Loop 2320 - Other Subscriber Information - Electronic file submission

Loops and Segments Table - Loop 2320 - Other Subscriber Information.

Required if other payers are known to potentially be involved in paying on this claim.


Usage : Required
Element : SBR01
Value :
P=Primary
S =Secondary
T=Tertiary
Use to indicate 'payer of last resort'

Comment : Code identifying the insurance carrier's level of responsibility for payment of a claim. If claim is being sent to Medicare Part B the code would be "P" to identify primary information.


Usage : Required
Element : SBR02 
Value :
01 = Spouse
04 = Grandfather or Grandmother
05 = Grandson or Granddaughter
07 = Nephew or Niece
10 = Foster Child
15 = Ward
17 = Stepson or Stepdaughter
18 = Self
19 = Child
20 = Employee
21=Unknown
22 = Handicapped Dependent
23 = Sponsored Dependent
24 = Dependent of a Minor Dependent
29 = Significant Other
32 = Mother
33 = Father
36 = Emancipated Minor
39= Organ Donor
40 = Cadaver Donor
41 = Injured Plaintiff
43 = Child Where Insured has No Financial Responsibility
53 = Life Partner
G8 = Other Relationship

Comment : Specifies the relationship to the insured


Usage : Situational
Element : SBR03
Value : Nil
Comment : Policy or group number


Usage : Situational
Element : SBR04
Value : Nil
Comment : Name of plan.


Usage : Required
Element : SBR05
Value :
AP = Auto Insurance Policy
C1 = Commercial
CP = Medicare Conditionally Primary
GP = Group Policy
HM = Health Maintenance Organization (HM0)
IP = Individual Policy
LD = Long Term Policy
LT = Litigation
MB = Medicare Part B
MC = Medicaid
MI = Medigap Part B
MP = Medicare Primary
OT = Other
PP = Personal Payment (Cash - No Insurance)
SP = Supplemental Policy

Comment : Code to identify the type of insurance policy within a specific insurance program.



Usage : Required
Element : SBR09
Value :
09 = Selfpay
10 = Central Certification
11 = Other Non-Federal Programs
12 = Preferred Provider Organization (PPO)
13 = Point of Service (POS)
14 = Exclusive Provider Organization (EPO)
15 = Indemnity Insurance
16 = Health Maintenance Organization (HMO) Medicare Risk
AM = Automobile Medical
BL = Blue Cross/Blue Shield
CH = Champus
CI=Commercial Insurance Co
DS= Disability
HM = Health Maintenance Organization
LI = Liability
LM = Liability Medical
MB= Medicare part B
MC = Medicaid
OF = Other Federal Program
TV= Title V
VA=Veteran Administration Plan Refers To Veterans Affairs Plan
WC = Workers' Compensation Health Claim
ZZ = Mutually Defined Unknown

Comment : Code to identify the type of claim.

EMC - Loop 2320 - Coordination of Benefits (COB) Payer Paid Amount and Allowed Amount.

Loops and Segments Table - Loop 2320 - Other Subscriber Information

Coordination of Benefits (COB) Payer Paid Amount and Allowed Amount.


Usage : Required
Element : AMT01
Value : D
Comment : Code to identify the primary paid amount.


Usage : Required
Element : AMT02
Value : Nil
Comment : Total amount paid by the primary payer.


Usage : Required
Element : AMT01
Value : B6
Comment : Code to identify the primary allowed amount.


Usage : Required
Element : AMT02
Value : Nil
Comment : Total amount allowed by the primary payer.



Subscriber Demographic Information.

Usage : Required
Element : DMG01
Value : D8
Comment : Code indicating the format of the date.


Usage : Required
Element : DMG02
Value : Nil
Comment : Date of birth (CCYYMMDD).


Usage : Required
Element : DMG03
Value :
F = Female
M = Male
U= Unknown

Comment : Code indicating the sex of the individual.

Other Insurance Coverage Information

Usage : Required
Element : OI03
Value :
N = No
Y = Yes

Comment : A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.



Usage  : Situational
Element : OI04
Value :
B = Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file
C = Signed CMS Claim Form on file
M = Signed signature authorization form for CMS Claim Form block 13 on file
P = Signature generated by provider because the beneficiary was not physically present for services
S = Signed signature authorization form for CMS Claim Form block 12 on file

Comment : Indicates how the beneficiary or subscriber authorization signature was obtained and how it is being retained by the provider.


Usage : Required
Element : OI06
Value :
 A = Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization
I= Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues
M = The Provider has Limited or Restricted Ability to Release Data Related to a Claim
N= No, Provider is Not Allowed to Release Data
O = On file at Payer or at Plan Sponsor
Y = Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Comment : Code indicating if the provider has on file a signed statement by the beneficiary authorizing the release of medical data to other organizations.

