Ohio Companion Guide 837 Fee-For-Service Institutional Claim

Ohio HIPAA 5010 Companion Guide – 837 Fee-For-Service Institutional Claim 

Ohio Companion Guide 

837 Fee-For-Service Institutional Claim 

March 2, 2012 

Updated: 02/07/2012 i 

Version: 2.0


Document Information 

Document Title: 837 Fee-For-Service Institutional Claim Companion Guide 

Document ID: 837 Fee-For-Service Institutional Claim Companion Guide 

Version: 2.0 

Owner: Ohio MITS Team 

Author: HP EDI Team 

The controlled master of this document is available online on the ODJFS Trading Partner website. 

http://jfs.ohio.gov/OHP/tradingpartners/info.stm 

Hard copies of this document are for information only and are not subject to document control.


Amendment History 

Document 

Version 

Number 

Submission 

Date Modified By Modifications 

1.0 HP EDI Team DRAFT Version 

2.0 HP EDI Team Initial Production version


Table of Contents 

EDI SUPPORT INFORMATION ............................................................................................................................................ 1 

DISCLOSURE STATEMENT ................................................................................................................................................ 2 

PURPOSE ............................................................................................................................................................................. 3 

INTRODUCTION ................................................................................................................................................................... 4 

GENERAL INFORMATION .................................................................................................................................................. 5 

DATA FORMATTING ........................................................................................................................................................... 6 

AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI) X12 FORMATTING ......................................................................................................................... 6 

AMERICAN STANDARD CODE FOR INFORMATION EXCHANGE FORMATTING ...................................................................................................................... 6 

REFERENCES ...................................................................................................................................................................... 7 

GOVERNMENT AND OTHER ASSOCIATION LINKS............................................................................................................................................................. 7 

ASC X12 STANDARDS LINKS ........................................................................................................................................................................................ 7 

SEGMENT INFORMATION .................................................................................................................................................. 9 

ISA - INTERCHANGE CONTROL HEADER ........................................................................................................................................................................ 9 

GS – FUNCTIONAL GROUP HEADER ............................................................................................................................................................................ 10 

BHT – BEGINNING OF HIERARCHICAL TRANSACTION .................................................................................................................................................... 11 

LOOP 1000A: NM1 – SUBMITTER NAME .................................................................................................................................................................... 12 

LOOP 1000B: NM1 – RECEIVER NAME ...................................................................................................................................................................... 13 

LOOP 2010AA: NM1 – BILLING PROVIDER NAME ....................................................................................................................................................... 14 

LOOP 2000B: SBR – SUBSCRIBER INFORMATION ........................................................................................................................................................ 15 

LOOP 2010BA: NM1 – SUBSCRIBER NAME ................................................................................................................................................................ 16 

LOOP 2010BB: NM1 - PAYER NAME .......................................................................................................................................................................... 17 

LOOP 2300: PWK - CLAIM SUPPLEMENTAL INFORMATION ........................................................................................................................................... 18 

LOOP 2300: AMT - PATIENT RESPONSIBILITY - ESTIMATED .......................................................................................................................................... 19 

LOOP 2300: NTE – BILLING NOTE .............................................................................................................................................................................. 20 

LOOP 2300: HI – VALUE INFORMATION....................................................................................................................................................................... 22 

LOOP 2310A: NM1 – ATTENDING PHYSICIAN NAME.................................................................................................................................................... 23 

LOOP 2310B: NM1 – OPERATING PHYSICIAN NAME .................................................................................................................................................... 24


LOOP 2310C: NM1 – OTHER OPERATING PHYSICIAN NAME ....................................................................................................................................... 25 

LOOP 2310D: NM1 – RENDERING PROVIDER NAME ................................................................................................................................................... 26 

LOOP 2310 E: NM1 – SERVICE FACILITY NAME .......................................................................................................................................................... 27 

LOOP 2320: SBR – OTHER SUBSCRIBER INFORMATION .............................................................................................................................................. 28 

LOOP 2320: CAS – CLAIM LEVEL ADJUSTMENTS ........................................................................................................................................................ 29 

LOOP 2400: SV2 – INSTITUTIONAL SERVICE LINE ....................................................................................................................................................... 30 

