837 Health Care Claim: Institutional - Louisiana Medicaid

837 Health Care Claim:InstitutionalHIPAA/V5010X223A2/837: Health Care Claim Institutional, Louisiana MedicaidVersion: 1.2Created: 10/25/2011Revised: 6/30/14The purpose of this guide is to clarify the usage of the X12 V5010X223A2 837Institutional HIPAA Implementation Guide for electronic submitters participating inthe LA Medicaid program.This guide is applicable to the following LA Medicaid claim types (file extensions):UB9 – Inpatient and Outpatient ServicesHOM – Home Health ServicesThis guide does not replace the published HIPAA Implementation Guide, nor doesit change the meaning of the published guide. Submitters must use this formatmandated by HIPAA as of January 01, 2012.If unfamiliar with how to read an implementation guide, refer to the final release ofX12 V5010X223A2 837 Institutional HIPAA Implementation Guide available throughWashington Publishing Company (WPC) at www.wpc-edi.com.Policy Statement:Each claim undergoes the editing common to all claims, e.g., verification of datesand balancing. Each claim is also edited for requirements that are unique to eachclaim type. All claims, whether submitted via paper or electronic, must complywith the policies and requirements as documented in the claim type specificprovider billing manuals and training packets that are distributed by Molina.Note: All data must be formatted in upper case.

Document Title837 Health Care Claim: Institutional Companion GuideAuthorTechnical Communications Group, Molina Medicaid Solutions LMMIS QARevision HistoryDate Description of Change LIFT By10/25/2011 Creation of Document 672903/12/12 Changes to CAS segment notes on pages 15 and 20.Changes to NTE Segment note on page 10.Creation of Change Log.6729 T Tate03/12/13 Change to the field size in CLM01 T. Tate4/10/13 Added HI Segment for Value Code with notes. T. Tate4/30/13 Note on quantity in CTP Segment added. T. Tate5/31/13 Update of CLM02 in CLM-Claim Information. T. Tate6/7/13 Update of CLM Segments. T. Tate9/9/2013 Update to CLM05 Segment 9086 T. Tate11/26/13 Update to CLM05 Segment 9257 T. Tate4/8/14 Updated HI Principle Diagnosis LA Medicaid note: LouisianaMedicaid does not accept or use the following qualifiers:BJ or ABJ – Admitting Diagnosis (removed)PR or APR – Patient’s Reason for VisitBN or ABN – External Cause of Injury3/20/14 Changed Principal Diagnosis HI01-01 Code List QualifierCode LA Medicaid note: For service/discharge dates before10/1/2014, use BK. For service/discharge dates on or after10/1/2014, use ABK.3/20/14 Changed Principal Diagnosis HI01-02 Description LA Medicaidnote: Use ICD-9 codes for service/discharge dates before10/1/2014. Use ICD-10 codes for service/discharge dates onor after 10/1/2014.4/8/14 Changed HI Other Diagnosis Information LA Medicaid note:Louisiana Medicaid does not accept or use the following qualifiers:BJ or ABJ – Admitting Diagnosis (removed)PR or APR – Patient’s Reason for VisitBN or ABN – External Cause of Injury3/20/14 Changed Other Diagnosis Information HI01-01 Code ListQualifier Code LA Medicaid note: For service/dischargedates before 10/1/2014, use BF. For service/discharge dateson or after 10/1/2014, use ABF.3/20/14 Changed Other Diagnosis Information HI01-02 Description LAMedicaid note: Use ICD-9 codes for service/discharge datesbefore 10/1/2014. Use ICD-10 codes for service/dischargedates on or after 10/1/2014.9278 R. Fillmore9278 R. Fillmore9278 R. Fillmore9278 R. Fillmore9278 R. Fillmore9278 R. Fillmore3/20/14 Changed document version to 1.2 9278 R. Fillmore6/30/14 Removed REF Referral Number Segment; changed effective None T. Tatedate for use of ICD 10 diagnosis codes in HI Segments.

