Exception Options for the 4010 Format

File Options

Option	Setting
Force Rendering information	Activate this option to force the creation of the rendering provider segments on non-billing group claims.
Force Subscriber information	Activate this option to populate the subscriber demographics segments when the patient is not the insured. This option populates the DMG and address segments in the subscriber loop of the 837 file for both 837I and 837P.
Globally enable National Provider Identifier (NPI)	Activate this option to enable sending NPIs. This submitter profile option applies to any fields (provider, group, or location) that have a saved NPI in the master file. If an NPI is not in the master files, then the Tax ID becomes the default used for the rendering and group. The field for Tax ID does not populate for locations.
Create Transaction Set(s) (ST/SE) per Payer Alias instead of Payer	Activate this option to group the claims by Payer Alias. When this option is activated and the eTrans ID changes, but not the payer Alias, a break in the claim is created. When this option is not activated, claims are grouped by Payer ID.
Create QSI Dental special format (ADA Claims)	Activate this option to send this segment whenever the tooth, surface, or quadrant populate for a claim line item.
Create Transaction Set(s) (ST/SE) per Billing Provider	Activate this option to create a new ST-SE loop when you are breaking the claim by billing provider.
Break 2000A loop on Billing information only (not Rendering) OR (below)	Activate this option when you want to break the 2000A loop by billing provider only.
Break 2000A loop on FL51 change (UB92 Claims) (if above unchecked)	Activate this option to break the UB92 claims on: FL51 number change Location
Break 2000B loop on every claim	Activate this option to force a billing provider (2000B) break for every claim. When selected, this option generates a separate 2000B loop for every 837 electronic claim; if not, one 2000B generates for the same subscriber.

Begin Hierarchical Transaction [Header Loop BHT Segments]

Option	Setting
Increment reference ID counter (BHT03)*	Activate this option to increment the reference ID counter (BHT03) by one (1) each time an ST/SE segment is included in the 837. This option is not required.
Reference ID (BHT03) counter value*	Enter the value that the reference counter ID starts from. For example, if you enter the value 10 in the Setting column to the right of this option, then the first reference ID for the first ST/SE segment in the 837 is 10. The second ST/SE segment reference ID, which is incremented by one, has a reference ID of 11. This option is not required.
Reference ID (BHT03) counter max*	Enter the maximum value that the reference ID counter can increment to before resetting. For example, if the reference counter is supposed to reset after the twentieth (20th) ST/SE segment in the 837, then enter 20 in the Setting column to the right of this option. When the reference ID counter reaches 20, it resets to the value that is set up in the in the Reference ID counter value field. This option is not required.

Provider Specialty [PRV Segments]

Option	Setting
Populate Provider Specialty Information (PRV05)	Activate this option to automatically populate the PRV05 element position in the 837 file with the provider specialty. This option should only be activated when you are setting up a submitter profile for a clearinghouse that translates the 837 back to NSF format. This option is not required.

*Consult the Trading Partner Agreement/Companion Guide for instructions on filling out this option.

Contact Information [1000A Loop PER Segments]

Option	Setting
Contact EDI number [PER04/06/08]	Enter the Contact EDI number in the Setting column to the right of this option. This option is not required.

*Consult the Trading Partner Agreement/Companion Guide for instructions on filling out this option.

Subscriber Information [2000B Loop SBR Segments]

Option	Setting
Override Insurance Type Code on Medicare Secondary/Tertiary Claims	Activate this option to override the Insurance Type Code on Medicare secondary/tertiary claims. You can select one of the following options: <none> 12-Medicare Secondary w/Employer Group Health Plan 13-Medicare Secondary End-Stage Renal Disease Beneficiary 14-Medicare Secondary, No-fault Insurance including Auto is Primary 15-Medicare Secondary, Worker's Compensation 16-Medicare Secondary Public Health Service (PHS) or Other Federal Agency 41-Medicare Secondary Black Lung 42-Medicare Secondary Veteran's Administration 43-Medicare Secondary Disabled <65 with Large Group Health Plan (LGHP) 47-Medicare Secondary, Other Liability Insurance is Primary The default value is 12. If an MSP Reason is set on the Detail 2 tab of the Insurance Maintenance window, it will override the submitter profile setting.

