Encounter Data Companion Guide - CSSC Operations

TABLE 4 - 837 INSTITUTIONAL HEALTH CARE CLAIM (CONTINUED)LOOP ID REFERENCE NAME CODES NOTES/COMMENTS1000B NM1 Receiver NameNM102 Entity Type Qualifier 2 Non-Person EntityNM103 Receiver Name EDSCMSNM109 Receiver ID 80881 Identifies CMS as the receiverof the transaction andcorresponds to the value inISA08 Interchange Receiver ID2010AA NM1 Billing Provider NameNM108NM109Billing Provider IDQualifierBilling Provider IdentifierXXNPI IdentifierMust be populated with a tendigit number, must begin with12010AA N4 Billing Provider City,State, Zip Code1999999976Institutional provider defaultNPI when the provider has notbeen assigned an NPIN403 Zip Code The full nine (9) digits of theZIP Code are required. If thelast four (4) digits of the ZIPcode are not available,populate a default value of“9999”.2010AA REF Billing Provider TaxIdentification NumberREF01REF02Reference IdentificationNumberBilling Provider TaxIdentification Number 1999999972000B SBR Subscriber InformationSBR01SBR09Payer ResponsibilityNumber CodeClaim Filing IndicatorCodeEISMAEmployer’s IdentificationNumber (EIN)Institutional provider defaultEINEDSCMS is considered thedestination (secondary) payerMust be populated with avalue of MA – Medicare Part A837 Institutional Companion Guide Version 9.0/August 201214