837 Dental LA Medicaid Companion Guide - Louisiana Medicaid

04/2009 Health Care Claim: Dental - 837GSFunctional Group HeaderPos: Max: 1Not Defined - MandatoryLoop: N/A Elements: 8User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxGS01 479 Functional Identifier CodeM ID 2/2LA Medicaid: Use the value HC for this elementGS02 142 Application Sender's CodeM AN 2/15LA Medicaid: Must be identical to the value in ISA06GS03 124 Application Receiver's CodeM AN 2/15LA Medicaid: Use LA-DHH-MEDICAID for this elementGS04 373 DateM DT 8/8LA Medicaid: Date expressed as CCYYMMDDGS05 337 TimeM TM 4/8LA Medicaid: The time format is HHMMGS06 28 Group Control NumberM N0 1/9LA Medicaid: Assigned and maintained by the senderGS07 455 Responsible Agency CodeM ID 1/2LA Medicaid: Use the value X for this elementGS08 480 Version / Release / Industry Identifier CodeLA Medicaid: Use the value 004010X097A1 for Production and004010X097D1 for TestM AN 1/12BHTBeginning of HierarchicalTransactionPos: 010 Max: 1Heading - MandatoryLoop: N/A Elements: 1User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxBHT06 640 Transaction Type CodeO ID 2/2LA Medicaid: Use the value CH for this elementNM1Submitter NamePos: 020 Max: 1Heading – OptionalLoop: 1000A Elements: 1User Option (Usage): SituationalElement Summary:Ref Id Element Name Req Type Min/MaxNM109 67 Identification CodeLA Medicaid: Use the 7 digit submitter ID (i.e. 45XXXXX) assigned byLouisiana MedicaidC AN 2/80004010X096A1-837D 3

Homework PolicyTime ScheduleKindergartenHomework is given at the discretion of the teacher. It must be signed by the parent or guardian.First GradeFifteen to twenty minutes of homework is given four times each week and must be signed by theparent or guardian. Homework should be students’ work, completed neatly, and handed in ontime.Second GradeTwenty to thirty minutes of homework is given daily, Monday through Thursday. It must besigned by a parent or guardian. Homework should be students’ work, completed neatly, andhanded in on time.School ProceduresBirthday InvitationsBirthday invitations may be distributed in class only if a boy gives invitations to all the boys, agirl gives invitations to all the girls, or if a boy or girl gives invitations to the entire class.Cellular TelephonesBoard Policy 2360 – Use of Technology includes a section on the use of electronic devices inschool. “No pupil knowingly and without the express permission of the Board, Superintendent orPrincipal or his/her designee shall use or have visible a beeper/paging device, cellular phone orelectronic device during the school day including during district provided transportation. Aviolation of this requirement is a disorderly person's offense.A person who discovers a student in violation of this policy shall report the violation to thePrincipal or designee, who shall confiscate the device. On the first offense, the device will beturned over to the parent(s) or legal guardian(s). On the second offense, additional appropriateactions shall be taken in accordance with Regulation No. 5600.”Emergency Reference Form and Information UpdatesAnnually, parents are required to complete an Emergency Information Form for each childattending school.In the event of an illness, injury, or other emergency situation, accurate and detailed informationis critical. It is essential that parents or guardians keep the school informed of changes in medicalconditions, address, telephone numbers, and employer information.Emergency DrillsEvacuation and fire drills are practiced throughout the school year. All individuals will leave theclassroom and walk in single file as a class to the assigned area outside of the building. Thebuilding must be vacated immediately. Emergency personnel, administrators, and teachers have4

04/2009 Health Care Claim: Dental - 837NM1Billing Provider NamePos: 015 Max: 1Detail – OptionalLoop:Elements: 22010AAUser Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxNM108 66 Identification Code QualifierX ID 1/2LA Medicaid: Use the qualifier XX for this elementNM109 67 Identification Code (Billing Provider Identifier)LA Medicaid: Enter the NPI registered with Louisiana Medicaid thatcorresponds to the Louisiana Medicaid Provider being reported in thisLoop.X AN 2/80If the provider is an atypical provider and has not registered an NPI withLouisiana Medicaid, continue to send either the EIN or SSN in this Loop,and continue to report the Louisiana Medicaid Provider Number in theSecondary Identification, REF Loop.For providers reporting NPI in this Loop, use the REF segment for reportingEIN or SSN.N4Billing Provider City/State/ZipCodePos: 030 Max: 1Detail – OptionalLoop:Elements: 12010AAUser Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxN403 116 Postal Code (Billing Provider Postal Zone or ZIP Code)LA Medicaid: Enter the 9-digit Zip Code. If a Zip code has been registeredwith your NPI registration due to the need for unique identification of theMedicaid Provider ID, then the Zip code must match. See note below.In certain situations, a provider may have a single NPI that is associatedwith multiple Louisiana Medicaid Provider numbers. To distinguish whichMedicaid Provider number is being referenced, a “Tie-Breaker” such as ZIPCode must be submitted to assure the proper cross reference. Use thesame ZIP Code that was registered for the Billing Provider in the LouisianaMedicaid NPI Registration application for the associated Medicaid ProviderNumber.O ID 3/15004010X096A1-837D 5