06/30/2014 Health Care Claim: Institutional - 837ISAInterchange Control HeaderPos: Max: 1Not Defined - MandatoryLoop: N/A Elements: 16User Option (Usage): RequiredElement Summary:RefISA01IdI01Element NameAuthorization Information QualifierLA Medicaid: Use 00 for this elementISA02 I02 Authorization InformationLA Medicaid: Must be spacesISA03 I03 Security Information QualifierLA Medicaid: Use 00 for this elementISA04 I04 Security InformationLA Medicaid: Must be spacesISA05 I05 Interchange ID QualifierLA Medicaid: Use the value ZZ for this element.ReqMTypeIDMin/Max2/2M AN 10/10M ID 2/2M AN 10/10M ID 2/2ISA06 I06 Interchange Sender ID M AN 15/15LA Medicaid: Use the 7 digit Molina assigned submitter ID (i.e.450XXXX) followed by spacesISA07 I05 Interchange ID Qualifier M ID 2/2ISA08I07LA Medicaid: Use the value ZZ for this element.Interchange Receiver ID M AN 15/15LA Medicaid: Use the value LA-DHH-MEDICAID for thiselementISA09 I08 Interchange DateLA Medicaid: The date format is YYMMDDM DT 6/6ISA10 I09 Interchange TimeM TM 4/4LA Medicaid: The time format is HHMMISA11 I10 Repetition SeparatorM 1/1LA Medicaid: Use the value ^ for this element – ASCII x5EISA12 I11 Interchange Control Version NumberM ID 5/5LA Medicaid: Use the value 00501 for this elementISA13 I12 Interchange Control NumberM N0 9/9LA Medicaid: Must be a positive unsigned number and identicalto the interchange trailer IEA02. Must be unique for everytransmission submitted.ISA14 I13 Acknowledgment RequestedM ID 1/1LA Medicaid: Use the value 0 or 1 for this elementISA15 I14 Usage IndicatorM ID 1/1LA Medicaid: T= Test DataP=Production DataISA16 I15 Component Element Separator M 1/1LA Medicaid: Must be a colon : -ASCII x3A2

06/30/2014 Health Care Claim: Institutional - 837GSFunctional Group HeaderPos: Max: 1Not Defined - MandatoryLoop: N/A Elements: 8User Option (Usage): RequiredElement Summary:RefGS01Id479Element NameFunctional Identifier CodeReqMTypeIDMin/Max2/2LA Medicaid: Use the value HC for this element.GS02 142 Application Sender’s Code M AN 2/15LA Medicaid: Must be identical to the value in ISA06GS03 124 Application Receiver’s Code M AN 2/15LA Medicaid: Use LA-DHH-MEDICAID for this elementGS04 373 Date M DT 8/8LA Medicaid: The date format is CCYYMMDDGS05 337 Time M TM 4/8LA Medicaid: The time format is HHMMGS06 28 Group Control Number M N0 1/9LA Medicaid: Assigned and maintained by the sender.GS07 455 Responsible Agency Code M ID ½LA Medicaid: Use the value X for this elementGS08 480 Version / Release / Industry Identifier Code M AN 1/12LA Medicaid: Use the value 005010X223A2 for this elementSTTransaction Set HeaderPos: 0050 Max: 1Heading - MandatoryLoop: N/A Elements: 3User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxST03 1705 Implementation Convention ReferenceLA Medicaid: Use the value 005010X223A2 for this elementO AN 1/35NM1Submitter NamePos: 0200 Max: 1Heading - OptionalLoop: 1000A Elements: 9User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxNM109 67 Identification CodeLA Medicaid: Use the 7 digit submitter ID (i.e. 450XXXX)assigned by Louisiana MedicaidX AN 2/803

06/30/2014 Health Care Claim: Institutional - 837NM1Receiver NamePos: 0200 Max: 1Heading - OptionalLoop: 1000B Elements: 5User Option (Usage): RequiredElement Summary:RefNM103Id1035Element NameName Last or Organization NameReqXTypeANMin/Max1/60LA Medicaid: Use the value LOUISIANA MEDICAIDMedicaid for this elementNM109 67 Identification Code X AN 2/80LA Medicaid: Use the value LA-DHH-MEDICAID for thiselementPRVUser Option (Usage): SituationalElement Summary:Billing Provider SpecialtyInformationPos: 0030 Max: 1Detail - OptionalLoop: 2000A Elements: 3RefPRV01Id1221Element NameProvider CodeReqMTypeIDMin/Max1/3LA Medicaid: Use the qualifier BI for this elementPRV02 128 Reference Identification Qualifier X ID 2/3LA Medicaid: Use the qualifier PXC for this element.Note: Qualifier changed from ZZ in 4010 transaction.PRV03 127 Reference Identification X AN 1/50LA Medicaid: Enter the Taxonomy Code associated with theNPI of the Billing Provider.This segment is required by Medicaid ONLY when Taxonomy isneeded for unique identification of the Medicaid Provider ID.In certain situations, a provider may have a single NPI that isassociated with multiple Louisiana Medicaid Provider numbers.To distinguish which Medicaid Provider number is beingreferenced, a “ Tie-Breaker” such as Taxonomy Code mustbesubmitted the same Taxonomy to assure the Code proper that cross was registered reference. for You themust Billing useProvider in the Louisiana Medicaid NPI Registration applicationfor the associated Medicaid Provider number.4