Option

Setting

Override Insurance Type Code on Medicare Secondary/Tertiary Claims

Activate this option to override the Insurance Type Code on Medicare secondary/tertiary claims. You can select one of the following options:

<none>
12-Medicare Secondary w/Employer Group Health Plan
13-Medicare Secondary End-Stage Renal Disease Beneficiary
14-Medicare Secondary, No-fault Insurance including Auto is Primary
15-Medicare Secondary, Worker's Compensation
16-Medicare Secondary Public Health Service (PHS) or Other Federal Agency
41-Medicare Secondary Black Lung
42-Medicare Secondary Veteran's Administration
43-Medicare Secondary Disabled <65 with Large Group Health Plan (LGHP)
47-Medicare Secondary, Other Liability Insurance is Primary

The default value is 12. If an MSP Reason is set on the Detail 2 tab of the Insurance Maintenance window, it will override the submitter profile setting.

NM1 Billing/Rendering Provider Name [2010AA/2310B Loops]

Option	Setting
Populate NM103 with the Provider/Payer Name/Organization (NM103)	Activate this option to place the provider name, payer name, or the name of the organization in the NM103 segment.
Populate NM109 with the Phys Billing Id [NM109]	Activate this option to place the group ID or individual ID in the NM109 segment instead of the tax ID. This option is only used for professional claims.
Populate NM107 with the specified provider credentials (comma-separated)	Activate this option to place the specified provider credential in the NM107 segment.

Billing/Pay-To Provider (2010AA/2010AB Loops)

Option	Setting
Populate Billing address with Service Location and Pay-To with Billing Information	Activate this option to populate the Pay-To Provider loop with billing information and to populate the billing address with the service location address.
Populate Pay-To Provider with Group and Billing Provider with Rendering	Activate this option to populate the Pay-To Provider loop with the group information and to populate the billing provider with the rendering information.

Subscriber Information [2010BA Loop Segments]

Option	Setting
Patient/Subscriber Override Policy Number [NM109]	Select the applicable options: Patient's Number in 2010BA only - override patient policy numbers print in the subscriber loop (2010BA, NM109) and the patient loop will not contain a policy number Subscriber # in 2010BA/Patient's # in 2010CA - override policy numbers print in the patient loop (2010CA, NM109) and the insured's policy number prints in the subscriber loop (2010BA, NM109)
Append plan code to the end of policy number	Activate this option to append the plan code to the end of the policy number.
Populate Secondary Identification with Subscriber SSN Number (REF)	You can override this setting with the payer option Payers master file > System tab > Electronic Claims subtab> Populate subscriber secondary ID with SSN check box.

Primary Payer [2010BB Loop Segments]

Option	Setting
Location(s) using Payer Alias [NM103]	Select one of the following payer alias options for the electronic claim file: <none> 1000B, NM103, and 2010BB, NM103 (uses the payer alias from the Payer master for both the 1000B, NM103, and 2010BB, NM103) 1000B, NM103 only (uses the payer alias from the payer master for the 1000B, NM103, and uses the payer name for 2010BB, NM103) 2010BB, NM103 only (uses the payer name from the payer master for the 1000B, NM103, and uses the payer alias for 2010BB, NM103)
Populate Plan Code as REF02 (FY Qualifier)	Select this option to send a REF segment in the 2010BB loop. The plan code (payer secondary qualifier) displays in the 2010BB - REF segment, when this option is activated.

Option

Setting

Location(s) using Payer Alias [NM103]

Select one of the following payer alias options for the electronic claim file:

<none>
1000B, NM103, and 2010BB, NM103 (uses the payer alias from the Payer master for both the 1000B, NM103, and 2010BB, NM103)
1000B, NM103 only (uses the payer alias from the payer master for the 1000B, NM103, and uses the payer name for 2010BB, NM103)
2010BB, NM103 only (uses the payer name from the payer master for the 1000B, NM103, and uses the payer alias for 2010BB, NM103)

Populate Plan Code as REF02 (FY Qualifier)

Select this option to send a REF segment in the 2010BB loop. The plan code (payer secondary qualifier) displays in the 2010BB - REF segment, when this option is activated.

Claim Information [2300 Loop CLM Segments]

Option	Setting
Populate Patient Ctrl Number with Unique Claim ID Number (CLM01)	Activate this option to send the unique system-assigned Claim ID Number instead of the Patient Control (Encounter) Number in the 2300 CLM01 segment.
Suppress CLM16 Value [CLM16]	Activate this option to suppress the default value of P for CLM16 for professional claims.