04/2009 Health Care Claim: Dental - 837REFBilling Provider SecondaryIdentification NumberPos: 035 Max: 20Detail - OptionalLoop:Elements: 22010AAUser Option (Usage): SituationalElement Summary:Ref Id Element Name Req Type Min/MaxREF01 128 Reference Identification QualifierM ID 2/3LA Medicaid: Use the value 1D for this element if an atypical provider andyou are reporting a Louisiana Medicaid Provider Number in this Loop.REF02 127 Reference IdentificationLA Medicaid: If the provider is considered an atypical provider and has notregistered an NPI with Louisiana Medicaid, you may continue to use theREF segment to submit the Louisiana Medicaid provider number.C AN 1/30If NPI is used in the NM109, EIN or SSN may be sent in this REF segment.REF segments may be repeated up to 8 times.HLSubscriber Hierarchical LevelPos: 001 Max: 1Detail - MandatoryLoop: 2000B Elements: 1User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxHL04 736 Hierarchical Child CodeLA Medicaid: Use the value 0 for this element.For Medicaid purposes, the subscriber will always equal the patient.Therefore, an additional subordinate HL segment will not be required. If apatient hierarchical level is included, the transaction will be rejected.O ID 1/1SBRSubscriber InformationPos: 005 Max: 1Detail - OptionalLoop: 2000B Elements: 1User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxSBR09 1032 Claim Filing Indicator CodeO ID 1/2LA Medicaid: Use the value MC for this element004010X096A1-837D 6

04/2009 Health Care Claim: Dental - 837CLMClaim InformationPos: 130 Max: 1Detail - OptionalLoop: 2300 Elements: 3User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxCLM01 1028 Claim Submitter's IdentifierM AN 1/38LA Medicaid: Use a unique number up to 20 charactersCLM05 C023 Health Care Service Location InformationO CompLA Medicaid: CLM05 applies to all service lines unless it is over written atthe line level.CLM05-1 1331 Facility Code ValueLA Medicaid: Use this element for codes identifying a place of servicefrom code source 237. As a courtesy, the codes are listed below; however,the code list is thought to be complete at the time of publication of thisimplementation guide. Since this list is subject to change, only codescontained in the document available from code source 237 are to besupported in this transaction and take precedence over any and all codeslisted here.M AN 1/211 Office12 Home21 Inpatient Hospital22 Outpatient Hospital31 Skilled Nursing Facility35 Adult Living Care FacilityCLM05-3 1325 Claim Frequency Type CodeLA Medicaid: Use the value 1 for an original claim, code 7 if the claim isan adjustment of a previous claim or code 8 if a void of a previous claimCLM12 1366 Special Program CodeLA Medicaid: Use the value 01 if service supports the EPSDT programO ID 1/1O ID 2/3REFOriginal Reference Number(ICN/DCN)Pos: 180 Max: 1Detail - OptionalLoop: 2300 Elements: 2User Option (Usage): SituationalElement Summary:Ref Id Element Name Req Type Min/MaxREF01 128 Reference Identification QualifierM ID 2/3LA Medicaid: Use the value F8 for this elementREF02 127 Reference IdentificationLA Medicaid: Use the Unisys claim ICN for this elementC AN 1/30004010X096A1-837D 8

04/2009 Health Care Claim: Dental - 837REFPrior Authorization or ReferralNumberPos: 180 Max: 2Detail - OptionalLoop: 2300 Elements: 2User Option (Usage): SituationalElement Summary:Ref Id Element Name Req Type Min/MaxREF01 128 Reference Identification QualifierM ID 2/3LA Medicaid: Use the value G1 for this elementREF02 127 Reference IdentificationLA Medicaid: Use the value of the Prior Authorization number assigned forthe service billedC AN 1/30NM1User Option (Usage): SituationalElement Summary:Referring Provider NamePos: 250 Max: 2Detail – OptionalLoop: 2310A Elements: 3Ref Id Element Name Req Type Min/MaxNM101 98 Entity Identifier CodeM ID 2/3LA Medicaid: Use the value DN for this element.NM108 66 Identification Code QualifierLA Medicaid: Use the qualifier XX for this element when reporting an NPI.The NPI is required as the CommunityCARE PCP referralauthorization number. This information should be supplied on thereferral from the PCP if needed.NM109 67 Identification Code (Referring Provider Identifier)LA Medicaid: Enter the NPI registered with Louisiana Medicaid thatcorresponds to the Louisiana Medicaid Provider being reported in thisLoop.X ID 1/2X AN 2/80If an atypical provider who has not registered an NPI with LouisianaMedicaid, you may continue to send either the EIN or SSN in this Loop,and continue to report the Louisiana Medicaid Provider Number in theSecondary Identification, REF Loop.004010X096A1-837D 9

