VERSION 004010X098A1 - Magellan Provider's Home Page

Magellan Behavioral Health 837 Professional Companion GuideLOOP ID - 2420F 2 N2/500L525 REF Referring Provider Secondary Identification O 5LOOP ID - 2000C >1LOOP ID - 2010CA 1 N2/015L015 NM1 Patient Name O 1 N2/015LOOP ID - 2300 100LOOP ID - 2310B 1 N2/250L250 NM1 Rendering Provider Name O 1 N2/250271 REF Rendering Provider Secondary Identification O 5LOOP ID - 2400 50 N2/365L370 SV1 Professional Service O 1LOOP ID - 2420A 1 N2/500L500 NM1 Rendering Provider Name O 1 N2/500525 REF Rendering Provider Secondary Identification O 5_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 2

Magellan Behavioral Health 837 Professional Companion GuideBHTElement Summary:Beginning of HierarchicalTransactionPos: 010 Max: 1Heading - MandatoryLoop: N/A Elements: 1Ref Id Element Name Req Type Min/Max UsageBHT02 353 Transaction Set Purpose CodeM ID 2/2 RequiredDescription: Code identifying purpose of transactionsetMagellan Specific Note: A reissue (18) shouldonly be sent when requested by Magellan._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 3

Magellan Behavioral Health 837 Professional Companion GuideNM1Element Summary:Receiver NamePos: 020 Max: 1Heading - OptionalLoop: 1000B Elements: 1Ref Id Element Name Req Type Min/Max UsageNM109 67 Identification CodeC AN 2/80 RequiredDescription: Code identifying a party or other codeMagellan Specific Note: This field storesMagellan's NAIC number (with a leading zero).Please populate with a value of '01260'._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 4

Magellan Behavioral Health 837 Professional Companion GuideCURElement Summary:Foreign Currency InformationPos: 010 Max: 1Detail - OptionalLoop: 2000A Elements: 1Ref Id Element Name Req Type Min/Max UsageCUR02 100 Currency CodeM ID 3/3 RequiredDescription: Code (Standard ISO) for country inwhose currency the charges are specifiedMagellan Specific Note: Magellan can onlyprocess US currency (code USD)._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 5

Magellan Behavioral Health 837 Professional Companion GuideNM1Billing Provider NamePos: 015 Max: 1Detail - OptionalLoop:Elements: 02010AAElement Summary:Magellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.MIS# will no longer be accepted after May 22, 2008._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 6

Magellan Behavioral Health 837 Professional Companion GuideNM1Billing Provider NamePos: 015 Max: 1Detail - OptionalLoop:Elements: 02010AAElement Summary:Ref Id Element Name Req Type Min/Max UsageNM108 66 Identification Code QualifierM ID 1/2 RequiredDescription: Code designating the system/methodof code structure used for Identification Code (67)If “XX - NPI” is used, then either the Employer’sIdentification Number or the Social Security Numberof the provider must be carried in the REF in thisloop.• 24 Employer’s Identification Number• 34 Social Security Number• XX Health Care Financing AdministrationNational Provider IdentifierRequired value if the National Provider ID ismandated for use.Magellan Specific Note: To comply with HIPAAregulations, Magellan will require NPI usage forprovider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.NM1Billing Provider NamePos: 015 Max: 1Detail - OptionalLoop:Elements: 02010AAElement Summary:Ref Id Element Name Req Type Min/Max UsageNM109 67 Identification CodeM AN 2/80 RequiredDescription: Code identifying a party or other codeMagellan Specific Note: To comply with HIPAAregulations, Magellan will require NPI usage forprovider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 7

Magellan Behavioral Health 837 Professional Companion GuideREFBilling Provider SecondaryIdentificationPos: 035 Max: 8Detail - OptionalLoop:Elements: 02010AAMagellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.MIS# will no longer be accepted after May 22, 2008._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 8

