Exception Options for the 5010 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.
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 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 UB 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 checked, 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.

*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

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 Provider Name

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 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

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 Name

Option	Setting
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)	Activate this option to generate a REF segment in the 2310BA loop, with ‘SY’ (Social Security number) as the qualifier. If this option is enabled, an example REF segment would be: REFSY<999999999>. 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

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 an 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 an 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

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.

Claim Date Information

Option	Setting
Populate Discharge Hour for Institutional claims (DTP 096)	Activate this option to populate the discharge hour for Institutional claims. The default is 0800.

Claim Note

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

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.

Reason for Visit Diagnosis Information

Option	Setting
Populate Reason for Visit Diagnosis	On the Diagnosis Selection window, when the admitting diagnosis code: IS populated, the first diagnosis code listed on the Diagnosis Selection window is populated in this field. IS NOT populated on the window. This field is populated with the first diagnosis code entered in Charge Entry.

Option

Setting

Populate Reason for Visit Diagnosis

On the Diagnosis Selection window, when the admitting diagnosis code:

IS populated, the first diagnosis code listed on the Diagnosis Selection window is populated in this field.
IS NOT populated on the window. This field is populated with the first diagnosis code entered in Charge Entry.

Supervising Provider Information

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.

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.

Other Payer Claim Adjustments

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

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

Institutional Service Item

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.

Service Item

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

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.

Anesthesia Line Item Note (Professional)

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

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.

Operating Provider

Option	Setting
Send Operating Provider on Institutional Claims	Enable this option to populate the 2310B NM172 Operating Provider segment on electronic 837I (UB) claims. To populate the 2310B NM172 Operating Provider segment on 837I claims for all payers, do the following: Populate the Operating Provider field in the UB sub-tab on the Payer > Practice tab AND Enable this option in the Submitter Profile To populate the 2310B NM1*72 Operating Provider segment on 837I claims for specific payers only, do the following: Populate the Operating Provider field in the UB sub-tab on the Payer > Practice tab AND Enable the Send Operating Phys check box on the SIM Library > Payer tab for specific SIM codes AND Do not enable this option in the Submitter Profile

Option

Setting

Send Operating Provider on Institutional Claims

Enable this option to populate the 2310B NM1*72 Operating Provider segment on electronic 837I (UB) claims.

To populate the 2310B NM1*72 Operating Provider segment on 837I claims for all payers, do the following:

Populate the Operating Provider field in the UB sub-tab on the Payer > Practice tab
AND
Enable this option in the Submitter Profile

To populate the 2310B NM1*72 Operating Provider segment on 837I claims for specific payers only, do the following:

Populate the Operating Provider field in the UB sub-tab on the Payer > Practice tab
AND
Enable the Send Operating Phys check box on the SIM Library > Payer tab for specific SIM codes
AND
Do not enable this option in the Submitter Profile

Exception Options for the 5010 Format

File Options

Begin Hierarchical Transaction [Header Loop BHT Segments]

Contact Information [1000A Loop PER Segments]

Subscriber Information

NM1 Billing Provider Name

Billing/Pay-To Provider

Subscriber Name

Primary Payer

Claim Information

Claim Date Information

Claim Note

Principal Procedure Information

Reason for Visit Diagnosis Information

Supervising Provider Information

Other Payer Claim Adjustments

Other Payer

Institutional Service Item

Service Item

Service Date

Anesthesia Line Item Note (Professional)

Ordering Provider

Operating Provider

Recommendations

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Exception Options for the 5010 Format

Exception Options for the 4010 Format

Creating a Claim Status Profile Library

Claim Edit Descriptions

Claim Edit Descriptions

Exception Options for the 4010 Format

Exception Options for the 5010 Format

Exception Options for the 4010 Format

Creating a Claim Status Profile Library

Claim Edit Descriptions

Claim Edit Descriptions