SYSTOC-to Professional Loop Maps for SYSTOC_EDI

Transcription

1 SYSTC-to Professional Loop aps for SYSTC_EDI

2 Contents About Professional Loop aps...3 Loop 1000A - Submitter Name...4 Loop 1000B - Receiver Identification...5 Loop 2000A - Billing / Pay-to-Provider...6 Loop 20AA - Billing Provider Name [Clinic Location]...7 Loop 2000B - Subscriber Hierarchical Level...9 Loop 20BA - Subscriber Information...10 Loop 20BB - Payer Name (Destination Payer)...12 Loop 2000C - Patient Hierarchical Level (Patient is not subscriber)...13 Loop 20CA - Patient Name...14 Loop Claim Information...16 Loop 2310A - Referring Provider Name...19 Loop 2310B - Rendering Provider Name...20 Loop 2310D - Service Facility Location (if different than Billing Provider)...22 Loop ther (Secondary) Subscriber Information...23 Loop 2330A - ther Subscriber Name...25 Loop 2330B - ther Payer Name...26 Loop Service Lines (Charge Detail)...27 Loop Drug Identification...29 Loop Line Adjudication...30 ii SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

3 About Professional Loop aps These maps are crosswalks of SYSTC and SYSTC_EDI data to the elements defined in the loops and segments of the Professional Claim structure (the electronic HCFA ). Use them in conjunction with the error list to identify missing or incorrect data in SYSTC and/or SYSTC_EDI. The columns titled,,, and refer to the 837 structure. The Location (SYSTC and SYSTC_EDI) column describes the location of the data in SYSTC and/or SYSTC_EDI. The # column identifies the location of an item on the (HCFA) Claim Form. The andatory / / ptional column indicates the information requirements based on the 837 Professional processing rules. andatory - information is required. - information is necessary based on a condition in another data element. ptional - information not required, but should be sent, if available. A document that maps the claim form boxes to the corresponding 837 loop, segment, and element can be found at the National Uniform Claim Committee (NUCC) website. The title is Claim Form ap to the X Health Care Claim: Professional If you require assistance contact SYSTC Technical Support at , option 1. About Professional Loop aps 3 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

4 Professional Loop 1000A - Submitter Name (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 41 Entity Identifier [Submitter] Defined by SYSTC_EDI 03 Clinic/Location Name SYSTC_EDI > Vendor Information > Vendor Supplied IDs > Submitter/Receiver (1000A/1000B) > Submitter Name Identification Qualifier [ETIN] Defined by SYSTC_EDI 09 Submitter ID SYSTC_EDI > Vendor Information > Vendor Supplied IDs > Submitter/Receiver (1000A/1000B) > Submitter ID PER IC Submitter Contact Information Name SYSTC_EDI > Vendor Information > Clinic Contact Person > Name 03 TE Communication Qualifier Defined by SYSTC_EDI 04 Communication SYSTC_EDI > Vendor Information > Clinic Contact Person > Phone and x Professional Loop 1000A - Submitter Name (40) 4 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

5 Professional Loop 1000B - Receiver Identification (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 41 Entity Identifier [Receiver] Defined by SYSTC_EDI 03 Receiver Name SYSTC_EDI > Vendor Information > Vendor Supplied IDs > Submitter/Receiver (1000A/1000B) > Receiver Name Identification Qualifier [ETIN] Defined by SYSTC_EDI 09 Receiver ID SYSTC_EDI > Vendor Information > Vendor Supplied IDs > Submitter/Receiver (1000A/1000B) > Receiver ID Professional Loop 1000B - Receiver Identification (40) 5 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

6 Professional Loop 2000A - Billing / Pay-to-Provider (40) Location (SYSTC and SYSTC_EDI) andatory ptional HL Hierarchical Level Defined by SYSTC_EDI PRV ZZ Billing Provider Taxonomy SYSTC_EDI > Vendor Information > Vendor Configuration > Billing Taxonomy (2000A PRV03) Professional Loop 2000A - Billing / Pay-to-Provider (40) 6 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

