Detail – Detail tab, Address2

N401 Service Facility Detail – Detail tab, City

N402 Service Facility Detail – Detail tab, State

N403 Service Facility Detail – Detail tab, Zip code

N404 Service Facility Detail – Detail tab, Country, if anything other than US

LOOP 2310D

(Only created if a supervising physician exists on the sequence and Supervising Provider pulls from Referring Doctor list.)


NM1(DQ)01 “DQ”

NM1(DQ)02 “1”

NM1(DQ)03 Referring Doctor Detail, Detail tab – Last Name

NM1(DQ)04 Referring Doctor Detail, Detail tab – First Name

NM1(DQ)05 Referring Doctor Detail, Detail tab – MI

NM1(DQ)06 Blank

NM1(DQ)07 Blank

NM1(DQ)08 If EB Setup – ANSI tab, Provider Qualifier is set to XX – NPI then this element gets populated with “XX”. If no NPI exists for the referring doctor, then Referral Detail, Detail tab – SSN/FID Qualifier

NM1(DQ)09 Referral Detail – Detail tab, NPI if NM1(DN)08 is set to XX, otherwise Referring Doctor Detail, Detail tab – SSN/FID

REF01 Segment created if NM1(DQ)08 is set to XX – NPI w/ Insurance ID. Referring Doctor Detail, Insurance ID tab – Qualifier

(If it doesn’t exist, the UPIN qualifier will be sent)



REF02 Referring Doctor Detail, Insurance ID tab – Referring Insurance No

(If it doesn’t exist, UPIN from Detail tab will be sent)

If “Remove Tax ID” is chosen from the 2310A drop-down in EB Setup, the system does not create this REF segment

LOOP 2310E

(Only created if Ambulance Addtl Info exists.)


NM1(45)01 “45”

NM1(45)02 “2”

NM1(45)03 Ambulance Addtl Info, Pick Up Facility

N301 Ambulance Addtl Info, Pick Up Address

N401 Ambulance Addtl Info, Pick Up City

N402 Ambulance Addtl Info, Pick Up State

N403 Ambulance Addtl Info, Pick Up Zip code

N404 Ambulance Addtl Info, Pick Up Country, if anything other than US

LOOP 2310F

(Only created if Ambulance Addtl Info exists.)


NM1(45)01 “45”

NM1(45)02 “2”

NM1(45)03 Ambulance Addtl Info, Drop Off Facility

N301 Ambulance Addtl Info, Drop Off Address

N401 Ambulance Addtl Info, Drop Off City

N402 Ambulance Addtl Info, Drop Off State

N403 Ambulance Addtl Info, Drop Off Zip code

N404 Ambulance Addtl Info, Drop Off Country, if anything other than US


LOOP 2320

(Only created if either EB Setup – ANSI tab – Include Other Ins is checked, or if sending a non-primary claim to report previous payers)

(One loop is created for each payer other than pending payer)


SBR01 The payer type, “P” for Primary, “S” for Secondary, and “T” for Tertiary

SBR02 The patient relationship to the insured for the payer listed in this loop

SBR03 Payer Group No from Patient Detail – Plan Sets for the payer listed in this loop

SBR04 If SBR03 contains data, this will be Blank, otherwise, Plan Name from Plan Detail – Plan tab for the payer listed in this loop

SBR05 If payer listed in this loop is not Primary and source of payment on Plan Detail – Plan tab = Medicare, then this element is populated with Claim Modification, Ins Type field

SBR06 Blank

SBR07 Blank

SBR08 Blank

SBR09 Plan Detail, Source of Payment for the payer listed in this loop

CAS01 (Note )If the Plan Detail – IDs tab, Send Disallowed is checked for the payer listed in this loop, a CAS*CO*45 (contractual write-off) segment will be created even if the disallowed amount is 0.