04/2009 Health Care Claim: Dental - 837PRVUser Option (Usage): SituationalElement Summary:Referring Provider SpecialtyInformationPos: 255 Max: 1Detail – OptionalLoop: 2310A Elements: 3Ref Id Element Name Req Type Min/MaxPRV01 1221 Entity Identifier CodeLA Medicaid: Use the qualifier RF when reporting the referringprovider.M ID 1/3PRV02 128 Reference Identification QualifierLA Medicaid: Use the qualifier ZZ when reporting the taxonomy codeof the referring provider.PRV03 127 Reference Identification (Referring Provider Identifier)LA Medicaid: Enter the taxonomy code provided by the referringprovider. For the CommunityCARE Program, the taxonomy code isrequired if the referring provider registered a taxonomy code withhis/her NPI. This information should be supplied on the referral fromthe PCP if needed.M ID 2/3M AN 1/30REFReferring Provider SecondaryIdentificationPos: 271 Max: 5Detail – OptionalLoop: 2310A Elements: 2User Option (Usage): SituationalLA Medicaid:Element Summary:Ref Id Element Name Req Type Min/MaxREF01 128 Reference Identification QualifierLA Medicaid: Use the value 1D for this element when reporting aLouisiana Medicaid Provider Number in this Loop.M ID 2/3Use one of the other listed qualifiers as appropriate if the physician is notan enrolled Louisiana Medicaid provider.REF02 127 Reference IdentificationLA Medicaid: If the referring provider is an atypical provider who hasnot registered an NPI with Louisiana Medicaid, you may continue tosend the 7-digit Medicaid provider number in this Loop.X AN 1/30004010X096A1-837D 10

04/2009 Health Care Claim: Dental - 837NM1Rendering Provider NamePos: 250 Max: 1Detail – OptionalLoop: 2310B Elements: 2User Option (Usage): SituationalElement Summary:Ref Id Element Name Req Type Min/MaxNM108 66 Identification Code QualifierX ID 1/2LA Medicaid: Use the qualifier XX for this element.Report the Medicaid Provider ID in the REF segment.NM109 67 Identification Code (Rendering Provider Identifier)LA Medicaid: Enter the NPI registered with Louisiana Medicaid thatcorresponds to the Louisiana Medicaid Provider being reported in thisLoop. If the provider is an atypical provider and has not registered an NPIwith Louisiana Medicaid, you may continue to send either the EIN or SSNin this Loop, and continue to report the Louisiana Medicaid ProviderNumber in the Secondary Identification, REF Loop.X AN 2/80REFRendering Provider SecondaryIdentificationUser Option (Usage): SituationalLA Medicaid:Used to report the rendering or attending provider Medicaid ID Number.Element Summary:Pos: 271 Max: 5Detail – OptionalLoop: 2310B Elements: 2Ref Id Element Name Req Type Min/MaxREF01 128 Reference Identification QualifierLA Medicaid: Use the value 1D for this element if an atypical provider,and you are reporting a Louisiana Medicaid Provider Number in this Loop.M ID 2/3REF02 127 Reference IdentificationLA Medicaid: If the provider is considered an atypical provider and has notregistered an NPI with Louisiana Medicaid, you may continue to use theREF segment to submit the Louisiana Medicaid provider number.C AN 1/30SV3Dental ServicePos: 380 Max: 1Detail - OptionalLoop: 2400 Elements: 1User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxSV304 C006 Oral Cavity DesignationO CompLA Medicaid: Required to report areas of the mouth that are being treated.1361 Oral Cavity Designation CodeLA Medicaid: Enter the appropriate oral cavity code when required. Referto the LA Medicaid Dental Services Manual for the oral cavity code list andfor which services they are requiredM ID 1/3004010X096A1-837D 11

04/2009 Health Care Claim: Dental - 837GEFunctional Group TrailerPos: Max: 1Not Defined - MandatoryLoop: N/A Elements: 2User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxGE01 97 Number of Transaction Sets IncludedM N0 1/6LA Medicaid: Number of transactions sets includedGE02 28 Group Control NumberLA Medicaid: Must be identical to the value in GS06M N0 1/9IEAInterchange Control TrailerPos: Max: 1Not Defined - MandatoryLoop: N/A Elements: 2User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxIEA01 I16 Number of Included Functional GroupsM N0 1/5LA Medicaid: Number of included functional groupsIEA02 I12 Interchange Control NumberLA Medicaid: Must be identical to the value in ISA13M N0 9/9004010X096A1-837D 12