837 Health Care Claim: Institutional - Louisiana Medicaid

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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
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837 Health Care Claim: Institutional - Louisiana Medicaid

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