Segment created only if the payer listed has already paid on the claim. Claim Adjustment Information – Adjudication section – Group Code (All reason codes that contain the same group code will be listed in the CAS segment, different group codes will create separate CAS segments)

CAS02 Claim Adjustment Information – Adjudication section – Reason Code

CAS03 Claim Adjustment Information – Adjudication section – Amount. If the payers are Tricare (through ENS or PI) or New York Medicaid direct, and the amount is less than $1.00, MicroMD automatically removes the leading zero

CAS04 Claim Adjustment Information – Adjudication section – Quantity


















AMT(D)01 Segment created only if the payer has already paid on the claim. “D” is entered here

AMT(D)02 Payer amount paid on the claim

AMT(EAF)01 Segment created only if the payer has already paid on the claim. “EAF” is entered here

AMT(EAF)02 Sum of patient responsibility (Coins + Deduc) from the claim

OI01 Blank

OI02 Blank

OI03 Patient Detail – Plan Sets tab – Assignment for the payer listed in this loop

OI04 If OI06 does not equal “N”, then Patient Detail – Plan Sets tab – Signature Source for the payer listed in this loop

OI05 Blank



OI06 Patient Detail – Plan Sets tab – Release of Information for the payer listed in this loop


LOOP 2330A



NM1(IL)01 “IL”

NM1(IL)02 If there is a checkmark in the NP Entity checkbox on the patient’s plan sets tab (in the Policyholder section if the relation is other than self) for payer listed in 2320, the system populates this segment with a “2”. The non-person entity whole name must also appear in the Last Name field. (Enter a dummy first name, as this is a required field.) If there is no check mark, the system enters a “1” in this segment

NM1(IL)03 If patient is self-insured, the last name is pulled from Patient Detail, Detail tab – Last Name for payer listed in 2320. If patient is not self-insured, and the insured is a guarantor in the system, the last name is pulled from Patient Detail – Detail tab of the insured account. If the insured is not a patient in the system, then the last name is pulled from the Insured Box on Patient Detail – Plan Sets tab

NM1(IL)04 If NM1(IL)02 = “1”, then pulls the first name from the same place as the last name is pulled for NM1(IL)03, otherwise Blank

NM1(IL)05 If NM1(IL)02 = “1”, then pulls the middle initial from the same place as the last name is pulled for NM1(IL)03, otherwise Blank

NM1(IL)06 Blank

NM1(IL)07 Pulls the generation from the same place as the last name is pulled for NM1(IL)03

NM1(IL)08 Patient Detail, Plan Sets tab – Policy Qualifier for payer listed in 2320

NM1(IL)09 If pending payer Plan Detail – IDs tab, NM109 10d is checked, then MicroMD first looks at Claim Transactions – Block 10D; otherwise, it uses the Patient Detail, Plan Sets tab – Policy for payer listed in 2320

N301 Segment created if patient insured relation is self, or if pending payer Plan Detail – IDs tab, Insured Address is checked. Address 1 is pulled from the same place as last name is pulled for NM1(IL)03

N302 Blank

N401 This segment is always created starting with 5010. City is pulled from the same place as last name is pulled for NM1(IL)03

N402 State is pulled from the same place as last name is pulled for NM1(IL)03

N403 Zip code is pulled from the same place as last name is pulled for NM1(IL)03



N404 Country is pulled from the same place as last name is pulled for NM1(IL)03, if set to anything other than US

LOOP 2330B



NM1(PR)01 “PR”

NM1(PR)02 “2”

NM1(PR)03 Plan Detail, Plan tab – Plan Name for payer listed in 2320

NM1(PR)04 Blank

NM1(PR)05 Blank

NM1(PR)06 Blank

NM1(PR)07 Blank

NM1(PR)08 Plan Detail - IDs tab – Payer ID Qualifier for payer listed in 2320

NM1(PR)09 If Claim Modification window, Ins Type is set to MI – Medigap IDs or if the Plan Detail – Plan tab, Source of Payment for the current payer is set to Medicare, the Medigap Id from Plan Detail – IDs tab for the current payer will be used if it exists. Otherwise, Plan Detail - IDs tab – Payer ID

If EB type is MDWV, then the value WV_MMIS_4UNISYS is entered here

N301 Segment only created if Plan Detail – IDs tab, 2330B N3 is checked for the payer listed in 2320. Plan Detail, Plan tab – Address line 1 for payer listed in 2320