7 Professional Loop 20AA - Billing Provider Name [Clinic Location] (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 85 Entity Identifier [Billing Provider] Defined by SYSTC_EDI 03 Billing Provider Name SYSTC_EDI > General Configuration 33 Billing provider location set from invoice SYSTC > File aintenance > Clinic Locations > Name [invoice location] Billing provider location = corporate (blank) location SYSTC > File aintenance > Clinic Locations > Name [blank location] XX Identification Qualifier: Employer's ID Number [FEIN] National Provider ID [NPI] Defined by SYSTC_EDI Use NPI if available; otherwise user FEIN Billing Provider ID [FEIN or NPI] SYSTC > File aintenance > Clinic Locations > [for location defined in N1] FEIN [24] or NPI [xx] 25 N3, N4 Billing Provider Address SYSTC_EDI > Professional Configuration tab 33 Billing provider address = primary remit location SYSTC > File aintenance > Clinic Locations > Edit Remit Address > [Primary Remit Address] Billing provider address = corporate (blank) location SYSTC > File aintenance > Clinic Locations > [for location defined in N1] REF EI Billing Provider Secondary Identification: Federal Employer's ID Number [FEIN if not used as primary ID in N1 SYSTC > File aintenance > Clinic Locations > [for location defined in N1] > FEIN [24] C (N1) REF Secondary Identification Used when Provider ID = XREF. Be sure XREF provider has Affiliations record with appropriate Benefit rg, Plan and Location IDs from SYSTC > File aintenance > edical Staff Reference Qualifier SYSTC > File aintenance > edical Staff > Affiliations [for XREF Staff ID] > Provider Num Professional Loop 20AA - Billing Provider Name [Clinic Location] (40) 7 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

8 Location (SYSTC and SYSTC_EDI) andatory ptional Additional Identifier SYSTC > File aintenance > edical Staff > Affiliations [for XREF Staff ID] > Group Num 33b REF G5 Alternate ID Qualifier (G5 is the default) SYSTC_EDI > Vendor Information > Custom 20AA REF > Alternate ID SYSTC_EDI > Vendor Information > Custom 20AA REF > Value Professional Loop 20AA - Billing Provider Name [Clinic Location] (40) 8 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

9 Professional Loop 2000B - Subscriber Hierarchical Level (40) Location (SYSTC and SYSTC_EDI) andatory ptional HL Hierarchical Level Defined by SYSTC_EDI SBR Subscriber Information S P If Resp Party = 2 All other (Primary) SYSTC > Billing Folder > Invoices > Responsible Party 6 18 Patient Relationship to Insured If Patient is the insured, otherwise blank 03 Subscriber ID SYSTC_EDI > Vendor Information > Vendor Configuration > Subscriber ID (2000B SBR03) Show Subscriber ID as Policy # SYSTC > Billing Folder > Invoices > Policy # Show Subscriber ID as Group # 11 SYSTC > Billing Folder > Invoices > Group # Show Subscriber ID as Claim # SYSTC > Billing Folder > Invoices > Claim # Show Subscriber ID as Patient SSN SYSTC > Billing Folder > Invoices > SSN Show Subscriber ID as Patient ID SYSTC > Billing Folder > Invoices > Patient ID 09 Claim Filing Indicator : (SYSTC Insurance Type) SYSTC > File aintenance > Benefit rganizations > Plans > Insurance Type WC B C CH F VA CI * ZZ Work Comp (see right) edicare Part B () edicaid (D) Champus (C) ther Federal (F) ChampVA (V) Comm. Insurance (G) ther () * (see right) utually def./ unk. (blank) When SYSTC > When SYSTC > Injury Folder > Injuries > WorkComp/Non WC = WorkComp, WC is sent > WorkComp/Non WC = WorkComp, WC is sent When Insurance Type =, the code in the SYSTC > File aintenance > Benefit rganizations > Plans > Plan Type is sent. PAT 05 D8 SYSTC > Patient Folder > Patient Summary > Date Death Professional Loop 2000B - Subscriber Hierarchical Level (40) 9 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

