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Standard ANSI l Payor overrides `i 7 Header ISA 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 00 ZZ Current Date Current Time U 00401 1 StateData.TestInd StateData.ReceiverID StateData.SubmitterID : GS HC X 004010X098A1 ST 837 RAM1 BHT 0019 CH REF 87 NM1 41 2 CompanyInfo.Company.sName 46 PER IC CompanyInfo.Company.sContact CompanyInfo.Company.sPhone TE0 Submitter Name (from state data, or companyinfo) 40 HL% ID that is incremented with each loop 0 20 PRV BI StateData.TaxonomyCode2 2000A - Billing/Pay-to Provider Hierarchical Level 1000B - Receiver Name 1000A - Submitter Name 2010AA - Billing Provider Name 85 24 N33 Submitter Address1(from state data, or companyinfo)3 Submitter Address2(from state data, or companyinfo) N4/ Submitter City(from state data, or companyinfo)0 Submitter State(from state data, or companyinfo). Submitter Zip(from state data, or companyinfo) 1C4 Provider number(from companyinfo, or additional info 2010AB - Pay-to Provider Name CompanyInfo.Company.sAddress CompanyInfo.Company.sAddress2 CompanyInfo.Company.sCity CompanyInfo.Company.sState CompanyInfo.Company.sZipcode% 2000B - Subscriber Hierarchical Level ID from loop 2000A.HL01 226 0 if BillInfoMain.sInsuredRelation = SELF, otherwise 1 SBR. P if first bill, S if second bill, T otherwise 18 AdditionalInfo.sSuppGroupNum AdditionalInfo.sSuppGroupName> AdditionalInfo.sSuppInsTypeCode if first bill, otherwise blank MB PAT D8 AdditionalInfo.dtDeathDate AdditionalInfo.iPatWeight 2010BA - Subscriber Name DMG IL BillInfoMain.sInsuredLastName BillInfoMain.sInsuredFirstName BillInfoMain.sInsuredMI BillInfoMain.sInsuredSuffix MI BillPayors.sPolicyNum BillInfoMain.sInsuredAddress BillInfoMain.sInsuredAddress2 BillInfoMain.sInsuredCity BillInfoMain.sInsuredState BillInfoMain.sInsuredZip BillInfoMain.dtInsuredBirth BillInfoMain.sInsuredGender 2010BB - Payor Name PR MEDICARE PART B PI CompanyInfo.Company.sMedicareNo AdditionalInfo.sSuppClmOffNum FY 2300 - Claim Info CLM 11-1 11-2 11-3 11-4 BillInfoMain.sTripNum BillInfoMain.curTotalBill AdditionalInfo.sPlaceOfSvc 05-1 05-2 05-3 Y AdditionalInfo.sAssignment AdditionalInfo.sSuppAssignment AdditionalInfo.sReleaseInfo AdditionalInfo.sPatSignSrc Very confusing, they are based off of the fields: AdditionalInfo.sEmergency, AdditionalInfo.sAccidentInd, AdditionalInfo.sAccidentState, and AdditionalInfo.sWorkRelated DTP 439 BillInfoMain.dtServiceDate DTP (only if adm hosp) DTP (only if accident) 435 NTE ADD# AdditionalInfo.sAdditionalNarrative CR1 LB DH AdditionalInfo.sTypeOfTransport AdditionalInfo.sTransportToFor Mileage from BillItems AdditionalInfo.sReasonRoundTrip AdditionalInfo.sReasonStretcher CRC HI 01-1 01-2 02-1 02-2 03-1 03-2 04-1 04-2 06-1 06-2 07-1 07-2 08-1 08-2: This segment lists all the diagnosis codes, up to 8 total. 2310A - Refering Provider Name DN AdditionalInfo.sPhysLastName AdditionalInfo.sPhysFirstName AdditionalInfo.sPhysMiddleInit 1G AdditionalInfo.sPhysUpin! 2310D - Service Facility Location 77 Picked up location category AdditionalInfo.sFacilityID Picked up location address Picked up location city Picked up location state Picked up location zip# 2320 - Other Subscriber Information OI S BillInfoMain.dtBirthDate BillInfoMain.sGender 2330A - Other Subscriber Name 2330B - Other Payor Name AdditionalInfo.sSuppInsName AdditionalInfo.sSuppInsOrgID 2400 - Service Line LX' Sequence number of service item 1-based SV1 01-3 01-4 Procedure code Modifier1 Modifier2 Monetary Amount UN Quantity6 Y if AdditionalInfo.sEmergency is Y or blank otherwise 472 Footer SE Total number of segments GE IEA> AdditionalInfo.sMedicallyNec AdditionalInfo.sSvcAvailFirstFac> AdditionalInfo.sPhysRestraints AdditionalInfo.sVisHemorrahage8 AdditionalInfo.sUnconscShock AdditionalInfo.sEmergency > AdditionalInfo.sBedConfinedA AdditionalInfo.sMovedByStretcher) This segment is based off the fields: > AdditionalInfo.sHospAdmission AdditionalInfo.sBedConfinedB BCBS AR 2010AA Carrier Loop Segment Position Sub-position Value 9 2010AB BCBS KS 2010BB Cahaba 1000A 3 StateData.AgencyID StateData.ProvKey Empire_NY All State data button fields Highmark HGSA if PA, EMPIRE if NJ 7 27 Palmetto CompanyInfo.Company.sTaxID 00883 2310D GA DPA 0001 8 1000B Medicare (PalmettoGBA) Noridian StateData.CarrierCode StateData.TradingID AdditionalInfo.sSuppInsTypeCode AdditionalInfo.sSuppInsInd Trailblazer National Heritage 2310A NM1*DN Billing.ANSIMDC.sPhysUpin& Batch number from ANSIMDC_SUBM_NUM key V00115 Group number from payor dialog
Administar ASF 2000B 4 Group Name from payor dialog 2330B AdditionalInfo.sSuppInsNum Cigna 6 StateData.StratusID
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