N302 Plan Detail, Plan tab – Address line 2 for payer listed in 2320

N401 Plan Detail, Plan tab – City for payer listed in 2320

N402 Plan Detail, Plan tab – State for payer listed in 2320

N403 Plan Detail, Plan tab – Zip code for payer listed in 2320

N404 Plan Detail, Plan tab – Country for payer listed in 2320, if set to anything other than US

REF(**)01 If current plan is Secondary, and Plan Detail – IDs tab for the current plan, TPL Required for Secondary checkbox is checked, then this field is filled in with Plan Detail – IDs tab 2330B TPL Qualifier from the current plan

REF(**)02 Plan Detail – IDs tab – TPL Code for payer listed in 2320. Attach 3 from Claim Modification will be tacked onto the end of the TPL Code if it exists



REF(F8)01 If the Payer ID is for Blue Shield of Florida, this segment will be created

REF(F8)02 Will use the Override ICN field from Claim Adjustment Information if it exists, otherwise it will use the Original-Ref No/CRN from Claim Modification. If neither of those exist, the segment will not be created

LOOP 2400


LX01 An incremental counter, starting at “1” for each batched sequence

SV101-1 Procedure Detail – Procedure tab, Qualifier

SV101-2 Claim Transactions – Code

SV101-3 Claim Transactions – M1




SV101-7 Element created if there is procedure documentation on the line item that matches the format: *SV=Drug Name Route Dosage*

Whatever is in between the equals sign (=) and the final asterisk (*) will be entered in this element

SV102 Claim Transactions – Fee

SV103 If Anesthesia Procedure is filled in, the Units or Minutes radio button will control population of this element, otherwise Plan Detail - IDs tab, Print Units or Minutes for pending payer

SV104 Claim Transactions – Unit

SV105 Segment only created if POS is different from CLM05, or if EB Setup – Line level Pos is checked. Claim Transactions – POS

SV106 Blank

SV107 Claim Transactions – Diag (Pointers)

SV108 Blank

SV109 Claim Transactions – Emergency Indication

SV110 Blank

SV111 If Claim Transactions – EPSDT is checked, a “Y” is entered here

SV112 If Claim Transactions – Family Planning is checked, a “Y” is entered here



SV501-1 Segment only created if this is a DME claim. Same as SV101-1

SV501-2 Same as SV101-2

SV502 “DA”

SV503 DME Form, Length of Need multiplied by 30.42 because days is required here

SV504 DME Form, Rental Price

SV505 DME Form, Purchase Price

SV506 DME Form, Rental Unit

PWK01 Segment only created if this is a DME claim. “CT” is populated here

PWK02 DME Form, Attachment Code

CR301 Segment only created if this is a DME claim. DME Form, Certification Code

CR302 “MO”

CR303 DME Form, Length of Need

CRC(70)01 Segment will only be created if sequence is marked as a Hospice Employed Provider. “70” is entered here

CRC(70)02 “Y”

CRC(70)03 “65”

CRC(09)01 Segment only created if this is a DME claim. “09” is populated here

CRC(09)02 DME Form, Condition Applies

CRC(09)03 DME Form, Condition Indicator 1

CRC(09)04 DME Form, Condition Indicator 2

DTP(472)01 “472”

DTP(472)02 If service date from and service date to are the same, “D8” is entered here. If they are different, “RD8” is used

DTP(472)03 If service date from and service date to are the same, Claim Transactions – Service Date From is entered here. If they are different, Service Date From “-“ Service Date To

DTP(607)01 Segment only created if this is a DME claim and when CR301 = “R” or “S”. “607” entered here

DTP(607)02 “D8”

DTP(607)03 DME Form, Revised Date



DTP(738)01 Segment created if documentation exists at the line level, and the following item exists in the note: ^738=YYYYMMDD^. “738” gets entered here

DTP(738)02 “D8”

DTP(738)03 The date value from ^738=YYYYMMDD^ gets entered here

DTP(739)01 Segment created if documentation exists at the line level, and the following item exists in the note: ^739=YYYYMMDD^. “739” gets entered here

DTP(739)02 “D8”

DTP(739)03 The date value from ^739=YYYYMMDD^ gets entered here

MEA01 Segment only created if this is a DME claim. “TR” is entered here

MEA02 “HT”

MEA03 DME Form, Patient Height

MEA01 Segment created if documentation exists at the line level, and the following item exists in the note: HCT# (where # is the value of the test result). “TR” is entered here