10 Professional Loop 20BA - Subscriber Information (40) Note: Either the patient or alt subscriber information is sent in this loop. Location (SYSTC and SYSTC_EDI) andatory ptional N1 IL Entity Identifier [Insured or Subscriber] Defined by SYSTC_EDI 03, 04 Subscriber Name SYSTC_EDI > Vendor Information > Vendor Configuration > Subscriber Type (Company Accounts) 4 03 () 04 () Patient Name [1] Show Patient as subscriber SYSTC > Patient Folder > Patient Summary Company Name [2] Show Company as subscriber from SYSTC: SYSTC > Company Folder > Companies 08 I Identification Qualifier Defined by SYSTC_EDI C 09 Subscriber ID SYSTC > Vendor Information > Vendor Configuration > Subscriber/Patient ID (20BA/CA N109)(Subscriber/Patient ID) C (Use Patient ID (WC)/Policy # unless vendor requires different value) Patient ID (WC)/Policy # (Non-WC) WC: SYSTC > Billing Folder > Invoices > Patient ID Non-WC: SYSTC > Billing Folder > Invoices > Policy Patient SSN (WC)/Policy # (Non-WC) WC: SYSTC > Billing Folder > Invoices > Patient SSN Non-WC: SYSTC > Billing Folder > Invoices > Policy Claim # (WC)/Policy # (Non-WC) WC: SYSTC > Injury Folder > Injuries > Claim # Non-WC: SYSTC > Billing Folder > Invoices > Policy Invoice Policy # SYSTC > Billing Folder > Invoices > Policy Injury Claim # Professional Loop 20BA - Subscriber Information (40) 10 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

11 Location (SYSTC and SYSTC_EDI) andatory ptional SYSTC > Injury Folder > Injuries > Claim # Patient ID SYSTC > Billing Folder > Invoices > Patient ID SSN SYSTC > Patient Folder > Patient Summary > SSN N3, N4 Subscriber Address SYSTC > Patient Folder > Patient Summary > Address 5 Patient [1] or Company [2] Company Folder > Accounts DG Patient DB SYSTC > Patient Folder > Patient Summary > Birth Date 3 or 11a 03 Gender SYSTC > Patient Folder > Patient Summary > Gender 3 or 11a REF IG Invoice Policy Number SYSTC > Billing Folder > Invoices > Policy *This segment only appears whe the Policy # is not used in N109. Y4 Injury Claim Number SYSTC > Injury Folder > Injuries > Claim # * This segment only appears when the Claim # is not used in N109. SY Patient Social Security Number SYSTC > Patient Folder > Patient Summary > SSN * This segment only appears when the SSN is not used in N109 and when the Insurance Type is not () edicare. Professional Loop 20BA - Subscriber Information (40) 11 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

12 Professional Loop 20BB - Payer Name (Destination Payer) (20) Location (SYSTC and SYSTC_EDI) andatory ptional N1 PR Entity Identifier [Payer] Defined by SYSTC_EDI 03, 04 Payer Name SYSTC > File aintenance > Benefit rganizations > Plans > Billing Address: Name 03, 04, 08 PL Identification Qualifier [Payer ID] Defined by SYSTC_EDI 09 Payer ID SYSTC > File aintenance > Benefit rganizations > Plans [for Payer in N1] > Payer ID # N3, N4 Payer Address SYSTC > File aintenance > Benefit rganizations > Plans [for Payer in N1] > Billing Address: Address REF FY Secondary Identifier Qualifier SYSTC > File aintenance > Benefit rganizations > Plans [for Payer in N1] > FEIN, (Type FY followed by a space and then no more than nine digits in the FEIN field.) Professional Loop 20BB - Payer Name (Destination Payer) (20) 12 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

13 Professional Loop 2000C - Patient Hierarchical Level (Patient is not subscriber) (40) Location (SYSTC and SYSTC_EDI) andatory ptional HL Hierarchical Level Defined by SYSTC_EDI PAT -G8 Patient's Relationship to Insured Patient Accounts: SYSTC > Patient Folder > Patient Summary SYSTC > > Accounts (button) > Insurance 1 or 2 > Relation Company Accounts: Always defaults to 20 6 Professional Loop 2000C - Patient Hierarchical Level (Patient is not subscriber) (40) 13 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