LOOP 2400: DTP – SERVICE LINE DATE ..................................................................................................................................................................... 33 

LOOP 2420B: NM1 – OTHER OPERATING PHYSICIAN NAME ........................................................................................................................................ 34 

LOOP 2420C: NM1 – RENDERING PROVIDER NAME .................................................................................................................................................... 35 

LOOP 2420F: NM1 – REFERRING PROVIDER NAME ..................................................................................................................................................... 36 

LOOP 2430: CAS – LINE ADJUSTMENTS .................................................................................................................................................................... 37


EDI SUPPORT INFORMATION 

Days Available: Monday through Friday 

Time Zone: Eastern Standard Time (EST) 

Time Available: 8:00 am to 5:00 pm 

Phone: (614) 387-1212 

Email: OIS-EDI-Support@JFS.Ohio.Gov 

Updated: 02/07/2012 Version: 2.0 

1


DISCLOSURE STATEMENT 

The ODJFS Companion Guides do not: 

Replace the HIPAA ANSI ASC X12N Implementation Guide. 

Contain any actions that would result in a Non-Compliant Transaction. 

The ODJFS Companion Guides are subject to change without prior notice. 

Providers and Trading Partners are responsible for periodically checking for Companion Guide updates on the ODJFS 

Trading Partner website. http://jfs.ohio.gov/OHP/tradingpartners/info.stm 

Each Medicaid Provider and/or Trading Partner has the ultimate responsibility to adhere to the HIPAA Federal 

Requirements as well as any Ohio State laws that are applicable including the Ohio Administrative Code.


PURPOSE 

ODJFS developed 5010 Companion Guides to supplement each 5010 Transaction Implementation Guide, based on 

Version 5, Release 1, with regards to: 

Specific Codes and/or Values that ODJFS will default on Outbound Transactions 

Specific Codes and/or Values that are unique to ODJFS to accept an Inbound Transaction 

ODJFS Companion Guides will not create a Non-Compliant Transaction.


INTRODUCTION 

The Health Insurance Portability and Accountability Act (HIPAA) require all Providers, Trading Partners and Payers in the 

United States to comply with the EDI Standards for Health Care. 

The ASC X12 HIPAA 837 Institutional Implementation Guide presents the basic requirements for planning and 

implementing an EDI-based system for the exchange of ASC X12 HIPAA compliant transactions with the Ohio Medicaid 

Information Technology System (MITS). In order to create a HIPAA compliant transaction, you must first meet the 

requirements of the ASC X12 HIPAA 837 Institutional Implementation Guide and then incorporate the ODJFS specific 

requirements. 

The segments and elements used in this document are necessary for the ODJFS adjudication system for Institutional 

Claims 

ODJFS has elected to create the following 837I Companion Guides: 

FFS 

Encounter


GENERAL INFORMATION 

This EDI Companion Guide supplements the ASC X12 HIPAA 5010 Version 5 Release 1 Implementation Guide. 

The objectives of this document are: 

To identify the specific information ODJFS will be sending and or receiving. 

To point out preferred Specific Codes/Values where multiple alternatives exist. 

To insure that ODJFS will always send or receive a Compliant Transaction: 

The Transaction will first meet the requirements of the ASC X12 HIPAA Implementation Guide. 

Every effort has been made to prevent errors in this document. However, if discrepancies exist between the EDI 

Companion Guide and the ASC X12 HIPAA Implementation Guide, the Implementation Guide is the final authority.


DATA FORMATTING 

All objects including *.837, *.999 files can either be wrapped or unwrapped, which means the files must contain carriage 

return/line feed control characters at the end of every line or the data in the files must be streamed to be processed. The 

method chosen must be consistent throughout the entire file. 

American National Standards Institute (ANSI) X12 Formatting 

The EDI objects must strictly adhere to the structure, syntax, and semantic requirements as specified in each Transaction 

Implementation Guide. 

American Standard Code for Information Exchange Formatting 

ODJFS does not accept Extended Binary Coded Decimal Interchange Code (EBCDIC) Transactions 

All HIPAA Inbound and Outbound Transactions will be in the American Standard Code for Information Exchange (ASCII) 

format. 