06/30/2014 Health Care Claim: Institutional - 837NM1Billing Provider NamePos: 0150 Max: 1Detail - OptionalLoop: 2010AA Elements: 8User Option (Usage): RequiredElement Summary:RefNM108Id66Element NameIdentification Code QualifierReqXTypeIDMin/Max1/2NM109 67LA Medicaid: Use the qualifier XX for this element whenreporting an NPI.Identification Code X AN 2/80LA Medicaid: This loop is for NPI only. Enter the NPIregistered with Louisiana Medicaid that corresponds to theLouisiana Medicaid Provider being reported in this Loop.If an atypical provider who has registered an NPI with LouisianaMedicaid, you should report the NPI in this Loop.If an atypical provider has not registered an NPI with LouisianaMedicaid, you should not use this Loop, you should report thelegacy Louisiana Medicaid Provider number in 2010BB REF02with qualifier G2.N4User Option (Usage): RequiredElement Summary:RefN403Id116Billing Provider City, State,ZIP CodeElement NamePostal CodeLA Medicaid: Enter the 9-digit Zip Code. If a Zip code wasregistered with the NPI registration due to the need for uniqueidentification of the Medicaid Provider ID, then the Zip codemust match.In certain situations, a provider may have a single NPI that isassociated with multiple Louisiana Medicaid Provider numbers.To distinguish which Medicaid Provider number is beingreferenced, a “ Tie-Breaker” such as ZIP Code must besubmitted to assure the proper cross reference. Use the sameZIP Code that was registered for the Billing Provider in theLouisiana Medicaid NPI Registration application for theassociated Medicaid Provider Number.Pos: 0300 Max: 1Detail - OptionalLoop: 2010AA Elements: 5ReqOTypeIDMin/Max3/155

06/30/2014 Health Care Claim: Institutional - 837HLUser Option (Usage): RequiredElement Summary:Subscriber HierarchicalLevelPos: 0010 Max: 1Detail - MandatoryLoop: 2000B Elements: 4RefHL04Id736Element NameHierarchical Child CodeReqOTypeIDMin/Max1/1LA Medicaid: Use the value 0 for this element.For Medicaid purposes, the subscriber will always equal thepatient. Therefore, an additional subordinate HL segment willnot be required.SBRSubscriber InformationPos: 0050 Max: 1Detail - OptionalLoop: 2000B Elements: 6User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxSBR09 1032 Claim Filing Indicator Code O ID 1/2LA Medicaid: Use the value MC for this elementNM1Subscriber NamePos: 0150 Max: 1Detail - OptionalLoop: 2010BA Elements: 8User Option (Usage): RequiredElement Summary:RefNM102Id1065Element NameEntity Type QualifierReqMTypeIDMin/Max1/1NM108 66NM109 67LA Medicaid: Use the value 1 for this elementIdentification Code Qualifier X ID 1/2LA Medicaid: Use the value MI for this elementIdentification Code X AN 2/80LA Medicaid: Use the thirteen digit Medicaid Recipient IDnumber for this element6

06/30/2014 Health Care Claim: Institutional - 837NM1Payer NamePos: 0150 Max: 1Detail - OptionalLoop: 2010BB Elements: 5User Option (Usage): RequiredElement Summary:RefNM108Id66Element NameIdentification Code QualifierReqXTypeIDMin/Max1/2LA Medicaid: Use the value PI for this element.NM109 67 Identification Code X AN 2/80LA Medicaid: Use the value LA-DHH-MEDICAID for thiselement.REFUser Option (Usage): SituationalElement Summary:Billing Provider SecondaryIdentificationPos: 0350 Max: 2Detail - OptionalLoop: 2010BB Elements: 2Pos: 1300 Max: 1Detail - OptionalLoop: 2300 Elements: 11RefREF01Id128REF02 127Element NameReference Identification QualifierReqMTypeIDMin/Max2/3LA Medicaid: Use the value G2 for this elementReference Identification X AN 1/50LA Medicaid: This Loop is only for legacy Louisiana MedicaidProvider numbers (7 numeric positions) and is only used foratypical providers that do not have an NPI registered withLouisiana Medicaid. If an atypical provider has a registeredNPI, they should use Loop 2010AA NM109 to submit theirNPI.CLMUser Option (Usage): RequiredElement Summary:Claim InformationPos: 1300 Max: 1Detail – OptionalLoop: 2300 Elements: 2RefCLM01Id1028Element NameClaim Submitter's IdentifierLA Medicaid: Use a unique number up to 20 characters.CLM02 782 Monetary AmountLA Medicaid: Monetary Amount must be less than one million dollarsCLM05 C023 Health Care Service Location Information O C O CCLM05-01 1331 Facility Code Qualifier (Facility Type Code) M AN 1/2LA Medicaid: The following bill type codes are the only ones that areacceptable for Louisiana Medicaid Inpatient, Outpatient or Home HealthClaim and Bayou Health Program (claims and/or encounters). Use of anyother bill type codes will result in your billing file being rejected. Refer tothe appropriate Program Provider Billing Manual for which codes to use forspecific programs. For File extension 837I – UB9 (inpatient/outpatient) 11X,ReqMTypeANMin/Max1/207