14 Professional Loop 20CA - Patient Name (40) Note: This Loop sends the information only when there is an Insurance Alternate Subscriber. Location (SYSTC and SYSTC_EDI) andatory ptional N1 QC Entity Identifier Defined by SYSTC_EDI 03, 04 Patient Name SYSTC > Patient Folder > Patient Summary 2 08 I Identification Qualifier Defined by SYSTC_EDI C 09 Patient ID SYSTC > Vendor Information > Vendor Configuration > Subscriber/Patient ID (20BA/CA N109) C (Use Patient ID (WC)/Policy # unless vendor requires different value) Patient ID (WC)/Policy # (Non-WC) WC: SYSTC > Billing Folder > Invoices > Patient ID Non-WC: SYSTC > Billing Folder > Invoices > Policy Patient SSN (WC)/Policy # (Non-WC) WC: SYSTC > Billing Folder > Invoices > Patient SSN Non-WC: SYSTC > Billing Folder > Invoices > Policy Claim # (WC)/Policy # (Non-WC) WC: SYSTC > Injury Folder > Injuries > Claim # Non-WC: SYSTC > Billing Folder > Invoices > Policy Invoice Policy # SYSTC > Billing Folder > Invoices > Policy Injury Claim # SYSTC > Injury Folder > Injuries > Claim # Patient ID SYSTC > Billing Folder > Invoices > Patient ID N3, N4 Patient Address SYSTC > Patient Folder > Patient Summary 5 DG Patient DB SYSTC > Patient Folder > Patient Summary > Birth Date 3 or 11a 03 Gender SYSTC > Patient Folder > Patient Summary > Gender 3 or 11a Professional Loop 20CA - Patient Name (40) 14 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

15 Location (SYSTC and SYSTC_EDI) andatory ptional REF IG Invoice Policy Number *This segment only appears when the Policy # is not used in N109. SYSTC > Patient Folder > Patient Summary Patient Folder > Patient Summary > Policy Y4 Injury Claim Number SYSTC > Injury Folder > Injuries > Claim # * This segment only appears when the Claim # is not used in N109. SY Patient Social Security Number SYSTC > Patient Folder > Patient Summary > SSN * This segment only appears when the SSN is not used in N109 and when the Insurance Type is not () edicare. Professional Loop 20CA - Patient Name (40) 15 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

16 Professional Loop Claim Information (40) Location (SYSTC and SYSTC_EDI) andatory ptional CL Health Claim Patient Account Number [Invoice Number] SYSTC > Billing Folder > Invoices [Inv#] Total Claim Charge Amount SYSTC_EDI > General Configuration > Include invoice adjustments in claim amounts (Loops 2300, 2400) 28 Invoice Total Charges (from Line Items) SYSTC > Billing Folder > Invoices > Charges (Line Item) Invoice Total Charges and Adjustments SYSTC > Billing Folder > Invoices > Charges + Adjustments (Line Item) Place of Service SYSTC_EDI > Professional Configuration tab > Always replace PS code 11 with code 20 (Loops 2300, 2400) 24B or SYSTC > Billing Folder > Invoices > Charge Detail (Line Item HCFA) > HCFA Loc 05-3 Claim Frequency Type SYSTC (version 7.25+) > Billing Folder > Invoices > Claim Frequency Note: SYSTC v7.24 and below used a claim frequency of Y Provider Signature on File Specified in SYSTC_EDI Y 07 A or C Provider Accept Assignment SYSTC > Billing Folder > Invoices > HCFA > Accept Assignment N or Y Assignment of Benefits SYSTC > Billing Folder > Invoices > HCFA > Accept Assignment N or Y Release of Information SYSTC > Injury Folder > Injuries > Info Rel B or blank Patient Signature Source SYSTC > Injury Folder > Injuries > Info Rel Related Causes Work Related Cause 10 E Employment related SYSTC > Injury Folder > Injuries > Work Comp Work Related or Non-Work Related AA Cause or Auto/ther Accident A related SYSTC > Injury Folder > Injuries > Work Comp or Non Work Comp (and Professional Loop Claim Information (40) 16 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