Claim Date Information [2300 Loop DTP Segments]

Option	Setting
Force Similar Illness/Symptom Onset Date (DTP 438)	Activate this segment to include the onset date (DTP 438 segment), if it is available. This option populates Box 15 on the HCFA paper claim form.
Populate Discharge Hour for Institutional claims (DTP 096)	Activate this option to populate the discharge hour for Institutional claims. The default is 0800.

Claim Amounts Due (2300 Loop AMT Segments)

Option	Setting
Report Payer Estimated Amount Due (Institutional AMT02)	Activate this option to populate the 2300 level AMTC5 segment for institutional (UB) claims attached to the submitter. The AMTC5 segment indicates the estimated amount due by the payer. This option is only available for the 4010 format.

Claim Prior Authorization or Referral Number (2300 REF Segment)

Option	Setting
Use Referral Number '9F' qualifier	Activate this option to use the 9F qualifier instead of the G1qualifier for 2300 REF segment for authorizations.

Claim Note (2300 Loop NTE Segment)

Option	Setting
Report Claim Note (2300 NTE) instead of Line Item Note (2400 NTE)	Activate this option to enable the narrative to be put in the 2300 claim-level NTE segment instead of the 2400 detail-level NTE segment. If there are multiple narratives, the system concatenates them together in order.

Principal Procedure Information [2300 Loop H1 Segment]

Option	Setting
Report first non clinic rate line item as the Principal Procedure	Activate this option to report the first non clinic rate line item as the principle procedure code with a qualifier of BP.
Populate date in 2300 Principal Procedural Info (HI01-4) for ICD Diagnoses	Activate this option to generate the file with the date even if the qualifier is a BP for ICD coding.
Populate date in 2300 Principal Procedural Info (HI01-4) for CPT4 Diagnoses	Activate this option to cause the file to be generated with the date even if the qualifier is a BP for CPT4 coding.

Principal Diagnosis Information (2300 Loop HI Segment)

Option	Setting
Populate admitting diagnosis code	Select this option to populate the 2300 CLM HI segment with the PR qualifier and the first diagnosis on the charge for institutional claim.
Do not include 2300 loop, HI segment if there is not a diagnosis on the claim	If this option is enabled, NextGen In-line Edits does not show the HI segment when the diagnosis code is not present. If the option is disabled and the diagnosis code is not present, an HI segment displays without the diagnosis code.

Referring Provider [2310A Loop Segments]

Option	Setting
Populate Referring Tax ID with Provider Default Tax ID (NM109)	Activate this option to populate the default provider tax ID as the referring NM109.

Attending Physician [2310A Loop Segments]

Option	Setting
Use default ID for Attending Physician ID (NM109)	Enter a default ID number. If that field in the electronic submission file is blank, it now populates with the ID entered here.

Operating Physician (2310B Loop Segments)

Option	Setting
Populate Operating Physician Information if applicable	Activate this option to populate the Operating Physician loop (2310B) with physician information, if applicable.

Other Provider Information (institutional 2310C Loop Segments)

Option	Setting
Populate Other Provider with Referring Provider information	Activate this option to populate the other provider loop (2310c) with referring provider information that is attached to the encounter. To populate the loop correctly, the provider must have a UPIN and Default Tax ID number entered on the System tab of the Provider master file.

Purchased Service Provider Name (2310C Loop NM1 Segment)

Option	Setting
Populate Purchased Service Provider Name (NM103 & NM104)	Activate this option to populate Purchased Service 2310C, NM103 and NM104 on the electronic HCFA 1500 claim.

Service Facility Information (Institutional 2310E Loop NM1 Segment)

Option	Setting
Populate Location Tax ID (NM108 and NM109)	Activate this option to populate the Location Tax ID in the 2310E NM1 segment if the NPI is inactive or blank. The location tax ID must be set in the Location master file.

