Health Care Claim:
Professional

Additionally, future changes may be made to this document as HIPAA Implementation Guide(s) and/or Data Dictionaries change.

• Interchange Control Header

• Functional Group Header

• Transaction Set Header

• Beginning of Hierarchical Transaction

• Transmission Type Identification

  • <1000A> Submitter Name
  • <1000A> Submitter EDI Contact Information

  • <1000B> Receiver Name

    • <2000A> Billing/Pay-To Provider Hierarchical Level

    • <2010AA> Billing Provider Name

    • <2010AA> Billing Provider Address

    • <2010AA> Billing Provider City/State/ZIP

    • <2010AA> Billing Provider Secondary Identification

    • <2010AA> Billing Provider Contact Information

      • <2000B> Subscriber Hierarchical Level

      • <2000B> Subscriber Information

      • <2010BA> Subscriber Name

      • <2010BA> Subscriber Address

      • <2010BA> Subscriber City/State/ZIP Code

      • <2010BA> Subscriber Demographic Information

      • <2010BB> Payer Name

        • <2300> Claim Level Information

        • <2300> Health Diagnosis Code

        • <2400> Service Line

        • <2400> Professional Service

        • <2400> Date - Service Date

        • <2400> Line Item Control Number

        • <2400> Line Note

• Transaction Set Trailer

• Functional Group Trailer

• Interchange Control Trailer

Item Number Notes:

1. The Interchange Sender ID (ISA06) must be the same for all AGENCY to NSMHA transactions.  The value used is 'SDS'.
   The Interchange Control Number, ISA13 [ID1], is the Batch Number and must be identical to the associated Interchange Trailer IEA02 [ID1].  NSMHA is expecting five digit leading zero sequential numbering starting at 00001 and reset when beyond 99999.
   ISA15 - Use 'T' for test data, 'P' for production data.  The ISA segment is a 105 byte fixed length record
2. Use the 3-digit RUID for the Agency.
3. ST/SE - Common ID for transaction Start/End
4. No notes for this item.
5. The Value of REF02 changes depending on whether the transaction is being piloted or in production mode.  See Implementation Guide and Addenda for details.
6. NM108 refers to ETIN as established by TPA.  Suggestion is to have the ETIN be the 2-character code for Sound Data Services in NM109
   • NM103 - Use 'Sound Data Services' as they are submitting the transaction
   • NM109 - Use 'SD'
7. PER - NSMHA wants IT Contact & Phone of person at the Sound Data Services.
8. No notes for this item.
9. No notes for this item.
10. NM1 <2010AA> Agency Name
11. Main address for the Agency who provided the services in the Claim Loop.
12. City/State/ZIP of the main address for the agency who provided the services in the claim loop.
13. No notes for this item.
14. <2010AA> Billing Provider (Agency).  Everything from the Billing Provider (Agency) down is assumed to be the Agency Pay-to Provider (Agency) Rendering Provider at Service Detail (Agency)
15. No notes for this item.
16. Use 'P' for SBR01
17. Following MHD's recommendation, NSMHA recommends using 'MI' only.  'ZZ' may have transaction problems, as there may be expectation for the universal identifier in some translators.
18. N3 <2010BA> - If client is homeless or their address is unknown, use 'Unknown' on Address1.
19. N4 <2010BA> - If client is homeless or their address is 'Unknown' in N3 <2010BA>, use either the City, State, & ZIP of service provider or client if known in N4.
20. DMG <2010BA> - Default if DOB is unknown, CCYY0101 - use January 1st for month & day and best guess for year.
21. No notes for this item.
22. CLM <2300>
    • Claim Submit Identifier is understood to be what is sent from the provider.  Per Implementation Guide, it is strongly recommended that this value be a unique number.
    • Claim Frequency Type Code
      • 1-Original = Add
      • 6-Corrected = Change
      • 7-Replacement = Change
      • 8-Void = Delete
    • Original Reference Number (ICN/DCN) - It is the intent that RSNs and MHD will not change the Claim Number.  To that end, this part of the loop is not necessary for our purposes.
    • EPSDT Referral (new segment added) - Applicable to medical physicians ordering EPSDT referrals to Mental Health.  EPSDT Services are at the <2400> level.
    • ROICode - Recommendation for providers to review pages 175-176 and consider changing business practices to attach a section 12 & 13 of HCFA 1500 related to informed consent to get informed signature as a part of the intake process.
    • Informed Consent obtained, recommended to use 'I' on CLM09 and 'B' on CLM10.
23. HI - If diagnosis not available, use either 7999 (deferred) or V7109 (unknown) - (e.g. for crisis).
24. No notes for this item.
25. Professional Service <2400>
    • SV101-3 through SV101-7 - Procedure Modifiers are not to be acted upon in the Agency to NSMHA transaction.
    • Unit or Basis for measurement code.  TPA recommendation is to use minutes.
    • Use SV111 to indicate service is a result of an EPSDT referral.  If service is a result of a referral, use 'Y'.  If service is not a result of a referral, do not populate this field.
26. Use the date for which the service was rendered.  For multi-day services (such as residential services) submit a separate claim for each date service was rendered.
27. No notes for this item.
28. Line Note - This is to capture the following elements.  Separate each element with the colon ":" character.
    • NTE02-1 Episode ID
    • NTE02-2 Episode Type
    • NTE02-3 Provider Type
    • NTE02-4 Facility Code
    • NTE02-5 Internalizing Disorder Screener Score (IDS)
    • NTE02-6 Externalizing Disorder Screener Score (EDS)
    • NTE02-7 Substance Disorder Screener Score (SDS)
    • NTE02-8 Co-Occurring Disorder Assessment Quadrant Value (AQUADVAL)
29. No notes for this item.
30. No notes for this item.
31. No notes for this item.

Only the loops specifically stated herein will be acted upon in the Agency to NSMHA transaction.