EDI 5010 Documentation 837 Professional - Loop 2300 Claim Information

        

2300 Claim information

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2300	CLM	Claim information	ID	3		R	CLM
		Element Separator	AN	1			*
	CLM01	Claim Submitter Identifier	AN	1/38	1028	R	Unique Claim Number
		Element Separator	AN	1			*
	CLM02	Monetary Amount	R	1/18	782	R	Total Charges
		Element Separator	AN	1			*
	CLM03	Claim Filling Indicator				Not Used
		Element Separator	AN	1			*
	CLM04	Non Institutional Claim Type				Not Used
		Element Separator	AN	1			*
	CLM05-1	Facility Code Value	AN	1/2	1331	R	Place of Service Code
		Component Element Separator					:
	CLM05-2	Facility Code Qualifier	ID	1/2		R	B
		Component Element Separator					:
	CLM05-3	Claim Frequency Type Code	ID	1	1325	R	1 = Original 2 = Replacement 8 = Void
		Element Separator	AN	1			*
	CLM06	Yes/No Provider Signature on File	ID	1	1073	R	Y
		Element Separator	AN	1			*
	CLM07	Provider Accept Assignment Code	ID	1	1359	R	A = Assigned B = Assignment Accepted on Clinical Lab Services Only C = Not Assigned
		Element Separator	AN	1			*
	CLM08	Yes/No Assignments of Benefit	ID	1	1073	R	Y
		Element Separator	AN	1			*
	CLM09	Yes/No Release of Information	ID	1	1363	R	Y
		Element Separator	AN	1			*
	CLM10	Patient signature source code	ID	1	1351	S	P
		Element Separator	AN	1			*

Examples:

CLM*249*60***11:B:1*Y*A*Y*Y

CLM*250*38***11:B:1*Y*A*Y*Y

********************************************************************************

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

CLM*252*303.04***11:B:1*Y*A*Y*Y~

By Loop

2300 - Claim Information	CLM	CLM*252*303.04***11:B:1*Y*A*Y*Y~
2300 - Claim Information - Clia Number	REF	REF*X4*CL324234~
2300 - Claim Information - ICDs	HI	HI*BK:410*BF:415*BF:36834*BF:5223~
2310B - Rendering Provider Name	NM1	NM1*82*1*Mark*David****XX*1111111111~
2310D - Service Facility Location	NM1	NM1*77*2*NY Office*****XX*1336177328~
2310D - Service Facility Location	N3	N3*5081 Tellus. Avenue*668-2204 Non Rd.~
2310D - Service Facility Location	N4	N4*White Plains*NY*809051232~
2310D - Service Facility Location	REF	REF*LU*484345~
2400 - Service Line	LX	LX*1~
2400 - Service Line	SV1	SV1*HC:99214*40*UN*1*11**1:2:3:4~
2400 - Service Line	DTP	DTP*472*RD8*20120109-20120109~
2400 - Service Line	REF	REF*6R*1140~
2400 - Service Line	LX	LX*2~
2400 - Service Line	SV1	SV1*HC:92570*180.04*UN*1*11**1~
2400 - Service Line	DTP	DTP*472*RD8*20120109-20120109~
2400 - Service Line	REF	REF*6R*1141~
2400 - Service Line	LX	LX*3~
2400 - Service Line	SV1	SV1*HC:90371*83*UN*1*11**3:4~
2400 - Service Line	DTP	DTP*472*RD8*20120109-20120109~
2400 - Service Line	REF	REF*6R*1142~

        

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