Claims adjudication and payment

The Following picture demonstrates how insurance company processing the claims received from the clearing house. 

You can also download the PDF Version of the above picture here.

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EDI 5010 Documentation 837 Professional - Loop 2400 Service Line

2400 Service Line

 

        

2400 Service Line LX
We need to repeat this loop for each line item in the claim

 

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2400	LX	Service Line	ID	2		R	LX
		Element Separator	AN	1			*
	LX01	Assigned Number	N0	1/6	554	R	Print Service Line Number
		Segment Terminator					~

 

2400 Professional Service SV

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2400	SV1	Professional Service	ID	3		R	SV1
		Element Separator	AN	1			*
	SV101-1	Product/Service ID Qualifier	ID	2	235	R	HC
		Component Element Separator		1			:
	SV101-2	Product/Service ID	AN	1/48	234	R	Print the Procedure Code
		Component Element Separator		1			:
	SV101-3	Procedure Modifier	AN	2	1339	S	Modifier 1
		Component Element Separator		1			:
	SV101-4	Procedure Modifier	AN	2	1339	S	Modifier 2
		Component Element Separator		1			:
	SV101-5	Procedure Modifier	AN	2	1339	S	Modifier 3
		Component Element Separator		1			:
	SV101-6	Procedure Modifier	AN	2	1339	S	Modifier 4
		Element Separator	AN	1			*
	SV102	Monetary Amount	R	1/18	782	R	Line Item Charge Amount
		Element Separator	AN	1			*
	SV103	Unit	ID	2	335	R	Unit (UN or MJ)
		Element Separator	AN	1			*
	SV104	Quantity	R	1/15	380	R	Service Unit Count
		Element Separator	AN	1			*
	SV105	Facility Code Value	AN	1/2	1331	R	Place of Service Code
		Element Separator	AN	1			*
	SV106	Service Type Code	ID	1/2	1365	Not Used
		Element Separator	AN	1			*
	SV107-1	Diagnosis Code Pointer	N0	1/2	1328	S	first diagnosis code pointer
		Component Element Separator		1			:
	SV107-2	Diagnosis Code Pointer	N0	1/2	1328	S	Second diagnosis code pointer
		Component Element Separator		1			:
	SV107-3	Diagnosis Code Pointer	N0	1/2	1328	S	Third diagnosis code pointer
		Component Element Separator		1			:
	SV107-4	Diagnosis Code Pointer	N0	1/2	1328	S	Fourth diagnosis code pointer
		Element Separator	AN	1			*
	SV108	Monetary Amount	R	1/18	782	Not Used
		Element Separator	AN	1			*
	SV109	Yes/No : Emergency Indicator	ID	1	1073	S	Y or N
		Element Separator	AN	1			*
	SV110	Multiple Procedure Code	ID	1/2	1340	Not Used
		Element Separator	AN	1			*
	SV111	Yes/No : EPSDT Indicator	ID	1	1073	S	Y or N
		Element Separator	AN	1			*
	SV112	Yes/No : Family Planning Indicator	ID	1	1073	S	Y or N
		Element Separator	AN	1			*
	SV113	Review Code	ID	1/2	1364	Not Used
		Element Separator	AN	1			*
	SV114	National or Local Assigned Review Value	AN	1/2	1341	Not Used
		Element Separator	AN	1			*
	SV115	Copay Status Code	ID	1/1	1327	Not Used
		Element Separator	AN	1			*
		Segment Terminator					~

2400 Service Date – DTP

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2400	DTP	Service Date	ID	3		R	DTP
		Element Separator	AN	1			*
	DTP01	Date/Time Qualifier	ID	3	374	R	472
		Element Separator	AN	1			*
	DTP02	Date time Period Format Qualifier	ID	2/3	1250	R	D8 or RD8
		Element Separator	AN	1			*
	DTP03	Date time Period	ID	1/35	1251	R	CCYYMMDD or CCYYMMDD-CCYYMMDD
		Segment Terminator					~

2400 Line Item Control Number

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2400	REF	Line Item Control Number	ID	3		R	REF
		Element Separator	AN	1			*
	REF01	Control Number	ID	2/3	128	R	6R
		Element Separator	AN	1			*
	REF02	Line Item Control Number	AN	1/50	127	R	Line Item control Number
		Segment Terminator					~

Example

LX*1~
SV1*HC:99214*60*UN*1*11**1~
DTP*472*RD8*20120921-20120921~
REF*6R*1134~

 

Example 2:

Claim Setup

Field	Value
Claim No	252
Claim Location	NY Office
Place of Service	11 - Office
Rendering Provider	David Mark
ICD Code	410,415, 368.34, 522.3

Line items

Procedure Code	Mod1	Mod2	Mod3	Mod4	ICD	FromDOS	ToDOS	Units	Unit Charges
99214					1,2,3,4	01/09/2012	01/09/2012	1	40
92570					1	01/09/2012	01/09/2012	1	180.04
90371					3,4	01/09/2012	01/09/2012	1	83

LX*1~
SV1*HC:99214*40*UN*1*11**1:2:3:4~
DTP*472*RD8*20120109-20120109~
REF*6R*1140~
LX*2~SV1*HC:92570*180.04*UN*1*11**1~
DTP*472*RD8*20120109-20120109~
REF*6R*1141~
LX*3~
SV1*HC:90371*83*UN*1*11**3:4~
DTP*472*RD8*20120109-20120109~
REF*6R*1142~

 

 

 

        

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