For additional information, see the EDI Trading Partner Information Guide found on the ODJFS Trading Partner website 

http://jfs.ohio.gov/OHP/tradingpartners/info.stm


REFERENCES 

In addition to the resources available on the ODJFS Trading Partner website there are additional websites that contain 

helpful information to assist with the 5010 Implementation of HIPAA Transactions. 

Government and Other Association Links 

Center for Medicare and Medicaid Services(CMS) 

o http://www.cms.hhs.gov 

Answers to Frequently Asked Questions 

o https://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=GiSFk8jj 

Health and Human Services (HHS) Office for Civil Rights (Privacy) 

o http://www.hhs.gov/ocr/hipaa/ 

WEDI SNIP: Workgroup for EDI, Strategic National Implementation Process 

o http://www.wedi.org/snip/ 

CMS website for National Provider Identifier (NPI) 

o http://www.cms.gov/NationalProvIdentStand/ 

ASC X12 Standards Links 

Washington Publishing Company 

o http://www.wpc-edi.com/ 

Data Interchange Standards Association 

o http://disa.org/


American National Standards Institute 

o http://ansi.org/ 

Accredited Standards Committee 

o http://www.x12.org 

Ohio Department of Job and Family Services Links 

ODJFS website 

o http://jfs.ohio.gov 

Ohio Health Plans (OHP) website 

o http://jfs.ohio.gov/ohp/


SEGMENT INFORMATION 

ISA - Interchange Control Header 

Usage: Required 

Segment Repeat: 1 

ATTRIBUTES Comments 

Element Name Use Min/ Data Codes/ 

Max Type Values 

ISA01 Authorization 

Information 

Qualifier 

R 2/2 ID 00 

ISA03 Security 

Information 

Qualifier 

R 2/2 ID 00 

ISA06 Interchange 

Sender ID 

R 15/15 AN 7-digit Trading Partner ID assigned by ODJFS 

This is a fixed-length field and it should be left 

justified and filled with spaces to meet the minimum 

length requirement of 15. 

ISA08 Interchange R 15/15 AN MMISODJFS This is a fixed-length field and it should be left 

Receiver ID 

justified and filled with spaces to meet the minimum 

length requirement of 15.


GS – Functional Group Header 






GS02 Application 

Sender’s 

Code 

R 2/15 AN 7-digit Trading Partner ID assigned by ODJFS. 

GS03 Application 

Receiver’s 

Code 

R 2/15 AN MMISODJFS


BHT – Beginning of Hierarchical Transaction 




Element Name Use Min/ Data Codes/ Values 

Max Type 

BHT02 Transaction Set 

Purpose Code 

R 2/2 ID 00 

BHT06 Claim Identifier R 2/2 ID CH


Loop 1000A: NM1 – Submitter Name 

Loop Repeat: 1 



ATTRIBUTES 



NM109 Identification R 2/80 AN 7 digit Ohio Medicaid Trading Partner ID assigned by 

Code 

ODJFS


Loop 1000B: NM1 – Receiver Name 






Max Type 

NM109 Identification 

Code 

R 2/80 AN MMISODJFS


Loop 2010AA: NM1 – Billing Provider Name 




Note: The billing provider must meet the definition of the health care provider (i.e., be a typical provider), must be a legal 

entity and must be assigned a NPI. 




NM109 Billing 

Provider 

Identifier 

R 2/80 AN ‘Typical’ Provider NPI


Loop 2000B: SBR – Subscriber Information 

Loop Repeat: >1 






SBR09 Claim Filing 

Indicator Code 

S 1/2 ID MC


Loop 2010BA: NM1 – Subscriber Name 








Code 

Qualifier 

X 1/2 ID MI 


Code 

R 2/80 AN ODJFS assigned Member ID


Loop 2010BB: NM1 - Payer Name 





Element Name Use Min/ Data Codes/Values 

Max Type 


Code 

Qualifier 

R 1/2 ID PI 

NM109 Payer 

Identifier 

R 2/80 AN MMISODJFS


Loop 2300: PWK - Claim Supplemental Information 



Usage: Situational 

Follow these instructions when an EDI claim requires an attachment. Completion of this information indicates an 

attachment is being sent. The claim will be suspended waiting for the attachment. 