17 Location (SYSTC and SYSTC_EDI) andatory ptional when Auto/ther contains A or from SYSTC > Injury Folder > State Form > Accident Information) 11-4 State in which the Auto Accident occurred SYSTC > Injury Folder > State Form > Accident Information > State DTP Dates 096 Discharge Date (Hospital) SYSTC > Billing Folder > Invoices > HCFA > Discharge Date Latest Visit or Consultation SYSTC > Billing Folder > Invoices > HCFA > Local Use (edicare) 297 Date Last Worked SYSTC > Injury Folder > State Form > Preinjury Date Last Worked 431 nset of Current Illness SYSTC > Injury Folder > Injuries > Injury Date Admission Date (Hospital) SYSTC > Billing Folder > Invoices > HCFA > Hospital Admission Date Date of Accident SYSTC > Injury Folder > Injuries > Injury Date (only whenauto/ther contains A or from Injury Folder > State Form > Accident Information) C 454 Initial Treatment Date SYSTC > Billing Folder > Invoices > Charge Detail (Line Item HCFA) > Treatment ID Initial Treatment Date is required when chiropractic services begin for one of these CPT codes: 98940, 98941, 98942, or C, AT F5 onetary Amount Defined by SYSTC_EDI. Prints when the receipt or adjustment has a payment type = Patient or is not associated with a payer ID. REF F8 Claim riginal Reference SYSTC > Billing Folder > Invoices > HCFA > riginal Ref # (edicare only) G1 Prior Authorization Number SYSTC > Billing Folder > Invoices > Charge Detail (Line Item HCFA) > Authorization X4 CLIA Number SYSTC > Billing Folder > Invoices > HCFA > utside Lab (edicare) 9F Referring Provider* Certification SYSTC > File aintenance > edical Staff > Comment (*for Provider in 2310A, N1 DN) (Type 9F followed by a space and then no more than 30 characters in the Comment field.) HI Healthcare Diagnosis (ICD9) 21 BK Primary Diagnosis ICD9 SYSTC > Billing Folder > Invoices > HCFA > ICD9-1 BF Additional Diagnosis ICDs SYSTC > Billing Folder > Invoices > HCFA > ICD9 2-4 PWK Claim Supplemental Info SYSTC_EDI > Vendor Information > Vendor Configuration > Include PWK (these Professional Loop Claim Information (40) 17 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

18 Location (SYSTC and SYSTC_EDI) andatory ptional codes included only if Include PWK is Always or nly for WC) Z Support Data for Claim Defined by SYSTC_EDI Professional Loop Claim Information (40) 18 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

19 Professional Loop 2310A - Referring Provider Name (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 DN Entity Identifier [Referring Provider] Defined by SYSTC_EDI 03, 04 Referring Provider Name SYSTC_EDI > Professional Configuration tab > Referring Provider (2310A) 17 Ref/ther staff on invoice SYSTC > Billing Folder > Invoices > HCFA > Referring/ther Staff Primary on injury SYSTC > Injury Folder > Injuries > Primary Phys Referring on injury SYSTC > Injury Folder > Injuries > Referred By 08 XX Identification Qualifier Assigned by SYSTC_EDI C 09 Referring Provider ID National Provider ID (NPI) SYSTC > File aintenance > edical Staff [for provider in N1] > NPI 17b NPI C REF 1D edicaid Provider Number SYSTC > File aintenance > edical Staff edicaid [for provider in N1] when the plan on the invoice in SYSTC > File aintenance > Benefit rganizations > Plans > Insurance Type = D (edicaid) 1G Provider UPIN Number SYSTC > File aintenance > edical Staff [for provider in N1] > UPIN 17a UPIN EI Employer's Identification SYSTC > File aintenance > edical Staff [for provider in N1] > FEIN 17a FEIN Professional Loop 2310A - Referring Provider Name (40) 19 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

