ANSI 837 Mapping Document Legend
| Focus: | To show Diamond requirements and how they relate to the ANSI 837 structure. |
| Results: | Documented actual physical location of Diamond fields in ANSI 837 format. Used DISA Tutorial and EDI Mapping Document and File Mapping Specifications from ANSI to Diamond document. |
| Columns: | Loop, Position, Segment ID, Sequence Name, Req. Des., Format and Length from EDI Implementation Guide, Sections 3, 4 and 5. Value -- ANSI and Diamond Requirements Notes - indicates field mapping specific to Diamond |
| Legend: |
Req. Des. Required Destination)
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| HSD: 01/29197 12:54 PM | ANSIMPLG.D0C | Page l of 1 |
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Sample ANSI 837 ASCII
File
Professional Claims (OPCLM)
File Name: provx.edi
ST*837*TRAINING
BGN*00*REF0001*961112***GEORGIACLM
REF*BQ*clm_edi_example
NM1*41*2*Bryant
PRV*BI*FW*JBRYANT
NM1*87*2*James*Bryant
SBR*P
NM1*QC*1*Gregory*Gordon****C1*ACM334568975
PAT*O1
DMG*D8*19560419*M
NM1*QC*1*Gordon*Gregory
CLM*PatNo22*105.00*HM*MD*B*11
DTP*150*D8*19961215
REF*ZZ*JBRYANT
LX*01
SV1*CJ<99201*78.OO*UN*1*11
LX*02
SV1*CJ<99213*55.25*VS*1*B*1
LX*03
SV1*CJ<00100*99.33*VS*1*B*1
SE*021*TRAINING
| HSD: 01/30/97 2:36 PM | ANSI.DOC |
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Place of Service and Bill Type Mapping
Below describes how the place of service and bill type codes are derived from the incoming EDI claims sets.
I. Professional claims - OPCLM:
If the claim is a professional claim then only the place of service can be derived: If CLM05 (the facility code qualifier) is set to "B" then the place of service is found in CLM06 (the facility code), if CLM05 is not "B" then it must be indicated in SV106, otherwise the claim will be rejected.
II. Institutional claims - INCLM:
If the claim is an institutional claim, first the place of service is calculated then the bill type code is derived:
a. place of service:
If CLM05 is "B" then the POS is found in CLM06; if CLM05 is set to "A" and if the second digit of CLM06 (the bill class) is a "1" or a "3" then the P05 is set to "21"; if CLM05 is "A" and the second digit of CLM06 is a "2" or a "4" then the P05 is set to "22"; otherwise the claim is rejected.
b. bill type code:
1. CLM05 = "A":
If CLM05 is "A" then the bill type code is concatenated from the first two digits of CLM06 (the UBC Bill Type) and the single digit CLM07 (the Claim Frequency Type Code); if a three digit code can not be created, then the claim is rejected.
2. CLM05 = "B":
If the place of service is being submitted in the claim segment, a bill type of 111 is automatically assigned (the first position is the 'type of facility', second is the 'bill classification', and third is the 'frequency'). The following POS codes are mapped differently however:
POS maps to Bill Type 1st, 2nd positions (3rd defaults to 1)
22 1,3
23 1,3
| HSD: 02/03/97 12:06 PM | Page 1 of 3 | posbtype.doc |
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Page missing.
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54 Institutional Care Mental Health
55 Substance Abuse Facility
56 Psych
81 Lab
99 Unlisted
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HSD: 02/03/97 12:06 PM | Page 3 of 3 | posbtype.doc |
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Mandatory ANSI 837 Segments
Required To Process Professional Claims
This lists the mandatory ANSI 837 segments required in a source file to enter a professional services claim in Diamond using the Claims EDI module. The segments listed are for vanilla version of the professional services claims header and detailfiles. If any fieldshave been changed from optional to required in the JUTILHMO.DAT or JUTJLDMO.DAT files, the user must include those additional requirements to this list.
Segment ID Name ST Transaction Set Header BQN Beginning Segment REF Reference Numbers NMI Individual or Organization Name PRV Provider/Vendor Information NMl Individual or Organization Name SBR Subscriber Information NM1 Individual or Organization Name PAT Patient Information DMG Demographic Information NMl Individual or Organization Name CLM Health Claim Header DTP Date / Time Period CD2 Diagnosis Code SVl Professional Service SB Transaction Set Trailer
Notes:
| HSD: 02/03/97 12:10PM | Page 1 of 1 | reqsegpr.doc |
Click here for the actual ANSI837 format matrix.
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