MEA02 “R2”

MEA03 HCT# where # is the result of the Hematocrit test. No spaces or other characters can exist between HCT and #. # is expected to be a number of any length. As soon as a non-numeric character (spaces, letters, etc.) is read, the value is entered in this element

CN101 Segment created if information exists on Claim Adjustment Information window for this line item specified in SV101-1, Contract Info section, with a minimum of Code and one of (Amount, Percent, Reference ID, Discount %, Version). Populated with Code from Claim Adjustment Information window, Contract Info section

CN102 Amount from Claim Adjustment Information window, Contract Info section (if exists)

CN103 Percent from Claim Adjustment Information window, Contract Info section (if exists)

CN104 Reference ID from Claim Adjustment Information window, Contract Info section (if exists)

CN105 Discount % from Claim Adjustment Information window, Contract Info section (if exists)

CN106 Version from Claim Adjustment Information window, Contract Info section (if exists)



REF(6R)01 “6R”

REF(6R)02 A SHA-1 encrypted value, unique to every line item

REF(EW)01 Segment only created if Plan Detail – Plan tab for pending payer, Source of Payment is set to Medicare. “EW” is entered here

REF(EW)02 Service Facility Detail, Service Facility tab – Mammo. Cert (If a value exists)

REF(X4)01 Segment only created if Plan Detail – Plan tab, Source of Payment is set to Medicare or Medicaid and Procedure Detail – Detail tab, CLIA Flag is checked. “X4” is entered here. Only one of REF(X4) or REF(F4) will exist.

REF(X4)02 Order of CLIA priority:




REF(F4)01 Segment only created if Plan Detail – Plan tab, Source of Payment is set to Medicare or Medicaid and Procedure Detail – Detail tab, CLIA Flag is checked, and Claim Transactions has a modifier of “90”. “F4” is entered here. Only one of REF(X4) or REF(F4) will exist.

REF(F4)02 Order of CLIA priority:




K301 Segment created if Plan Detail – IDs tab, K3 File Information is checked and line level documentation consists of an entry exists in the note in the format of An asterisk, followed by the keyword SVCTIME, then two (2) spaces, a four (4) digit start time in 24 hour format, a hyphen, a four (4) digit end time in 24 hour format, and ended with an asterisk: e.g. *SVCTIME 0000-1111* (where 0000 is the 4 digit start time in 24 hour format, and 1111 is the 4 digit end time in 24 hour format). The value from line level documentation 0000-1111 is entered here

NTE01 Claim Transactions – Document Procedure qualifier for the line item

NTE02 Claim Transactions – Document Procedure note for the line item

PS101 Segment only created if Claim Adjustment Information for the line item has Purchased Service information filled in. The element gets filled in with the NPI from Referring Detail – Detail tab for the provider listed in Provider in the Purchased Service section

PS102 The Charge from the Purchased Service section


LOOP 2410

(Created if NDC information exists on the sequence)


LIN01 Blank

LIN02 “N4”

LIN03 Claim Adjustment Information, NDC Code (Line Level)

CTP01 Blank

CTP02 Blank

CTP03 Blank

CTP04 Claim Adjustment Information, Units (Line Level)

CTP05 Claim Adjustment Information, Measurement (Line Level)

REF(XZ)01 “XZ”

REF(XZ)02 Claim Adjustment Information, Rx Number (Line Level)

LOOP 2420B

(Only created if there are multiple purchased service providers per claim)


NM1(QB)01 “QB”

NM1(QB)02 Using Referral Detail for referring doctor listed in PS101, if Non-Person Entity is checked, a “2” is entered here, otherwise a “1” is used.