Supervising Provider Information [2310E Loop NM1 Segment]

Option	Setting
Populate Supervisor Information if applicable	Activate this option to print supervising provider information on the claim. The supervising information populates the 837 electronic file only if the rendering is a PA (or a specialty that has enable supervising billing flagged) and is credentialed. If multiple secondary reference qualifiers are set up at the practice level, the supervisor also needs to be set up. If secondary reference qualifiers are set up, the REF segment displays the appropriate qualifier and data value. Otherwise, only the NM1 segment will display.
Populate Supervising Provider when same as Rendering	Activate this option to print supervising provider information on the claim when the supervising physician is also the rendering physician. The information appears in the NM1 segment of the 2310 loop.
Populate Billing Prov with Supervising Prov if Enabled	Activate this option to populate the Billing Provider loop (2000A) with the information from the Supervising Provider loop (2310E) if the rendering physician is not fully qualified, for example, if the rendering physician is a physician assistant.

Other Subscriber Information [2320 Loop SBR Segments]

Option	Setting
Use HIPAA Relationship Code Values (SBR02)	Activate this option to update the relationship codes for Other Subscriber (SBR02) for both Professional and Institutional claims.
No Insurance Type Code for Other Subscribers [SBR05] on Institutional Claims	Activate this option to prevent the display of the insurance type in the 837 electronic file in the Insurance Type Code field in the 2320 SBR segment.

Other Subscriber Information [2320 Loop NM1 Segments]

Option	Setting
Use Override Policy Number (NM109)	Activate this option to populate the NM109 for the other subscriber with the override policy number. The plan number of the secondary insurance appears in the 2330A loop.

Other Subscriber Information [2320 Loop AMT Segments]

Option	Setting
Suppress AMT segments	Activate this option to exclude the AMT segment in the 2320 loop when submitting primary claims. This option is used when the secondary payment has been posted and the claim is being resubmitted to the primary. This option is only available for the 4010 format.
Populate claim-level approved amount AMT segment in the 2320 Loop	Activate this option to populate the claim-level approved amount AMT segment in the 2320 loop of the claim. This option is only available for the 4010 format.

Other Payer Claim Adjustments [2320 Loop CAS Segments]

Option	Setting
Populate claim-level CAS segments in the 2320 Loop	Activate this option to display adjustment information at both the claim and the detail level.

Other Payer [2330B Loop Segments]

Option	Setting
Report Medigap/COBA ID if available [NM109]	Activate this option to populate the NM109 segment in the 2330B loop with the Medigap/COBA ID instead of the NEIC/e Trans ID when the other payer is Medigap.

Professional Service Item [2400 Loop SV1 Segments]

Option	Setting
Populate Service Type Codes (SV106)*	Activate this option to set up a submitter profile for a clearinghouse that translates the 837 back to NSF format. This option is not required.
Report minutes instead of units on Anesthesia claims (SV104)	Activate this option to change the reporting of anesthesia-type service items from anesthesia units to minutes. It will change UN in SV103 to MJ. It will also change the calculation of units for anesthesia claims (base units + (# of minutes/15)) to the total number of minutes in SV104.

*Consult the Trading Partner Agreement/Companion Guide for instructions on filling out this option.

Institutional Service Item [2400 Loop SV2 Segments]

Option	Setting
Do not report the Clinic Rate SIM	Activate this option to prevent reporting of the encounter rate SIM and exclude the encounter rate charge amount from the total claim amount in the CLM segment.
Suppress HCPCS Qualifier (SV202-1) if HCPCS Code (SV202-2) is blank	Activate this option to prevent a value being placed in the 2400, SV202-1 when no value populates the SV202-2 field.

Service Item [2400 Loop SV1/SV2 Segments]

Option	Setting
Enable procedure codes up to nine characters long	Activate this option to allow 9-digit procedure codes in the 837electronic file.

Service Date [2400 Loop DTP Segments]

Option	Setting
Always send date range in DTP segment	Activate this option to print the date of service as the beginning and ending dates in the 2400 loop when no date range is specified.

DMERC CRC [2400 Loop CRC Segments]

Option	Setting
Do not populate DMERC CRC segment	Activate this option to populate the ordering provider information with the referring provider information on claims that are DME.

Anesthesia NTE (Professional 2400 Loop NTE Segment)

Option	Setting
Populate with start and stop times if narrative is blank	Activate this option to populate the NTE segment with START [start time] and STOP [stop time] when the narrative in charge entry is blank for an anesthesia SIM.

Ordering Provider [2420E Loop Segments]

Option	Setting
Populate Ordering Prov. with Referring Prov. on Professional DME Claims	Activate this option only for DME claims. This creates the Ordering Phys loop only for SIMs that are marked as DME.