06/30/2014 Health Care Claim: Institutional - 83712X, 13X, 14X, 18X, 21X, 71X, 72X,76X, 81X, 82X, 83X, 85X, 86X; 89X.For file extension 837I – HOM (Home Health) 32XCLM05-03 1325 Claim Frequency Type Code O ID 1/1LA Medicaid: Use the value 1 for an original claim, code 7 if the claim is anadjustment of a previous claim, or code 8 if a void of a previous claim.8

06/30/2014 Health Care Claim: Institutional - 837CL1Institutional Claim CodePos: 1400 Max: 1Detail - OptionalLoop: 2300 Elements: 3User Option (Usage): RequiredElement Summary:RefIdElement NameReqTypeMin/MaxCL1011315Admission Type CodeOID1/1LA Medicaid: Type of admission.CL102 1314Admission Source Code O ID 1/1LA Medicaid: Point of origin for admission.CL103 1352 Patient Status Code O ID 1/2LA Medicaid: Patient status as of statement through date.REFService AuthorizationException CodeUser Option (Usage): SituationalPos: 1800 Max: 1Detail - OptionalLoop: 2300 Elements: 2Element Summary:RefREF01Id128Element NameReference Identification QualifierLA Medicaid: Use the value 4N for this segment.ReqMTypeIDMin/Max2/3REF02 127 Reference Identification X AN 1/50LA Medicaid: Use the value 3 for this element when a Hospital isbilling for services associated with moderate to high levelemergency physician care.Moderate to high-level complexity corresponds to the level of carenoted in the definition of evaluation and management CPT codes99283, 99284 and99285.Use the value 1 if billing for services associated with low levelcomplexity which corresponds to the level of care noted in thedefinition of evaluation and management CPT codes 99281 and99282.The value in this REF02 segment corresponds to the same datathat would be placed in Form Locator 7 in the UB-04 billingdocument.9

06/30/2014 Health Care Claim: Institutional - 837REFPrior AuthorizationPos: 1800 Max: 1Detail - OptionalLoop: 2300 Elements: 2User Option (Usage): SituationalLA Medicaid:Use this segment if the service billed was prior authorized or the hospital stay was pre-certified by Louisiana Medicaid.Testing Tip: For extended Home Health or Hospice services, provide the Prior Authorization Number received andfor inpatient stays provide the Hospital Precertification Number received from Louisiana Medicaid.Element Summary:RefREF01Id128Element NameReference Identification QualifierReqMTypeIDMin/Max2/3LA Medicaid: Use the value G1 for this element.REF02 127 Reference Identification X AN 1/50LA Medicaid: For inpatient stays, use the HospitalPrecertification Number received from Louisiana Medicaid.For extended Home Health or Hospice services, use the PriorAuthorization Number received from Louisiana Medicaid.REFUser Option (Usage): SituationalPayer Claim ControlNumberPos: 1800 Max: 1Detail - OptionalLoop: 2300 Elements: 2Element Summary:RefREF01Id128Element NameReference Identification QualifierReqMTypeIDMin/Max2/3LA Medicaid: Use the value F8 for this element.REF02 127 Reference Identification X AN 1/50LA Medicaid: Use the Molina assigned claim number (ICN) forthis element. The claim number (ICN) is required when the ClaimFrequency Code in CLM05-03 is 7 or 8.10

06/30/2014 Health Care Claim: Institutional - 837NTEBilling NotePos: 1900 Max: 1Detail - OptionalLoop: 2300 Elements: 2User Option (Usage): SituationalElement Summary:RefNTE01Id363Element NameNote Reference CodeLA Medicaid: When appropriate, enter”ADD‟first occurrence of this segment.in theReqTypeIDMin/Max3/3NTE02 352 Description X AN 1/80LA Medicaid: TheMother‟ s 13-digit Recipient ID is no longerneeded by the La Medicaid Program in claims processing for the baby’sclaims; therefore use of this NTE segment is not necessary.HIValue InformationPos: Max: 2Detail - OptionalLoop: 2300 Elements: 12User Option (Usage): SituationalElement Summary:Ref Id Element Name Reg Type Min/MaxHI01 C022 Health Care Code Information MHI01-1 1270 Code List Qualifier Code M ID 1/3LA Medicaid: Use BE for this elementHI01-2 1271 Value Code M AN 1/30LA Medicaid:Use 80 for Covered DaysUse 81 for Non-Covered DaysUse 82 for Co-Insurance DayUse 83 for Lifetime Reserve DaysHI01-5 782 Value Code Amount O R 1/18LA Medicaid: Values greater than 999 are invalid11