ATTRIBUTES 

Element Name Usage Min/ Data Codes/ 


PWK01 Report Type 

Code 

R 2/2 ID B4 

PWK02 Report 

Transmission 

Code 

PWK06 Identification 

Code 

R 1/2 ID BM 

EL 

FT 

R 2/50 ID JFS03197 

JFS03198 

JFS03199 

JFS00653 

JFS99999 

Comments 

FT - use when sending the attachment via the MITS 

Portal 

− the attachment documents include the Abortion 

Certification Form (JFS 03197) 

− the attachment document(s) include the Consent for 

Sterilization Form (JFS 03198) 

− attachment document(s) include the Acknowledgment 

of Hysterectomy Information Form (JFS 03199) 

− attachment document(s) include the Medical Claim 

Review Request Form (JFS 06653) 

− other attachment document(s) do not include any of the 

forms listed above


Loop 2300: AMT - Patient Responsibility - Estimated 

Loop Repeat: >1 




Element Name Use Min/ Data 

Max Type 

AMT01 Amount 

Qualifier 

Code 

R 1/3 ID F3 

AMT02 Identification R 1/18 R In most cases the Patient Responsibility 

Code 

Amount -Estimated should not be 

submitted. 

Never report Medicaid co-payment amounts 

collected (or incurred) or the co-payments 

will be deducted twice. 

Report spend down amounts incurred or 

paid if the billed charges for the services on 

the claim were used to become eligible for 

Medicaid. 

Report Patient Liability amounts whenever 

applicable (e.g., patient liability for LTC 

room and board claims) and NF Medicare 

crossover claims.


Loop 2300: NTE – Billing Note 







NTE01 Note S 3/3 ID ADD ADD-when the non-emergency emergency co-payment 

Reference 

Code 

applies (See NTE02 comments) 

ADD-will be used by providers to denote timely filing 

exemption (See NTE02 Comments) 

NTE02 Claim Note 

Text 

R 1/80 AN 

CER 

CER –required if billing provider is Medicaid School program 

(MSP) provider 

For hospitals, when the non-emergency emergency copayment 

applies, the 10 character code (COPAY NEMR) 

must be the first item listed in the NTE02. There must always 

be a single space between the word COPAY and NEMR. 

Example: NTE*ADD*COPAY NEMR


NTE02 Description R 1/80 AN When a claim could not be filed within the normal claim 

filing limit due to the pendency of an administrative 

hearing decision by ODJFS or an eligibility 

determination by a County Department of Job and 

Family Services (CDJFS) the (1) or (2) below applies. 

(1) For appeals/hearings, report the appeals/hearing 

number and date (The XXXXXXX is the hearing 

number) in this format: 

APPEALS XXXXXXX CCYYMMDD 

(2) For a delayed eligibility determination, enter the 

eligibility determination decision date in this format. 

DECISION CCYYMMDD 

Example (1): NTE*ADD*APPEALS 123456A 20110906 

Example (2): NTE*ADD*DECISION 20110831


Loop 2300: HI – Value Information 




NOTE: Hospitals must use value code 54 (newborn birth weight in grams) to specify the birth weight for newborn 

hospitalizations as well as any neonates that group to DRG 385. Report birth weight in C02205, Monetary Amount. 

For nursing facility room and board claims, use value code 31 patient liability amount, to report the amount of lump sum 

payment per month. See AMT 2300 when patient liability is not lump sum. 