20 Professional Loop 2310B - Rendering Provider Name (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 82 Entity Identifier [Rendering Provider] Defined by SYSTC_EDI 03, 04 Rendering Provider Name SYSTC_EDI > Professional Configuration tab > Rendering Provider (2310B) Billing provider on invoice header SYSTC > Billing Folder > Invoices > HCFA > Billing Provider Staff on invoice item SYSTC > Billing Folder > Invoices > Charge Detail > Staff ID Primary on injury SYSTC > Injury Folder > Injuries > Primary Phys 08 XX 24 Identification Qualifier National Provider ID (NPI) Defined by SYSTC_EDI Use NPI if available; otherwise use FEIN Employer's ID Number (FEIN) 09 Rendering Provider ID [NPI or FEIN] SYSTC > File aintenance > edical Staff [for provider in N1] > NPI [XX] or FEIN [24] 24J PRV ZZ Rendering Provider Taxonomy SYSTC > File aintenance > edical Staff [for provider in N1] > Specialty (SYSTC 7.26 and prior) or Taxonomy (SYSTC 7.27 and later) REF Secondary Identification 24I 0B State License Number SYSTC > File aintenance > edical Staff [for provider in N1] > Registration 1A Blue Cross Provider Number SYSTC > File aintenance > Benefit rganizations > Plans [for Plan ID in File aintenance > edical Staff > Affiliations] [for provider in N1] Plan Name must contain the words Blue Cross 1B Blue Shield Provider Number SYSTC > File aintenance > Benefit rganizations > Plans [for Plan ID in File aintenance > edical Staff > Affiliations] [for provider in N1] Plan Name must contain the words Blue Shield or BCBS Professional Loop 2310B - Rendering Provider Name (40) 20 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

21 Location (SYSTC and SYSTC_EDI) andatory ptional 1C edicare Provider Number SYSTC > File aintenance > edical Staff [for provider in N1] when the plan on the invoice in SYSTC > File aintenance > Benefit rganizations > Plans > Insurance Type = (edicare) 1D edicaid Provider Number SYSTC > File aintenance > edical Staff [for provider in N1] when the plan on the invoice in SYSTC > File aintenance > Benefit rganizations > Plans > Insurance Type = D (edicaid) 1H CHAPUS ID Number SYSTC > File aintenance > Benefit rganizations > Plans > Insurance Type = C (Champus) [for Plan ID in File aintenance > edical Staff > Affiliations] [for provider in N1] G2 Provider Commercial Number Defaults if none of the previous REF codes apply REF Provider Number SYSTC > File aintenance > edical Staff > Affiliations [for provider in N1] > Provider Number Professional Loop 2310B - Rendering Provider Name (40) 21 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

22 Professional Loop 2310D - Service Facility Location (if different than Billing Provider) (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 77 Entity Identifier [Service Location] If HCFA Loc = 11 (office), 20 (urgent care), or a space Defined by SYSTC_EDI. SYSTC > File aintenance > Setup Billing > Fees HCFA Loc (Place of Service) 32 FA Any other HCFA Loc. 03 Service Location Name SYSTC > File aintenance > Clinic Locations (invoice location) > Name 08 XX Identification Qualifier National Provider ID (NPI) Defined by SYSTC_EDI 09 Service Location ID (NPI) SYSTC > File aintenance > Clinic Locations (invoice location) > NPI 32a N3, N4 Service Address SYSTC > File aintenance > Clinic Locations (invoice location) > Address Professional Loop 2310D - Service Facility Location (if different than Billing Provider) (40) 22 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

23 Professional Loop ther (Secondary) Subscriber Information (40) Location (SYSTC and SYSTC_EDI) andatory ptional SBR P Relationship SYSTC_EDI > Professional Configuration tab > Always include secondary subscriber and payer info (not just for edicare) 6 Included when the above field in SYSTC_EDI is checked or the Insurance Type (in SYSTC) is edicare. For Patient Accounts SYSTC > Patient Folder > Patient Summary > Insurance Information > Relation For Company Accounts SYSTC > Company Folder > Accounts > Relation 03 Policy Group SYSTC_EDI > Vendor Information > Vendor Configuration > Subscriber ID (2000B SBR03) Show Patient as subscriber 9a SYSTC > Billing Folder > Invoices > Policy Show Company as subscriber: SYSTC > Billing Folder > Invoices > Group CAS C CR A PI PR Claim Adjustment Group SYSTC > Billing Folder > Receipts/Adjustments > EB fields EB in SYSTC are defined in SYSTC File aintenance > Setup Billing > EB s. EB s must be constructed as follows: [Group ][Reason ] For example, an EB code like: C1 represents the group code C (Contractual bligation) and the reason code 1 (Deductible Amount). You may find it helpful to enter an abbreviated description of both the group and reason codes in the field. Valid Group s are: C Contractual bligation, CR Correction and Reversal, A ther Adjustment, PI Payer Initiated Reduction, PR Patient Responsibility. For a complete list of Claim Adjustment Reason s, visit the Washington Publishing Company website: Professional Loop ther (Secondary) Subscriber Information (40) 23 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