Magellan Behavioral Health 837 Professional Companion GuideREFBilling Provider SecondaryIdentificationPos: 035 Max: 8Detail - OptionalLoop:Elements: 02010AAElement Summary:Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierM ID 2/3 RequiredDescription: Code qualifying the ReferenceIdentification0B - State License Number1A - Blue Cross Provider Number1B - Blue Shield Provider Number1C - Medicare Provider Number1D - Medicaid Provider Number1G - Provider UPIN Number1H - CHAMPUS Identification Number1J - Facility ID NumberB3 - Preferred Provider Organization NumberBQ - Health Maintenance Organization CodeNumberEI - Employer’s Identification NumberFH - Clinic NumberG2 - Provider Commercial NumberG5 - Provider Site NumberLU - Location NumberSY - Social Security Number – may not be used formedicareU3 - Unique Supplier Identification Number (USIN)X5 - State Industrial Accident Provider NumberREF02 127 Reference IdentificationM AN 1/30 RequiredDescription: Reference information as defined for aparticular Transaction Set or as specified by theReference Identification Qualifier_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 9

Magellan Behavioral Health 837 Professional Companion GuideNM1Pay–To Provider NamePos: 015 Max: 1Detail - OptionalLoop:Elements: 02010ABMagellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.MIS# will no longer be accepted after May 22, 2008.Element Summary:Ref Id Element Name Req Type Min/Max UsageNM108 66 Identification Code QualifierM ID 1/2 RequiredDescription: Code designating the system/methodof code structure used for Identification Code (67)If “XX - NPI” is used, then either the Employer’sIdentification Number or the Social SecurityNumber of the provider must be carried in theREF in this loop.• 24 Employer’s Identification Number• 34 Social Security Number• XX Health Care Financing AdministrationNational Provider IdentifierRequired value if the National Provider ID ismandated for use.Magellan Specific Note: To comply with HIPAAregulations, Magellan will require NPI usage forprovider primary identifiers after May 22, 2008._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 10

Magellan Behavioral Health 837 Professional Companion GuideMIS# will no longer be accepted after this date.NM1Pay–To Provider NamePos: 015 Max: 1Detail - OptionalLoop:Elements: 02010ABElement Summary:Ref Id Element Name Req Type Min/Max UsageNM109 67 Identification CodeM AN 2/80 RequiredDescription: Code identifying a party or other codeMagellan Specific Note: To comply with HIPAAregulations, Magellan will require NPI usage forprovider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 11

Magellan Behavioral Health 837 Professional Companion GuideREFPay-to-Provider SecondaryIdentificationPos: 035 Max: 5Detail - OptionalLoop:Elements: 02010ABMagellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.MIS# will no longer be accepted after May 22, 2008._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 12

Magellan Behavioral Health 837 Professional Companion GuideREFPay-to-Provider SecondaryIdentificationPos: 035 Max: 5Detail - OptionalLoop:Elements: 02010ABElement Summary:Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierM ID 2/3 RequiredDescription: Code qualifying the ReferenceIdentification0B - State License Number1A - Blue Cross Provider Number1B - Blue Shield Provider Number1C - Medicare Provider Number1D - Medicaid Provider Number1G - Provider UPIN Number1H - CHAMPUS Identification Number1J - Facility ID NumberB3 - Preferred Provider Organization NumberBQ - Health Maintenance Organization CodeNumberEI - Employer’s Identification NumberFH - Clinic NumberG2 - Provider Commercial NumberG5 - Provider Site NumberLU - Location NumberSY - Social Security Number – may not be used formedicareU3 - Unique Supplier Identification Number (USIN)X5 - State Industrial Accident Provider NumberREF02 127 Reference IdentificationM AN 1/30 RequiredDescription: Reference information as defined for aparticular Transaction Set or as specified by theReference Identification Qualifier_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 13

