ANSI 837 - Florida Blue - BCBSF

Florida Blue 837 P Companion Guide 2012Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan RequirementB232330B - Other Payer Claim ControlNumberREF01REF02331 If LOOP ID – 2330B OTHER PAYER NAME issubmitted in the transaction, then the OtherPayer’s Claim Control Number must be reported inthe following REF segment or the claim will bereturned as a provider correctable error and mustbe corrected and resubmitted electronically.B242330B - Other Payer Claim ControlNumberDTP01DTP03• REF01=F8• REF02= Other Payer’s Claim ControlNumber; If the other payer is Medicare,enter the Medicare Report Number (aka –Medicare ICN)325 When SBR09=MB, Florida Blue requires:More than 30 days have elapsed from theMedicare Remittance date before submitting toFlorida BlueB252400 – Service Line NumberSV101-1 352 HC• DTP01=573• DTP02=D8• DTP03=Date Claim Paid (aka MedicareRemittance Date)Product/Service ID QualifierFlorida Blue requires submission of above value inthis field as only HCPCS Procedure codes areaccepted by Florida Blue at this time.B262400 - Professional ServiceProcedure Modifier(s)SV101- 3SV101- 4353 Please submit the appropriate modifiers in priorityorder.SV101-5SV101-6B272410 - Drug IdentificationLIN424DME ProvidersDrug IdentificationDrug QuantityCTP426LIN – NDC must be submittedCTP – Quantity must be submitted.Note:Refer to Specialty Pharmacy Billing Section VII.C.181 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012