24 Location (SYSTC and SYSTC_EDI) andatory ptional Note: A separate CAS segment is generated for each Group. The system will handle a maximum of six reason codes for each group code. Claim Adjustment Reason See explanation above (CAS ) for defining EB code descriptions. 03 onetary Amount SYSTC > Billing Folder > Receipts/Adjustments > Line Items AT D Amount Qualifier Defined by SYSTC_EDI Payer Paid Amount onetary Amount Defined by SYSTC_EDI AT F2 Amount Qualifier Defined by SYSTC_EDI Remaining Patient Liability onetary Amount Defined by SYSTC_EDI 05 onetary Amount Defined by SYSTC_EDI. Prints when the receipt or adjustment has a payment type = Patient. C DG ther Insured DB SYSTC > Patient Folder > Patient Summary > Birth Date[for secondary subscriber] 9b (*) *if value exists, it must be transmitted 03 Gender SYSTC > Patient Folder > Patient Summary > Gender[for secondary subscriber] 9b (*) I 06 ther Insurance Release of Information SYSTC > Injury Folder > Injuries > Info Rel 12, 13 Professional Loop ther (Secondary) Subscriber Information (40) 24 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

25 Professional Loop 2330A - ther Subscriber Name (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 IL Entity Identifier [Insured or Subscriber] Defined by SYSTC_EDI 03 Subscriber Name SYSTC_EDI > Vendor Information > Vendor Configuration > Subscriber Type (Company Accounts) Patient Last Name [1] Company Name [2] Show Patient as subscriber SYSTC > Patient Folder > Patient Summary Show Company as subscriber SYSTC > Company Folder > Companies 04 Subscriber Name SYSTC_EDI > Vendor Information > Vendor Configuration > Subscriber Type (Company Accounts) Patient First Name Show Patient as subscriber SYSTC > Patient Folder > Patient Summary 08 I Identification Qualifier Assigned by SYSTC_EDI 09 Subscriber ID SYSTC_EDI > Vendor Information > Vendor Configuration > Subscriber/Patient ID (20BA/CA N109) (Use Invoice Resp Party unless vendor requires different value) Invoice Resp Party WC: SYSTC > Billing Folder > Invoices > Patient ID Non-WC: SYSTC > Billing Folder > Invoices > Policy Invoice Policy # SYSTC > Billing Folder > Invoices > Policy Injury Claim # SYSTC > Injury Folder > Injuries > Claim # Patient ID SYSTC > Billing Folder > Invoices > Patient ID N3, N4 ther Subscriber Address SYSTC > Patient Folder > Patient Summary [for secondary subscriber] > Address lines Professional Loop 2330A - ther Subscriber Name (40) 25 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

26 Professional Loop 2330B - ther Payer Name (40) Location (SYSTC and SYSTC_EDI) andatory ptional N1 PR Entity Identifier [Payer] Defined by SYSTC_EDI 03, 04 Payer Name SYSTC > File aintenance > Benefit rganizations > Plans > Billing Address: Name PI Identification Qualifier [Payer ID] Assigned by SYSTC_EDI 09 Payer ID SYSTC > File aintenance > Benefit rganizations > Plans > Payer ID Professional Loop 2330B - ther Payer Name (40) 26 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