Magellan Behavioral Health 837 Professional Companion GuideNM1Element Summary:Subscriber NamePos: 015 Max: 1Detail - OptionalLoop:Elements: 42010BARef Id Element Name Req Type Min/Max UsageNM103 1035 Name Last or Organization NameO AN 1/35 RequiredDescription: Individual last name or organizationalnameMagellan Specific Note: Full legal name isnecessary to correctly identify the subscriber.Use name as printed on Member Identificationcard.NM104 1036 Name FirstO AN 1/25 SituationalDescription: Individual first nameMagellan Specific Note: Full legal name isnecessary to correctly identify the subscriber.Use name as printed on Member Identificationcard.NM108 66 Identification Code QualifierC ID 1/2 RequiredDescription: Code designating the system/methodof code structure used for Identification Code (67)Magellan Specific Note: Only value 'MI' is usedby Magellan.NM109 67 Identification CodeC AN 2/80 RequiredDescription: Code identifying a party or other codeMagellan Specific Note: Submit the numberprinted on the Member Identification Card._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 14

Magellan Behavioral Health 837 Professional Companion GuideREFSubscriber SecondaryIdentificationPos: 035 Max: 4Detail - OptionalLoop:Elements: 12010BAElement Summary:Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierM ID 2/3 RequiredDescription: Code qualifying the ReferenceIdentificationMagellan Specific Note: "SY" Social SecurityNumber is necessary to identify the subscriber._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 15

Magellan Behavioral Health 837 Professional Companion GuideN3Element Summary:Payer AddressPos: 025 Max: 1Detail - OptionalLoop:Elements: 12010BBRef Id Element Name Req Type Min/Max UsageN301 166 Address InformationM AN 1/55 RequiredDescription: Address informationMagellan Specific Note: PO Box number can besent in this segment. Send only claimsubmission PO Box number in this field. Forexample send '1000' not 'PO Box 1000'. This isthe same PO Box as used for paper claims.Radiology NIA claims go to ‘1428’.If PO Box number is not sent here, it must besent in 2010BB REF segment with a qualifier"FY". The 2010BB REF segment is preferred andHIPAA compliant._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 16

Magellan Behavioral Health 837 Professional Companion GuideREFElement Summary:Payer Secondary IdentificationPos: 035 Max: 3Detail - OptionalLoop:Elements: 22010BBRef Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierM ID 2/3 RequiredDescription: Code qualifying the ReferenceIdentificationMagellan Specific Note: This value is either 'NF'(for NAIC number) or 'FY' (for PO Box number forinternal routing.) If PO box number is sent in thissegment, Magellan should receive two REFsegments. This segment is the preferredsubmittal location for PO Box number (as aClaim Office Number).REF02 127 Reference IdentificationC AN 1/30 RequiredDescription: Reference information as defined for aparticular Transaction Set or as specified by theReference Identification QualifierMagellan Specific Note: This field is used tostore Magellan's NAIC number (with a leadingzero) or an additional PO BOX number. Pleasepopulate with a value of '01260' for theIdentification number or populate with the POBOX value for an additional PO BOX. RadiologyNIA claims go to ‘1428’._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 17

Magellan Behavioral Health 837 Professional Companion GuideCLMElement Summary:Claim InformationPos: 130 Max: 1Detail - OptionalLoop: 2300 Elements: 1Ref Id Element Name Req Type Min/Max UsageCLM05 C023 Health Care Service Location InformationO Comp RequiredCLM05-3 1325Description: To provide information that identifiesthe place of service or the type of bill related to thelocation at which a health care service was renderedClaim Frequency Type CodeDescription: Code specifying the frequency of theclaim; this is the third position of the Uniform BillingClaim Form Bill TypeMagellan Specific Note: Claims with a value of'7' or '8' may result in a duplicate claim rejection.O ID 1/1 Required_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 18