EMC - Loop 2330A Other Subscriber Name and Address

Loops and Segments Table - Loop 2330A Other Subscriber Name and Address

Usage : Required
Element : NM101
Value : IL
Comment : Code identifying the insured or subscriber


Usage : Required
Element : NM102
Value :
1 = Person
2 = Nonperson Entity

Comment : Code qualifying the type of entity.


Usage : Required
Element : NM103
Value : NIL
Comment : Last Name or Organization Name


Usage : Situational
Element : NM104
Value : NIL
Comment : Subscriber first name


Usage : Situational
Element : NM105
Value : NIL
Comment : Subscriber middle.


Usage : Situational
Element : NM107
Value : NIL
Comment : Subscriber generation (suffix)


Usage : Required
Element : NM108
Value : MI = Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.
Comment : Code to indicate Member ID



Usage : Required
Element : NM109
Value : Nil
Comment : Identification Number.


Usage : Required
Element : N301
Value : Nil
Comment : Address Information (address 1)


Usage : Situational
Element : N302
Value : Nil
Comment : Address Information (address 2) required if second address exists.


Usage : Situational
Element : N401
Value : Nil
Comment : City Name Required when information is available.


Usage : Situational
Element : N402
Value : Nil
Comment : State or Province Code Required when information is available.


Usage : Situational
Element : N403
Value : Nil
Comment : Postal Code Required when information is available.


Usage : Situational
Element : N404
Value : Nil
Comment : Country Code Required if the address is out of the U.S.

Other Payer Name - Loop 2330 B

Loops and Segments Table - Loop 2330B - Other Payer Name

Usage : Required
Element : NM101
Value : PR = Payer
Comment : Code to identify an organizational entity or other payer.


Usage : Required
Element : NM102
Value : 2= Nonperson Entity
Comment : Code to identify type of entity.


Usage : Required
Element : NM103
Value : Nil
Comment : Name Last or Organization Name.


Usage : Required
Element : NM108
Value :
 PI = Payer Identification
XV = Health Care Financing Administration National Plan ID

Comment : Code to identify Payer or organization.


Usage : Required
Element : NM109
Value : Nil
Comment : Payer Identification Code.

Electronic claim loop 2400 and element CN101

Loops and Segments Table - Loop 2400 - Service Line

Contract Information

Usage : Required
Element : CN101
Value :
01 = Diagnosis Related Group (DRG)
02 = Per Diem
03 = Variable Per Diem
04 = Flat
05 = Capitated
06 = Percent
09 = Other

Comment : Code to identify the contract type.


Usage : Situational
Element : CN102
Value : Nil
Comment : The amount of the contract agreement (Obligated to Accept as Payment in Full Amount).


Approved Amount

Usage : Required
Element : AMT01
Value : AAE
Comment : Code to identify the amount approved by the primary payer.

Usage : Required
Element : AMT02
Value : Nil
Comment : Code to identify the primary payer approved amount for each service line.

LOOP 2430 IN EMC - Line Adjudication Information

Loops and Segments Table - Loop 2430 - Line Adjudication Information


Usage : Required
Element : SVD01
Value : Nil
Comment : Payer Identification Code.


Usage : Required
Element : SVD02
Value : Nil
Comment : The amount paid by the primary payer for each service line. Zero "0" is an acceptable value for this element.


Usage : Required
Element : SVD03-1
Value :
HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
IV=Home Infusion EDI Coalition (HIEC) Product/Service Code
ZZ = Mutually Defined

Comment : Code to identify the type of medical procedure.


Usage : Required
Element : SVD03-2
Value : Nil
Comment : Procedure Code

Value : Required
Element : SVD03-3
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 1


Value : Required
Element : SVD03-4
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 2

Value : Required
Element : SVD03-5
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 3.

Value : Required
Element : SVD03-6
Value : Nil
Comment : Procedure Code Modifier. Procedure Modifier 4.


Value : Required
Element : SVD05
Value : Nil
Comment : Paid units of service.

Value : Situational
Element : SVD06
Value : Nil
Comment : Assigned Number (used only for bundling of service lines).


Line Adjustment

Usage : Required
Element : CAS01
Value :
CO = Contractual Obligations
CR = Correction and Reversals
OA = Other Adjustments
PI = Payer Initiated Reductions
PR = Patient Responsibility

Comment : Code to identify the general category of payment adjustment.


Usage : Required
Element : CAS02
Value : Nile
Comment: Claim Adjustment Reason codes are located on the Explanation of Benefits.