Exception Options for the 4010 Format

File Options

Begin Hierarchical Transaction [Header Loop BHT Segments]

Provider Specialty [PRV Segments]

Contact Information [1000A Loop PER Segments]

Subscriber Information [2000B Loop SBR Segments]

NM1 Billing/Rendering Provider Name [2010AA/2310B Loops]

Billing/Pay-To Provider (2010AA/2010AB Loops)

Subscriber Information [2010BA Loop Segments]

Primary Payer [2010BB Loop Segments]

Claim Information [2300 Loop CLM Segments]

Claim Date Information [2300 Loop DTP Segments]

Claim Amounts Due (2300 Loop AMT Segments)

Claim Prior Authorization or Referral Number (2300 REF Segment)

Claim Note (2300 Loop NTE Segment)

Principal Procedure Information [2300 Loop H1 Segment]

Principal Diagnosis Information (2300 Loop HI Segment)

Referring Provider [2310A Loop Segments]

Attending Physician [2310A Loop Segments]

Operating Physician (2310B Loop Segments)

Other Provider Information (institutional 2310C Loop Segments)

Purchased Service Provider Name (2310C Loop NM1 Segment)

Service Facility Information (Institutional 2310E Loop NM1 Segment)

Supervising Provider Information [2310E Loop NM1 Segment]

Other Subscriber Information [2320 Loop SBR Segments]

Other Subscriber Information [2320 Loop NM1 Segments]

Other Subscriber Information [2320 Loop AMT Segments]

Other Payer Claim Adjustments [2320 Loop CAS Segments]

Other Payer [2330B Loop Segments]

Professional Service Item [2400 Loop SV1 Segments]

Institutional Service Item [2400 Loop SV2 Segments]

Service Item [2400 Loop SV1/SV2 Segments]

Service Date [2400 Loop DTP Segments]

DMERC CRC [2400 Loop CRC Segments]

Anesthesia NTE (Professional 2400 Loop NTE Segment)

Ordering Provider [2420E Loop Segments]

Recommendations

Exception Options for the 5010 Format

Exception Options for the 4010 Format

Exception Options for the 5010 Format

Claims-2 Tab

Claims-2 Tab

Creating a Claim Status Profile Library

Exception Options for the 4010 Format

File Options

Begin Hierarchical Transaction [Header Loop BHT Segments]

Provider Specialty [PRV Segments]

Contact Information [1000A Loop PER Segments]

Subscriber Information [2000B Loop SBR Segments]

NM1 Billing/Rendering Provider Name [2010AA/2310B Loops]

Billing/Pay-To Provider (2010AA/2010AB Loops)

Subscriber Information [2010BA Loop Segments]

Primary Payer [2010BB Loop Segments]

Claim Information [2300 Loop CLM Segments]

Claim Date Information [2300 Loop DTP Segments]

Claim Amounts Due (2300 Loop AMT Segments)

Claim Prior Authorization or Referral Number (2300 REF Segment)

Claim Note (2300 Loop NTE Segment)

Principal Procedure Information [2300 Loop H1 Segment]

Principal Diagnosis Information (2300 Loop HI Segment)

Referring Provider [2310A Loop Segments]

Attending Physician [2310A Loop Segments]

Operating Physician (2310B Loop Segments)

Other Provider Information (institutional 2310C Loop Segments)

Purchased Service Provider Name (2310C Loop NM1 Segment)

Service Facility Information (Institutional 2310E Loop NM1 Segment)

Supervising Provider Information [2310E Loop NM1 Segment]

Other Subscriber Information [2320 Loop SBR Segments]

Other Subscriber Information [2320 Loop NM1 Segments]

Other Subscriber Information [2320 Loop AMT Segments]

Other Payer Claim Adjustments [2320 Loop CAS Segments]

Other Payer [2330B Loop Segments]

Professional Service Item [2400 Loop SV1 Segments]

Institutional Service Item [2400 Loop SV2 Segments]

Service Item [2400 Loop SV1/SV2 Segments]

Service Date [2400 Loop DTP Segments]

DMERC CRC [2400 Loop CRC Segments]

Anesthesia NTE (Professional 2400 Loop NTE Segment)

Ordering Provider [2420E Loop Segments]

Exception Options for the 5010 Format