Magellan Behavioral Health 837 Professional Companion GuidePWK Claim Supplemental InformationPos: 155 Max: 10Detail - OptionalLoop: 2300 Elements: 4Magellan Specific Note: Magellan may not utilize this supplemental information segment.Element Summary:Ref Id Element Name Req Type Min/Max UsagePWK01 755 Report Type CodeM ID 2/2 RequiredDescription: Code indicating the title or contents ofa document, report or supporting itemPWK02 756 Report Transmission CodeDescription: Code defining timing, transmissionmethod or format by which reports are to be sentPWK05 66 Identification Code QualifierDescription: Code designating the system/methodof code structure used for Identification Code (67)PWK06 67 Identification CodeO ID 1/2 RequiredC ID 1/2 SituationalC AN 2/80 SituationalDescription: Code identifying a party or other code_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 19

Magellan Behavioral Health 837 Professional Companion GuideCN1Element Summary:Contract InformationPos: 160 Max: 1Detail - OptionalLoop: 2300 Elements: 1Ref Id Element Name Req Type Min/Max UsageCN101 1166 Contract Type CodeM ID 2/2 RequiredDescription: Code identifying a contract typeMagellan Specific Note: If submitting a CaseRate Claim, this field should be populated with avalue of '04'._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 20

Magellan Behavioral Health 837 Professional Companion GuideREFElement Summary:Claim Identification Number forClearing Houses and OtherTransmission IntermediariesPos: 180 Max: 30Detail - OptionalLoop: 2300 Elements: 2Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierM ID 2/3 RequiredDescription: Code qualifying the ReferenceIdentificationMagellan Specific Note: Please populate thisfield with a value of 'D9' and provideaccompanying trace number in REF02.REF02 127 Reference IdentificationC AN 1/30 RequiredDescription: Reference information as defined for aparticular Transaction Set or as specified by theReference Identification QualifierMagellan Specific Note: Magellan would like allclearinghouses and/or providers to submit aunique trace number within this field. Thisnumber will be relayed back to the sender withinthe response file, which will allow the sender totrace a specific claim to a specific claimresponse._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 21

Magellan Behavioral Health 837 Professional Companion GuideHIHealth Care Diagnosis CodePos: 231 Max: 1Detail - OptionalLoop: 2300 Elements: 4Magellan Specific Note: Magellan will only use the first 4 diagnosis codes for processing.Element Summary:Ref Id Element Name Req Type Min/Max UsageHI01 C022 Health Care Code InformationM Comp RequiredDescription: To send health care codes and theirassociated dates, amounts and quantitiesWith a few exceptions, it is not recommended toput E codes in HI01. E codes may be put in anyother HI element using BF as the qualifier.The diagnosis listed in this element is assumedto be the principal diagnosis.HI01 – 1 1270 Code List Qualifier CodeM ID 1/3 RequiredDescription: Code identifying a specific industrycode listBK - Principal DiagnosisHI01 – 2 1271 Industry CodeDescription: Code indicating a code from a specificindustry code listHI02 C022 Health Care Code InformationDescription: To send health care codes and theirassociated dates, amounts and quantitiesHI02 – 1 1270 Code List Qualifier CodeM AN 1/30 RequiredO Comp SituationalM ID 1/3 RequiredDescription: Code identifying a specific industrycode listBF - DiagnosisHI02 – 2 1271 Industry CodeM AN 1/30 RequiredDescription: Code indicating a code from a specificindustry code listHI03 C022 Health Care Code InformationDescription: To send health care codes and theirassociated dates, amounts and quantitiesHI03 – 1 1270 Code List Qualifier CodeO Comp SituationalM ID 1/3 RequiredDescription: Code identifying a specific industrycode listBF - DiagnosisHI03 – 2 1271 Industry CodeM AN 1/30 RequiredDescription: Code indicating a code from a specificindustry code list_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 22