Usage : Required
Element : CAS03
Value : Nil
Comment : Monetary Amount
Use this amount for the adjustment amount


Usage : Situational
Element : CAS04
Value : Nil
Comment : Quantity
Use as needed to show payer adjustment


Usage : Situational
Element : CAS05
Value : Nil
Comment : Claim Adjustment Reason Code
Use as needed to show payer adjustment


Usage : Situational
Element : CAS06 /CAS09 / CAS12 /  CAS15 / CAS18
Value : Nil
Comment : Monetary Amount
Use as needed to show payer adjustment


Usage : Situational
Element : CAS07 / CAS10 / CAS13/ CAS16/ CAS19
Value : Nil
Comment : Quantity
Use as needed to show payer adjustment.


Usage : Situational
Element : CAS08 /CAS11/CAS14/CAS17
Value : Nil
Comment : Claim Adjustment Reason Code
Use as needed to show payer adjustment


Line Adjudication Date

Usage : Required
Element : DTP01
Value : 573
Comment : Date/Time Qualifier.


Usage : Required
Element : DTP02
Value : D8
Comment : Date Expressed in Format CCYYMMDD

Usage : Required
Element : DTP03
Value : Nil
Comment : Date Time Period

Electronic claim submission LOOP 2300

Loops and Segments Table - Loop 2300 - Claim Information

Contract Information

Usage : Situational
Element : CN101
Value :
01 = Diagnosis Related Group (DRG)
02 = Per Diem
03 = Variable Per Diem
04 = Flat
05 = Capitated
06 = Percent
09 = Other

Comment :Code to identify a contract type.


Usage : Situational
Element : CN102
Value : Nil
Comment : The amount of the contract agreement (Obligated to Accept as Payment in Full Amount).

Claim Rejections for Invalid/Incomplete Information Submitted in the UTN Field


Palmetto GBA will reject claims when information is entered into the Prior Authorization fields (the 2300 – Claim Information Loop or 2400 Service Line Loop and the Prior Authorization reference (REF) segment, REF02 data element, and the corresponding REF01 data element field) when the information entered is not applicable to the intended use of these fields. Populating these loops and segments for other purposes is incorrect.


Applicable rejections will appear on remittance noticed with:

CARC 15 - The authorization number is missing, invalid, or does not apply to the billed services or provider



Remarks codes:

N704 - Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted;
or

N517 - Resubmit a new claim with the requested information

EMC - Loop 2000B - Element - SBR01, SBR02 and SBR 09

Loops and Segments Table

The following are instructions for the segments and elements that are required when submitting MSP information electronically. Please note that some segments and elements are situational but may become required when used.

Loop 2000B - Subscriber Information

Usage : Required
Element : SBR01
Value :
P=Primary
S =Secondary
T=Tertiary
Use to indicate 'payer of last resort'
Comment : Code identifying the insurance carrier's level of responsibility for payment of a claim. (To identify whether Medicare is primary, secondary or tertiary) For Medicare Secondary Payer (MSP) claims being sent to Medicare Part B the code would be "S".

Usage: Situational
Element : SBR02
Value : 18
Comment : Specifies the relationship to the person insured.


Usage: Situational
Element : SBR03
Value : Nil
Comment : Policy or group number


Usage: Situational
Element : SBR04
Value : Nil
Comment :The name of group plan


Usage: Situational
Element : SBR05
Value :
12 = Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13 = Medicare Secondary End-Stage Disease Beneficiary in the 12 month coordination period with an employer's group health plan
14 = Medicare Secondary, No-fault Insurance including Auto is Primary
15= Medicare Secondary Worker's Compensation
16 = Medicare Secondary Public Health Services (PHS) or Other Federal Agency
41 = Medicare Secondary Black Lung
42 = Medicare Secondary Veteran's Administration
43 = Medicare Secondary Disabled Beneficiary Under Age 65 with Large group Health Plan (LGHP)
47 = Medicare Secondary, Other Liability Insurance is Primary

Comment : Code to identify the type of insurance policy within a specific insurance program.
(Required when SBR01 = S)


Usage: Situational
Element : SBR09
Value :
09 = Selfpay
10 = Central Certification
11 = Other Non-Federal Programs
12 = Preferred Provider Organization (PPO)
13 = Point of Service (POS)
14 = Exclusive Provider Organization (EPO)
15 = Indemnity Insurance
16 = Health Maintenance Organization (HMO) Medicare Risk
AM = Automobile Medical
BL = Blue Cross/Blue Shield
CH = Champus
CI = Commercial Insurance Co.
DS= Disability
HM= Health Maintenance Organization
LI = Liability
LM = Liability Medical
MB = Medicare Part B
MC = Medicaid
OF = Other Federal Program
TV = Title V
VA = Veteran Administration Plan
WC = Workers' Compensation Health Claim
ZZ = Mutually Defined

Comment : Code to identify the type of claim.