Element Name Use Min/ Max Data Type Codes/ 

HI01-01 Code List Qualifier 

Code 

R 1/3 ID 

Values 

BE Value


Loop 2310A: NM1 – Attending Physician Name 






Max Type 

NM109 Attending 

Provider 

Primary 

Identifier 



Loop 2310B: NM1 – Operating Physician Name 






Max Type 

NM109 Operating 

Physician 

Primary 

Identifier 



Loop 2310C: NM1 – Other Operating Physician Name 






Max Type 

NM109 Other 

Operating 

Physician 

Identifier 



Loop 2310D: NM1 – Rendering Provider Name 






Max Type 

NM109 Rendering 

Provider 

Identifier 



Loop 2310 E: NM1 – Service Facility Name 







NM109 Service 

Facility 

Identifier 

R 2/80 AN ‘Typical Provider NPI


Loop 2320: SBR – Other Subscriber Information 






Max Type 

SBR09 Claim Filing 

Indicator 

S 1/2 ID MA For Original Medicare part A claims 

Code 

MB For Original Medicare part B claims 

16 

CI 

BL 

When other payer is a Medicare HMO 

When other payer is commercial insurance (other 

than blue cross) 

When other payer is Blue Cross/ Blue Shield Plan 

Any other appropriate value except MC (MC should 

only used in 2000B loop) 

Others, if appropriate


Loop 2320: CAS – Claim Level Adjustments 




NOTE: Medicaid is the payer of last resort. The claim must first be adjudicated by all payers submitted in the 2330B loop 

before submitting the claim to ODJFS, unless an exception set forth in Rule 5101:3-1-08 of the Ohio Administrative Code 

(OAC) applies. The total amount paid by the payer in 2330B for all services on the claim must be submitted (AMT 2320). 

If the payer in 2330B adjudicated the claim at the claim/header level, the associated Adjustment Code Group (s), 

Adjustment Reason Code(s) and Amount(s) must be submitted in this loop/segment. If the payer in 2330B adjudicated 

the claim at the detail level (i.e., made line payments and/or made line adjustments that caused the line payment to differ 

from the line billed charges), the 2430 loop must be completed. If the payer in 2330B adjudicated the claim at the detail, 

but made some adjustments at the header/claim level that caused the claim payment to differ from the sum of the line 

payments, the 2320 CAS must be submitted in addition to the appropriate adjustments made in 2430 CAS. 

Most inpatient institutional claims are adjudicated at the header/claim level. 

COB balancing rules apply and may be enforced (See IG Balancing). 

ATTRIBUTES 

Element Name Usage Min/ Data 

Max Type 

CAS01 Claim 

Adjustment 

Group Code 

R 1/2 ID 

Codes/ 

Values 

CO 

CR 

OA 

PI 

PR 

Contractual Obligations 

Comments 

Correction and Reversals 

Other adjustments 

Payer Initiated Reductions 

Patient Responsibility


Loop 2400: SV2 – Institutional Service Line 




Note: For NF claims see special detail billing instruction Note for Loop 2400: DTP-Service Line Date 




SV2-01 Service Line R 1/48 AN 00 For Independent Free-standing ESRD Dialysis Clinics 

Revenue Code 

the following revenue codes do not allow procedure 

(CPT/HCPCS) codes: 

0821-Hemodialysis 

0831-IPD 

0841-CAPD 

0851-CCPD 

0825-Hemodialysis Support Services 

0835-IPD Support Service 

0845-CAPD Support Services 

0855-CCPD Support Services 

0829-Hemodialysis Training 

0839-IPD Training 

0849-CAPD Training 

0859-CCPD Training


Element Name Use Min/ 

Max 

SV2-03 

Monetary 

Amount 


S 1/18 

Data 

Type 

R 

Codes/ 

Values 

For Independent Free-standing Dialysis Clinics the 

following revenue center codes do require procedure 

(CPT/HCPCS) codes: 

0304 - Clinical Laboratory 

0310 - Pathological Laboratory 

0730 - Diagnostic Services 

0634 - Erythropoietin (EPO) less than 10,000 units 

0635 - Erythropoietin (EPO) 10,000 units or greater 

0636 - Separately billable drugs / injections / 

immunizations 

For Nursing Facility room and board claims, the valid 

revenue codes are: 

0101 - All inclusive room and board 

0183 - therapeutic leave 

0185 - hospitalization leave 

0160 - Short-term stay for waiver consumer 

For Nursing Facility room and board claims, include 

charges associated with the revenue codes and 

identify those charges as covered or non-covered 

charges. Long Term Care facility room and board 

claims do not require procedure (CPT/HCPCS) 

codes. See Note for Loop 2400: DTP-Service Line 

Date. 