Magellan Behavioral Health 837 Professional Companion GuideHIHealth Care Diagnosis CodePos: 231 Max: 1Detail - OptionalLoop: 2300 Elements: 4Magellan Specific Note: Magellan will only use the first 4 diagnosis codes for processing.Element Summary:Ref Id Element Name Req Type Min/Max UsageHI04 C022 Health Care Code InformationO Comp SituationalDescription: To send health care codes and theirassociated dates, amounts and quantitiesHI04 – 1 1270 Code List Qualifier CodeM ID 1/3 RequiredDescription: Code identifying a specific industrycode listBF - DiagnosisHI04 – 2 1271 Industry CodeM AN 1/30 RequiredDescription: Code indicating a code from a specificindustry code list_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 23

Magellan Behavioral Health 837 Professional Companion GuideREFReferring Provider SecondaryIdentificationPos: 271 Max: 5Detail - OptionalLoop: 2310A Elements: 1Magellan Specific Requirement: If a referral is required and the patient is a Medicaid recipient this REF segment isnecessary in order for Magellan to correctly identify the Referring Provider.Element Summary:Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierDescription: Code qualifying the ReferenceIdentificationMagellan Specific Note: If a referral is requiredand the patient is a Medicaid recipient theReferring Provider Medicaid Number isnecessary to adjudicate the claim.M ID 2/3 Required_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 24

Magellan Behavioral Health 837 Professional Companion GuideNM1Rendering Provider NamePos: 250 Max: 1Detail - OptionalLoop: 2310B Elements: 0Element Summary:Magellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned.Rendering Provider is required on TennCare Caserate claims._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 25

Magellan Behavioral Health 837 Professional Companion GuideNM1Rendering Provider NamePos: 250 Max: 1Detail - OptionalLoop: 2310B Elements: 0Element Summary:Ref Id Element Name Req Type Min/Max UsageNM108 66 Identification Code QualifierM ID 1/2 RequiredDescription: Code designating thesystem/method of code structure used forIdentification Code (67)If “XX - NPI” is used, then either the Employer’sIdentification Number or the Social SecurityNumber of the provider must be carried in theREF in this loop.• 24 Employer’s Identification Number• 34 Social Security Number• XX Health Care Financing AdministrationNational Provider IdentifierRequired value if the National Provider ID ismandated for use.Magellan Specific Note: To comply with HIPAAregulations, Magellan will require NPI usage forprovider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.NM109 67 Identification CodeM AN 2/80 RequiredDescription: Code identifying a party or other codeMagellan Specific Note: To comply with HIPAAregulations, Magellan will require NPI usage forprovider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 26

Magellan Behavioral Health 837 Professional Companion GuideREFRendering Provider SecondaryIdentificationPos: 271 Max: 5Detail - OptionalLoop: 2310B Elements: 0Magellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned.Rendering Provider is required on TennCare Caserate claims.MIS# will no longer be accepted after May 22, 2008._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 27

Magellan Behavioral Health 837 Professional Companion GuideREFRendering Provider SecondaryIdentificationPos: 271 Max: 5Detail - OptionalLoop: 2310B Elements: 0Element Summary:Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierM ID 2/3 RequiredDescription: Code qualifying the ReferenceIdentification0B - State License Number1A - Blue Cross Provider Number1B - Blue Shield Provider Number1C - Medicare Provider Number1D - Medicaid Provider Number1G - Provider UPIN Number1H - CHAMPUS Identification Number1J - Facility ID NumberB3 - Preferred Provider Organization NumberBQ - Health Maintenance Organization CodeNumberEI - Employer’s Identification NumberFH - Clinic NumberG2 - Provider Commercial NumberG5 - Provider Site NumberLU - Location NumberSY - Social Security Number – may not be used formedicareU3 - Unique Supplier Identification Number (USIN)X5 - State Industrial Accident Provider NumberREF02 127 Reference IdentificationM AN 1/30 RequiredDescription: Reference information as defined for aparticular Transaction Set or as specified by theReference Identification Qualifier_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 28

