Name of Manual - Blue Cross and Blue Shield of Minnesota

Health Care Options
HICF 1500 Form Locator 837P
Item # Title Loop ID Segment Notes
10b Is Patient’s
Condition
Related to: Auto
Accident
10c Is Patient’s
Condition
Related to: Other
Accident
10d Reserved for
local use
14 Date of Current
Illness, Injury,
Pregnancy
2300 CLM11 Titled Related Causes Code in
the 837P
2300 CLM11 Titled Related Causes Code in
the 837P
2300 K3 This is specific for reporting
Workers’ Compensation
Condition Codes.
2300 DTP03 Titled in the 837P:
a. Onset of current illness or
injury date.
b. Acute manifestation date.
c. Accident date.
d. Last menstrual period
date.
For institutional claims (UB-04 or 837I) report the appropriate
occurrence code. Occurrence codes and dates are entered in
Form Locator(s) 31-34, 35-36 on the UB-04 or in Loop 2300
of the 4010A1 837I transaction. The following occurrence
codes may be submitted as appropriate.
01:Accident / Medical Coverage
Code indicating accident-related injury for which there is
medical payment coverage. Provide the date of accident /
injury.
02: No Fault Insurance Involved - Including Auto
Accident/ Other
Code indicating the date of an accident, including auto or other
where state has applicable no-fault liability laws (i.e., legal
basis for settlement without admission or proof of guilt).
5-32 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)