27 Professional Loop Service Lines (Charge Detail) (40) Location (SYSTC and SYSTC_EDI) andatory ptional LX Service Line counter SV1 Procedure SYSTC > Billing Folder > Invoices > Charge Detail [Line Item] > Fee 24D 1 HC Assigned by SYSTC_EDI 2 Service Detail ID Fee Alt code or Drug Fee code overrides if Alt Type = ND in SYSTC_EDI > Professional Configuration tab > Drug (ND) Fee Settings > Service Detail ID (2400 SV1-2) Use Fee Comment 1 SYSTC > File aintenance > Setup Billing > Fees [for the invoice Line Item] > Comment line 1 Use Fee Alt SYSTC > File aintenance > Setup Billing > Fees [for the invoice Line Item] > Alt Use Fee SYSTC > File aintenance > Setup Billing > Fees [for the invoice Line Item] > Fee Use Drug/ed Default SYSTC_EDI > Professional Configuration tab > Drug (ND) Fee Settings > Drug/ed Default 3-5 Fee odifiers 1-3 SYSTC > Billing Folder > Invoices > Charge Detail [Line Item] > Fee odifier 1, 2, or 3 Line Charges SYSTC_EDI > General Configuration > Include invoice adjustments in claim amounts (Loops 2300, 2400) 24F Invoice Total Charges (Line Items) SYSTC > Billing Folder > Invoices > Charges (Line Item) Invoice Total Charges and Adjustments SYSTC > Billing Folder > Invoices > Charges + Adjustments (Line Item) 03 Unit type, defaults to UN SYSTC > File aintenance > Setup Billing > Fees > Unit Type 04 Units of Service SYSTC > Billing Folder > Invoices > Charge Detail [Line Item] > Quantity 24G Note: When billing secondary payers, the number of units billed to the payer may not be the same as the charge quantity. For example, Professional Loop Service Lines (Charge Detail) (40) 27 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

28 Location (SYSTC and SYSTC_EDI) andatory ptional the initial charge may have a quantity of 3, but the first payer only payed for 2. The secondary payer will be billed for a quantity of Place of Service SYSTC_EDI > Professional Configuration tab > Always replace PS code 11 with code 20 (Loops 2300, 2400) 24 B otherwise SYSTC > Billing Folder > Invoices > Charge Detail [Line Item] > HCFA Loc Diagnosis 1st 2nd SYSTC > Billing Folder > Invoices > Charge Detail [Line Item] > ICD9-1, ICD9-2 24E ICD9-1 () ICD9-2 () 09 Emergency Indicator Defaults to blank 24 C DTP Service Date Range SYSTC > Billing Folder > Invoices > Charge Detail [Line Item] > SYSTC > Service Begin and End Dates NTE ADD Note/Additional Information/Special Instruction SYSTC > File aintenance > Setup Billing > Fees > when SYSTC_EDI > Vendor Information > Vendor Configuration > Include Fee (2400 NTE) is checked. Professional Loop Service Lines (Charge Detail) (40) 28 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

29 Professional Loop Drug Identification (40) Location (SYSTC and SYSTC_EDI) andatory ptional LIN Drug (ND) Fee Settings Drug Fee code overrides if *Alt Type = ND and SYSTC_EDI > Professional Configuration tab > Drug (ND) Fee Settings > Drug Item ID (2410 LIN03) C* Use Fee Alt as NDC SYSTC > File aintenance > Setup Billing > Fees [for the invoice Line Item] > Alt Use Fee Comment 1 as NDC SYSTC > File aintenance > Setup Billing > Fees [for the invoice Line Item] > Comment line 1 Use Fee Comment 2 as NDC SYSTC > File aintenance > Setup Billing > Fees [for the invoice Line Item] > Comment line 2 Professional Loop Drug Identification (40) 29 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )

30 837 Professional Loop Line Adjudication Information (40) Location (SYSTC and SYSTC_EDI) andatory ptional SVD 1 Identification Defined by SYSTC_EDI. Uses the ID of the ther Payer (Loop 2330B N109) of the current onetary Amount Defined by SYSTC_EDI 3 Composite ed Procedure ID Defined by SYSTC_EDI. Uses the same codes as on the original 837 (Loop 2400 SV1 ). 5 Quantity Defined by SYSTC_EDI. Uses the same quantity as on the original 837 receipt line item for the charge (Loop 2400 SV1 04). CAS 1 C, CR, A, PI, PR Claim Adjustment Group See Professional Loop ther (Secondary) Subscriber Information (40) on page 23 for details. DTP Date/Time Qualifier Defined by SYSTC_EDI Remittance Date 2 D8 Date/Time Format Qualifier Defined by SYSTC_EDI 3 Adjudication or Payment Date Defined by SYSTC_EDI. Uses the date of the receipt record. 837 Professional Loop Line Adjudication Information (40) 30 SYSTC-to Professional Loop aps for SYSTC_EDI v3.1 (Rev )