Magellan Behavioral Health 837 Professional Companion GuideSV1Element Summary:Professional ServicePos: 370 Max: 1Detail - OptionalLoop: 2400 Elements: 1Ref Id Element Name Req Type Min/Max UsageSV101 C003 Composite Medical Procedure IdentifierM Comp RequiredSV101 - 3 1339Description: To identify a medical procedure by itsstandardized codes and applicable modifiersProcedure ModifierDescription: This identifies special circumstancesrelated to the performance of the service, as definedby trading partnersMagellan Specific Note: EAP claims can only beprocessed using a case closing form. Do notsubmit EAP claims (modifier "HJ") on the 837.O AN 2/2 Situational_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 29

Magellan Behavioral Health 837 Professional Companion GuideCN1Element Summary:Contract InformationPos: 465 Max: 1Detail - OptionalLoop: 2400 Elements: 1Ref Id Element Name Req Type Min/Max UsageCN101 1166 Contract Type CodeM ID 2/2 RequiredDescription: Code identifying a contract typeMagellan Specific Note: If submitting a CaserateClaim, this field should be populated with a valueof '04'._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 30

Magellan Behavioral Health 837 Professional Companion GuideNM1Rendering Provider NamePos: 500 Max: 1Detail - OptionalLoop: 2420A Elements: 0Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned.Rendering Provider is required on TennCare Caserate claims._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 31

Magellan Behavioral Health 837 Professional Companion GuideREFRendering Provider SecondaryIdentificationPos: 525 Max: 5Detail - OptionalLoop: 2420A Elements: 0Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned.Rendering Provider is required on TennCare Caserate claims._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 32

Magellan Behavioral Health 837 Professional Companion GuideREFReferring Provider SecondaryIdentificationPos: 525 Max: 5Detail - OptionalLoop: 2420F Elements: 1Magellan Specific Requirement: If a referral is required and the patient is a Medicaid recipient this REF segment isnecessary in order for Magellan to correctly identify the Referring Provider.Element Summary:Ref Id Element Name Req Type Min/Max UsageREF01 128 Reference Identification QualifierM ID 2/3 RequiredDescription: Code qualifying the ReferenceIdentificationMagellan Specific Note: If a referral is requiredand the patient is a Medicaid recipient theReferring Provider Medicaid Number isnecessary to adjudicate the claim._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 33

Magellan Behavioral Health 837 Professional Companion GuideNM1Element Summary:Patient NamePos: 015 Max: 1Detail - OptionalLoop:Elements: 32010CARef Id Element Name Req Type Min/Max UsageNM104 1036 Name FirstO AN 1/25 RequiredDescription: Individual first nameMagellan Specific Note: Full legal name isnecessary to correctly identify the patient. Usename as printed on Member Identification card.NM105 1037 Name MiddleO AN 1/25 SituationalDescription: Individual middle name or initialMagellan Specific Note: Full legal name isnecessary to correctly identify the patient. Usename as printed on Member Identification card.NM108 66 Identification Code QualifierC ID 1/2 SituationalDescription: Code designating the system/methodof code structure used for Identification Code (67)Magellan Specific Note: Only value 'MI' is usedby Magellan._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 34

Magellan Behavioral Health 837 Professional Companion GuideNM1Rendering Provider NamePos: 250 Max: 1Detail - OptionalLoop: 2310B Elements: 0Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 35

Magellan Behavioral Health 837 Professional Companion GuideREFRendering Provider SecondaryIdentificationPos: 271 Max: 5Detail - OptionalLoop: 2310B Elements: 0Magellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned.Rendering Provider is required on TennCare Caserate claims.MIS# will no longer be accepted after May 22, 2008._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 36

Magellan Behavioral Health 837 Professional Companion GuideSV1Element Summary:Professional ServicePos: 370 Max: 1Detail - OptionalLoop: 2400 Elements: 1Ref Id Element Name Req Type Min/Max UsageSV101 C003 Composite Medical Procedure IdentifierM Comp RequiredDescription: To identify a medical procedure by itsstandardized codes and applicable modifiers1339 Procedure ModifierDescription: This identifies special circumstancesrelated to the performance of the service, as definedby trading partnersMagellan Specific Note: EAP claims can only beprocessed using a case closing form. Do notsubmit EAP claims (modifier "HJ") on the 837.O AN 2/2 Situational_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 37