06/30/2014 Health Care Claim: Institutional - 837HIPrincipal DiagnosisPos: 2310 Max: 1Detail - OptionalLoop: 2300 Elements: 1User Option (Usage): RequiredLA Medicaid:Louisiana Medicaid does not accept or use the following qualifiers:PR or APR – Patient’s Reason for VisitBN or ABN – External Cause of InjuryElement Summary:RefHI01HI01-01IdC0221270Element NameHealth Care Code InformationCode List Qualifier CodeReqMMTypeIDMin/MaxLA Medicaid: For service/discharge dates before 10/1/2015, useBK. For service/discharge dates on or after 10/1/2015, use ABK.HI01-02 1271 Description X AN 1/80LA Medicaid: Use ICD-9 codes for service/discharge dates before10/1/2015. Use ICD-10 codes for service/discharge dates on orafter 10/1/2015.HI01-09 1073 Yes/No Condition or Response Code X AN 1/80LA Medicaid: Use the appropriate „ Present On Admission‟(POA)indicator for this element.Valid „ Present On Admission‟N – noU – unknownW – not applicableY - yesindicators are:1/312

06/30/2014 Health Care Claim: Institutional - 837HI Other Diagnosis InformationPos: 2310 Max: 1Detail - OptionalLoop: 2300 Elements: 12User Option (Usage): SituationalLA Medicaid:Louisiana Medicaid does not accept or use the following qualifiers:PR or APR – Patient’s Reason for VisitBN or ABN – External Cause of InjuryElement Summary:RefHI01HI01-01IdC0221270Element NameHealth Care Code InformationCode List Qualifier CodeLA Medicaid: For service/discharge dates before 10/1/2015, useBF. For service/discharge dates on or after 10/1/2015, use ABF.ReqMMTypeIDMin/MaxHI01-02 1271 Description X AN 1/80LA Medicaid: Use ICD-9 codes for service/discharge datesbefore 10/1/2015. Use ICD-10 codes for service/discharge dateson or after 10/1/2015, for other condition(s) that coexist ordevelop(s) subsequently during the patient's treatment.HI01-09 1073 Yes/No Condition or Response Code X AN 1/80LA Medicaid: Use the appropriate „ Present On Admission‟(POA) indicator for this element.Valid „ Present On Admission‟ indicators are:N – noU – unknownW – not applicableY - yes1/313

06/30/2014 Health Care Claim: Institutional - 837HICondition InformationPos: 2310 Max: 2Detail - OptionalLoop: 2300 Elements: 12User Option (Usage): SituationalElement Summary:Ref Id Element Name Req Type Min/MaxHI01 C022 Health Care Code Information MHI01-01 1270 Code List Qualifier Code M ID 1/3LA Medicaid: Use BG for this elementHI01-02 1271 Industry Code X AN 1/80LA Medicaid: Use A1 for this element if the service isrendered as a result of an EPSDT referral.Use A4 for this element if the service is related to familyplanning.NM1Attending Provider NamePos: 2500 Max: 1Detail - OptionalLoop: 2310A Elements: 8User Option (Usage): OptionalLA Medicaid:If present, the attending provider identified in this Loop applies to the entire claim, unless overridden at the line level bythe presence of Loop 2420C.Element Summary:RefNM101Id98NM108 66NM109 67Element NameEntity Identifier CodeReqMTypeIDMin/Max2/3LA-Medicaid: Use the value 71 for this elementIdentification Code Qualifier X ID 1/2LA Medicaid: Use the qualifier XX for this element whenreporting an NPI.Identification Code X AN 2/80LA Medicaid: This loop is for NPI only. Enter the NPIregistered with Louisiana Medicaid that corresponds to theLouisiana Medicaid Provider being reported in this Loop.If an atypical provider who has registered an NPI with LouisianaMedicaid, you should report the NPI in this Loop.If an atypical provider has not registered an NPI with Louisiana14