When submitting an Institutional Service Line for a 

covered day within a Nursing Facility, please enter


Element Name Use Min/ 

Max 

SV2-04 Unit or Basis for 

Measurement 

Code 

SV2-05 Service Unit 

Count 

SV2-07 Line Item Denied 

Charge or Non- 

Covered Charge 

Amount 


Data 

Type 

Codes/ 

Values 

R 2/2 ID DA 

UN 

covered charge amount. 

For non-covered days within a Nursing Facility room 

and board claim, the SV203 must be set to zeros. 

Use the SV207 to enter the non-covered charge 

amount. 

Days – For ESRD Clinics, only one date of service 

may be submitted for a RCC. 

Units- Multiple units may be billed by Independent 

Free-standing ESDR Dialysis Clinics only for certain 

CPT/HCPCS codes itemized with certain RCCs. 

R 1/15 R For Nursing Facility room and board claims, enter the 

number of units (days) associated with each 

occurrence of a Revenue Code. 

When submitting an Institutional Service Line for a 

non-covered day within a Nursing Facility room and 

board claim, the SV207 must contain the amount of 

non-covered charges, and the SV203 must be set to 

zeros. 

S 1/18 R When submitting an Institutional Service Line for a 

non-covered day within a Nursing Facility room and 

board claim, the SV207 must contain the amount of 

non-covered charges, and the SV203 must be set to 

zeros.


Loop 2400: DTP – Service Line Date 




Note: NFs are to no longer bill service dates at the detail section of the claim. As a result, MITS will use the service 

dates reported at the Header of the claim and the number of units on each detail to calculate the begin and end date for 

each detail of the claim. Providers MUST bill the detail lines of their claims in date order sequence in order to 

assure the correct assignment of dates at the detail line. 

Claim Example: Using a NF claim that was billed with Header first date of service (FDOS) 9/1/11 and last date of 

service (TDOS) of 9/30/11 and 7 Detail Lines, the FDOS and TDOS will be determined as follows: 

1) 101 (covered) Units Billed = 1 FDOS = 9/1/11 TDOS = 9/1/11 

2) 101 (non-covered) Units Billed = 6 FDOS = 9/2/11 TDOS = 9/7/11 



5) 101 (non-covered) Units Billed = 7 FDOS = 9/14/11 TDOS = 9/20/11 






DTP02 Date Time 

Period Format 

Qualifier 

R 2/3 ID D8


Loop 2420B: NM1 – Other Operating Physician Name 






Max Type 

NM109 Other 

Operating 

Physician 

Identifier 



Loop 2420C: NM1 – Rendering Provider Name 






Max Type 

NM109 Rendering 

Provider 

Identifier 



Loop 2420F: NM1 – Referring Provider Name 






Max Type 

NM109 Referring 

Provider 

Identifier 



Loop 2430: CAS – Line Adjustments 




NOTE: Medicaid is the payer of last resort. The claim must first be adjudicated by all payers submitted in the 2330B loop 

before submitting the claim to ODJFS unless an exception set forth in Rule 5101:3-1-08 of the Ohio Administrative Code 

applies The total amount paid by the payer in 2330B for all services on the claim must be submitted (AMT 2320). If the 

payer in 2330B adjudicated the claim at the detail level (i.e., made line payments and/or made line adjustments that 

caused the line payment to differ from the line billed charges), the 2430 loop must be completed. If the payer in 2330B 

adjudicated the claim at the detail but made some adjustments at the header/claim level that caused the claim payment to 

differ from the sum of the line payments, the 2320 CAS must be submitted in addition to the appropriate adjustments 

made in 2430 CAS. 

Most Inpatient claims are adjudicated at the header/claim level. 

COB balancing rules may be enforced (See IG Balancing). 

ATTRIBUTES 

Element Name Usage Min/ Data 

Max Type 

CAS01 Claim 

Adjustment 

Group Code 

R 1/2 ID 

Codes/ 

Values 

CO 

CR 

OA 

PI 

PR 

Contractual Obligations 

Comments 

Correction and Reversals 

Other adjustments 

Payer Initiated Reductions 

Patient Responsibility

Ohio Companion Guide 837 Fee-For-Service Institutional Claim

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