Magellan Behavioral Health 837 Professional Companion GuideNM1Rendering Provider NamePos: 500 Max: 1Detail - OptionalLoop: 2420A Elements: 0Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 38

Magellan Behavioral Health 837 Professional Companion GuideREFRendering Provider SecondaryIdentificationPos: 525 Max: 5Detail - OptionalLoop: 2420A Elements: 0Magellan Specific Note:Provider Primary Id:Magellan will accept a National Provider Identifier (NPI) and its associated qualifier (NM109 using an ‘XX’ qualifier), butMagellan is requiring a dual usage of an NPI as the primary identifier with a federal tax ID (TIN) (REF02 using an ‘EI’qualifier) and/or a social security number (SSN) (REF02 using an ‘SY’ qualifier) in their respective secondary identifierREF segments for the following provider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderIf an NPI is used for the above provider types without a TIN (REF02 using an ‘EI’ qualifier) and/or SSN (REF02 using an‘SY’ qualifier) for a secondary identifier, claim will be rejected in a 997 or 277U.To comply with HIPAA regulations, Magellan will require NPI usage for provider primary identifiers after May 22, 2008.MIS# will no longer be accepted after this date.Secondary Ids2010AA REF-02; 2010AB REF-02; 2310B REF-02; 2420A REF-02 should be sent as outlined in the rules noted below:• In REF-01 use qualifier "G2" Commercial Identifier to report the MIS# and "SY" SSN to report the Social SecurityNumber.• The Magellan Provider Identifier (MIS#) is required for TennCare. (This is for PO Boxes 12700, 12400)• Roster providers for TennCare also require a Social Security Number along with the MIS#. (This is for PO Boxes12700, 12400)• All other accounts: The Magellan Provider Identifier (MIS#) is requested for all providers. Use qualifier "G2"Commercial Number to report the MIS#.• In the future, the MIS# will be required for all non-Medicaid claims.Magellan Specific Note:If more than one Rendering Provider (based on Primary ID match) is submitted on a claim, the claim will not load to thehost adjudication system and a negative response will be returned.Rendering Provider is required on TennCare Caserate claims.MIS# will no longer be accepted after May 22, 2008._________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 39

Magellan Behavioral Health 837 Professional Companion GuideChange SummaryChange history of this documentRevision Date Version # Change Description Author7/31/03 1 Added Change Summary Section Al Howlett9/15/03 2 Added 2000B and 2000C Loop 2400 SV1-01-3 Business Al HowlettRules10/3/03 3 Language modification to 2400 SV1-01-3 business rule. Al Howlett12/16/03 4 Removed or modified REF segments and their respective Al Howlettloops03/17/04 5 Modified several REF, NM1, SV1 and N3 segments: Al Howlett• Remove MIS# requirement for all providers• Add note defining specific accounts and provider IDrequirements for adjudication• Changed PO Box submittal requirement: If it is notsent in Payer address, it must be sent in PayerSecondary ID REF segment• Allow only one rendering provider per claim4/21/04 6 Revised wording for Magellan Note: MIS# and otherprovider ID requirement2/14/08 7 Revised National Provider Identifier (NPI) and itsassociated qualifier requirements (NM108, NM109) and therequirement for the dual usage of an NPI primary identifierwith a TIN (REF02 using an ‘EI’ qualifier) and/or a SSN(REF02 using an ‘SY’ qualifier in their respectivesecondary identifier REF segments for the followingprovider loops:• 2010AA Billing Provider• 2010AB Pay-To Provider• 2310B Rendering Provider• 2420A Rendering ProviderHHHusmannNicole Stephens_________________________________________________________________________________________________________________________Revised: February 14, 2008 HIPAA X12 837p (004010X098A1) Version 7 40