06/30/2014 Health Care Claim: Institutional - 837Medicaid, you should not use this Loop, you should report thelegacy Louisiana Medicaid Provider number in 2310A REF02with qualifier G2.PRVAttending ProviderSpecialty InformationPos: 2550 Max: 1Detail - OptionalLoop: 2310A Elements: 3User Option (Usage): SituationalElement Summary:RefPRV01Id1221Element NameProvider CodeReqMTypeIDMin/Max1/3LA Medicaid: Use the qualifier AT for this elementPRV02 128 Reference Identification Qualifier X ID 2/3LA Medicaid: Use the qualifier PXC for this element.Note: Qualifier changed from ZZ in the 4010 transaction.PRV03 127 Reference Identification X AN 1/50LA Medicaid: Enter the Taxonomy Code associated with theNPI of the Attending Provider.This segment is required by Medicaid ONLY when Taxonomy isneeded for unique identification of the Medicaid Provider ID.In certain situations, a provider may have a single NPI that isassociated with multiple legacy Louisiana Medicaid Providernumbers. To distinguish which Medicaid Provider number isbeing referenced, a “ Tie-Breaker” such as Taxonomy Codemust be submitted to assure the proper cross reference. Youmust use the same Taxonomy Code that was registered for theAttending Provider in the Louisiana Medicaid NPI Registrationapplication for the associated Medicaid Provider number.REFAttending ProviderSecondary IdentificationPos: 2710 Max: 4Detail - OptionalLoop: 2310A Elements: 2User Option (Usage): SituationalElement Summary:RefREF01Id128REF02 127Element NameReference Identification QualifierReqMTypeIDMin/Max2/3LA Medicaid: Use the value G2 for this elementReference Identification X AN 1/50LA Medicaid: This Loop is only for legacy Louisiana MedicaidProvider numbers (7 numeric positions) and is only used foratypical providers that do not have an NPI registered withLouisiana Medicaid. If an atypical provider has a registeredNPI, they should use Loop 2310A NM109 to submit their NPI.15

06/30/2014 Health Care Claim: Institutional - 837NM1Referring Provider NamePos: 2500 Max: 1Detail - OptionalLoop: 2310F Elements: 9User Option (Usage): OptionalLA Medicaid:If present, the referring provider identified in this Loop applies to the entire claim, unless overridden at the line level bythe presence of Loop 2420D.Element Summary:RefNM101Id98NM108 66NM109 67Element NameEntity Identifier CodeReqMTypeIDMin/Max2/3LA-Medicaid: Use the value DN for this elementIdentification Code Qualifier X ID 1/2LA Medicaid: Use the qualifier XX for this element whenreporting an NPI.Identification Code X AN 2/80LA Medicaid: This loop is for NPI only. Enter the NPIregistered with Louisiana Medicaid that corresponds to theLouisiana Medicaid Provider being reported in this Loop.If an atypical provider who has registered an NPI with LouisianaMedicaid, you should report the NPI in this Loop.If an atypical provider has not registered an NPI with LouisianaMedicaid, you should not use this Loop, you should report thelegacy Louisiana Medicaid Provider number in 2310F REF02with qualifier G2.REFReferring ProviderSecondary IdentificationPos: 2710 Max: 3Detail - OptionalLoop: 2310F Elements: 2User Option (Usage): SituationalElement Summary:RefREF01Id128REF02 127Element NameReference Identification QualifierReqMTypeIDMin/Max2/3LA Medicaid: Use the value G2 for this elementReference Identification X AN 1/50LA Medicaid: This Loop is only for legacy Louisiana MedicaidProvider numbers (7 numeric positions) and is only used foratypical providers that do not have an NPI registered withLouisiana Medicaid. If an atypical provider has a registeredNPI, they should use Loop 2310F NM109 to submit their NPI.16

06/30/2014 Health Care Claim: Institutional - 837SBROther SubscriberInformationPos: 2900 Max: 1Detail - OptionalLoop: 2320 Elements: 6User Option (Usage): SituationalElement Summary:Ref Id Element Name Req Type Min/MaxSBR09 1032 Insurance Type Code O ID 1/2LA Medicaid: Do not use MC – Medicaidfor this segment when providing informationabout another payer involved in this claim.CASClaim Level AdjustmentsPos: 2950 Max: 5Detail - OptionalLoop: 2320 Elements: 19User Option (Usage): SituationalLA Medicaid:REQUIRED: If claim has been adjudicated by payer identified in this Loop and has claim level adjustment information.Use Loop 2320 only if claim level data is provided by other payer. If claim line data is available from payer, it MUST be supplied inLoop 2430, except for inpatient claims. Louisiana Medicaid requires claim line data for adjudication if it is furnished by the payer;however, send TPL information at only the Claim level for inpatient claims.Element Summary:Ref Id Element Name Req Type Min/MaxCAS01 1033 Claim Adjustment Group Code M ID 1/2LA Medicaid: When PR is used for this element, includesegments for Deductible Amount, Coinsurance Amount, andCo-Payment Amount.NM1Other Payer NamePos: 3250 Max: 1Detail - OptionalLoop: 2330B Elements: 5User Option (Usage): RequiredElement Summary:Ref Id Element Name Req Type Min/MaxNM108 66 Identification Code Qualifier X ID 1/2LA Medicaid: Use the qualifier PI for this element.NM109 67 Identification Code X AN 2/80LA Medicaid: Enter the Carrier Code issued by LouisianaMedicaid for the payer identified in Loop 2320.17

