837 Health Care Claim: Institutional - Louisiana Medicaid

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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
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837 Health Care Claim: Institutional - Louisiana Medicaid

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