NM1(QB)02 Referral Detail – Last name

NM1(QB)03 If NM1(QB)02 = “1” then Referral Detail – Fist Name, otherwise Blank

NM1(QB)04 If NM1(QB)02 = “1” then Referral Detail - MI, otherwise Blank

NM1(QB)05 Blank

NM1(QB)06 Blank

NM1(QB)07 Blank

NM1(QB)08 “XX”

NM1(QB)09 Referral Detail - NPI


LOOP 2420C

(Created if Plan Detail - IDs tab, Enable 2420C is checked and Plan Detail - IDs tab, Emdeon 2310D is not checked)


NM1(77)01 “77”

NM1(77)02 “2”

NM1(77)03 Service Facility Detail, Service Facility tab – Description

NM1(77)04 Blank

NM1(77)05 Blank

NM1(77)06 Blank

NM1(77)07 Blank

NM1(77)08 “XX”

NM1(77)09 Service Facility Detail - NPI

N301 Service Facility Detail, Service Facility tab – Address 1

N302 Service Facility Detail, Service Facility tab – Address 2

N401 Service Facility Detail, Service Facility tab – City

N402 Service Facility Detail, Service Facility tab – State

N403 Service Facility Detail, Service Facility tab – Zip code

LOOP 2420E

(Created if EB Type is DMRA, DMRB, DMRC, DMRD or if EB Type is THIN (Payer IDs 00885, 05655, 19003) or if EB Type is ENS (Payer IDs DMERA, DMERB, DMERC, DMERD) or if EB Type is Practice Insight (Payer IDs 811, 635, DMED))


NM1(DK)01 “DK”

NM1(DK)02 “1”

NM1(DK)03 Referring Doctor Detail, Detail tab – Last Name

NM1(DK)04 Referring Doctor Detail, Detail tab – First Name

NM1(DK)05 Referring Doctor Detail, Detail tab – MI

NM1(DK)06 Blank

NM1(DK)07 Blank



NM1(DK)08 If EB Setup – ANSI tab, Provider Qualifier is set to XX – NPI then this element gets populated with “XX”. If no NPI exists for the referring doctor, then Referral Detail, Detail tab – SSN/FID Qualifier

NM1(DK)09 Referral Detail – Detail tab, NPI if NM1(DN)08 is set to XX, otherwise Referring Doctor Detail, Detail tab – SSN/FID

N301 Referral Detail – Address1

N302 Referral Detail – Address2

N401 Referral Detail – City

N402 Referral Detail – State

N403 Referral Detail – Zip code

N404 Referral Detail – Country, if anything other than US

LOOP 2430

(Created if a previous payer has already adjudicated the claim, and there are line level adjustments posted against the claim)


SVD01 Set to NM1(PR)09 from 2330B

SVD02 Payment made on the claim

SVD03 Is set to the same value as SV101 from 2400

SVD04 Blank

SVD05 Is set to the same value as SV104 from 2400

CAS01 (Note) If the Plan Detail – IDs tab, Send Disallowed is checked for the payer listed in this loop, a CAS*CO*45 (contractual write-off) segment will be created even if the disallowed amount is 0.

Segment only created if the payer has already paid on the claim. Information pulls from the line level Claim Adjustment Information window. Claim Adjustment Information – Adjudication section – Group Code

(Note) When the Disallowed Amount is 0, the CAS*CO*45 segment will ONLY be created if the Transaction Line’s fee is equal to both the allowed amount and the payment amount for that transaction line (all three must be equal to one another).





















DTP(573)01 “573”

DTP(573)02 The payment date recorded in MicroMD. The date will first be looked at on the Claim Adjustment Information – Adjudication section – Payment Date; otherwise, it uses the Date Paid on the claim


LOOP 2440

(Created if sending DME CMN. The information contained in this loop will change based on which CMN is being sent. In the example below, the DME 06.03B TENS form is being sent)


LQ01 “UT”

LQ02 DME Form number (example 06.03B)

FRM01 DME Form Question number (examples 1, 2, 3, 4, 5, 6)

FRM02 DME Form, answers to Yes or No Questions (examples, 1, 4, 5)

FRM03 DME Form, answers to Text Questions (examples 2, 3)

FRM04 DME Form, answers to Date Questions (example 6)

TRAILER


SE01 Count of the number of segments, from ST to SE

SE02 Set to the same value as ST02

ENVELOPING


GE01 Count of the number of transaction sets, ST-SE

GE02 Set to the same value as GS06

IEA01 Count of the number of functional groups, GS-GE

IEA02 Set to the same value as ISA13

(5010) ansi to micromd mapping troubleshooting guide ...€¦ · (5010) ansi to micromd mapping...

Documents