06/30/2014 Health Care Claim: Institutional - 837This number must be identical to Loop 2430 SVD01LXService Line NumberPos: 3650 Max: 1Detail - OptionalLoop: 2400 Elements: 1User Option (Usage): RequiredElement Summary:RefLX01Id554Element NameAssigned NumberLA Medicaid: The service line number incremented by 1 for eachservice line.ReqMTypeN0Min/Max1/6Louisiana Medicaid will process and store up to 28 lines forInpatient, 99 lines for Outpatient and 13 lines for LTC, Hospice,ADHC and ICF/MR claims.This number will be the key to the provider and practicemanagement system for matching the Explanation of Benefits,Electronic Remittance Advice, or 835.DTPDate - Service DatePos: 4550 Max: 1Detail - OptionalLoop: 2400 Elements: 3User Option (Usage): RequiredElement Summary:RefDTP01Id374DTP02 1250DTP03 1251Element NameDate/Time QualifierReqMTypeIDMin/Max3/3LA Medicaid: Use the value 472 for this elementDate Time Period Format Qualifier M ID 2/3LA Medicaid: Use the value D8 for a single date of service or RD8to specify from and to dates.Date Time Period M AN 1/35LA Medicaid: Service Line Date(s) of service are required on allOutpatient, Home Health, LTC, Hospice, ADHC and ICF/MRclaims.18

06/30/2014 Health Care Claim: Institutional - 837LINLA MEDICAID:Drug IdentificationPos: 4930 Max: 1Detail - OptionalLoop: 2410 Elements: 2A federal statute mandates that providers must report National Drug Code (NDC) information for allphysician-administered drugs on LA Medicaid claims submissions. This requirement applies to both electronic andhard copy claims. Providers are required to submit NDC information for the corresponding HCPCS code forphysician-administered drugs. Claims must reflect the NDC from the label of the product administered.Louisiana Medicaid also requires DME providers to report NDC information associated with HCPCS codes on claimssubmitted for enteral therapy products. This requirement also applies to pharmacies that dispense DME supplies toMedicaid recipients.Element Summary:RefLIN02Id235Element NameProduct/Service ID QualifierReqMTypeIDMin/Max2/2LA Medicaid: Use the value N4 for this elementLIN03 234 Product/Service ID M AN 1/48User Option (Usage): SituationalLA Medicaid: Enter the National Drug Code associated with thephysician-administered drug identified as the service in Loop2400 SV202-02.19

06/30/2014 Health Care Claim: Institutional - 837CTPDrug QuantityPos: 4940 Max: 1Detail - OptionalLoop: 2410 Elements: 2User Option (Usage): RequiredLA Medicaid:Quantity, and Unit or Basis for Measurement Codes are all required for claims for drugs to process correctly.Element Summary:Ref IdCTP04 380Element NameQuantityLA Medicaid: Enter the quantity or actual units administered.The maximum quantity that can be added for Louisiana Medicaid isseven whole numbers and three decimal places.ReqXTypeRMin/Max1/15CTP05-01 355 Unit or Basis for Measurement Code M ID 2/2LA Medicaid: Enter the appropriate unit or basis of measurementcode:F2 - International UnitGR – GramME - MilligramML - MilliliterUN - UnitNM1User Option (Usage): OptionalRendering Provider NamePos: 5000 Max: 1Detail - OptionalLoop: 2420C Elements: 8LA Medicaid:If present, the rendering provider identified in this Loop applies to the linelevel, and overrides the attending provider identified at the claim level in Loop2310A.20

06/30/2014 Health Care Claim: Institutional - 837Element Summary:RefNM101Id98Element NameEntity Identifier CodeReqMTypeIDMin/Max2/3LA-Medicaid: Use the value 71 for this elementNM108 66 Identification Code Qualifier X ID 1/2NM109 67LA Medicaid: Use the qualifier XX for this element whenreporting an NPI.Identification Code X AN 2/80LA Medicaid: This loop is for NPI only. Enter the NPIregistered with Louisiana Medicaid that corresponds to theLouisiana Medicaid Provider being reported in this Loop.If an atypical provider who has registered an NPI with LouisianaMedicaid, you should report the NPI in this Loop.If an atypical provider has not registered an NPI with LouisianaMedicaid, you should not use this Loop, you should report thelegacy Louisiana Medicaid Provider number in 2420C REF02with qualifier G2.REFRendering ProviderSecondary IdentificationPos: 5250 Max: 20Detail - OptionalLoop: 2420C Elements: 3User Option (Usage): SituationalElement Summary:RefREF01Id128REF02 127Element NameReference Identification QualifierReqMTypeIDMin/Max2/3LA Medicaid: Use the value G2 for this elementReference Identification X AN 1/50LA Medicaid: This Loop is only for legacy Louisiana MedicaidProvider numbers (7 numeric positions) and is only used foratypical providers that do not have an NPI registered withLouisiana Medicaid. If an atypical provider has a registeredNPI, they should use Loop 2420C NM109 to submit their NPI.21

06/30/2014 Health Care Claim: Institutional - 837NM1Referring Provider NamePos: 5000 Max: 1Detail - OptionalLoop: 2420D Elements: 9User Option (Usage): OptionalLA Medicaid:If present, the referring provider identified in this Loop applies to the line level, and overrides the referring provideridentified at the claim level in Loop 2310F.Element Summary:RefNM101Id98Element NameEntity Identifier CodeReqMTypeIDMin/Max2/3LA-Medicaid: Use the value DN for this elementNM108 66 Identification Code Qualifier X ID 1/2LA Medicaid: Use the qualifier XX for this element whenreporting an NPI.NM109 67 Identification Code X AN 2/80LA Medicaid: This loop is for NPI only. Enter the NPIregistered with Louisiana Medicaid that corresponds to theLouisiana Medicaid Provider being reported in this Loop.If an atypical provider who has registered an NPI with LouisianaMedicaid, you should report the NPI in this Loop.If an atypical provider has not registered an NPI with LouisianaMedicaid, you should not use this Loop, you should report thelegacy Louisiana Medicaid Provider number in 2420D REF02with qualifier G2.REFReferring ProviderSecondary IdentificationPos: 5250 Max: 20Detail - OptionalLoop: 2420D Elements: 3User Option (Usage): SituationalElement Summary:RefREF01Id128REF02 127Element NameReference Identification QualifierReqMTypeIDMin/Max2/3LA Medicaid: Use the value G2 for this elementReference Identification X AN 1/50LA Medicaid: This Loop is only for legacy Louisiana MedicaidProvider numbers (7 numeric positions) and is only used foratypical providers that do not have an NPI registered withLouisiana Medicaid. If an atypical provider has a registeredNPI, they should use Loop 2310F NM109 to submit their NPI.22

06/30/2014SVDLine AdjudicationInformationPos: 5400 Max: 1Detail - OptionalLoop: 2430 Elements: 5User Option (Usage): SituationalLA Medicaid:REQUIRED:information.If claim has been adjudicated by payer identified in Loop 2330B and has line level adjustmentUse Loop 2430 only if line level data is provided by other payer. If claim line data is available from payer, it MUST besupplied in this Loop, except for Inpatient claims. Louisiana Medicaid requires claim line data for adjudication if it isfurnished by the payer; however, send TPL information at only the Claim level (2320) for Inpatient claimsElement Summary:RefSVD01Id67Element NameIdentification CodeReqMTypeANMin/Max2/80LA Medicaid: Enter Louisiana Medicaid issued Carrier Code.This number should match NM109 in Loop 2330B identifyingOther Payer.SVD02 782 Monetary Amount M R 1/18LA Medicaid: Enter amount Other Payer paid for this service line.CASLine AdjustmentPos: 5450 Max: 5Detail - OptionalLoop: 2430 Elements: 19User Option (Usage): SituationalLA Medicaid:REQUIRED: If claim has been adjudicated by payer identified in Loop 2320 and has line level adjustment information.Use Loop 2430 only if line level data is provided by other payer. If claim line data is available from payer, it MUST be supplied inLoop 2430, except for Inpatient claims. Louisiana Medicaid requires claim line data for adjudication if it is furnished by the payer;however, send TPL information at only the Claim level for inpatient claims.Element Summary:Ref Id Element Name Req Type Min/MaxCAS01 1033 Claim Adjustment Group Code M ID 1/2LA Medicaid: When PR is used for this element, includesegments for Deductible Amount, Coinsurance Amount andCo-Payment Amount23

06/30/2014 Health Care Claim: Institutional - 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 Included M N0 1/6LA Medicaid: Number of Transaction Sets includedGE02 28 Group Control Number M N0 1/9LA Medicaid: Must be identical to the value in GS06IEAInterchange 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 Groups M N0 1/5LA Medicaid: Number of included Functional GroupsIEA02 I12 Interchange Control Number M N0 9/9LA Medicaid: Must be identical to the value in ISA1324