Common Options for the 5010 Format

Prior to setting up these options, you may want to Consult the Trading Partner Agreement/Companion Guide for instructions on filling out this option. Each option with an asterisk (*) for example, Element Separator*, may apply to a trading partner.

Separators/Delimiters

Option	Setting
Component element separator*	Enter the component element separator character in the Setting column to the right of this option. The component element separator is a character used to separate multiple components that are associated to make up an element within a segment. Typically, the component element separator is a colon (:). This option is required.
Element separator*	Enter the element separator character in the Setting column to the right of this option. The element separator is a character used to separate the elements that make up a segment. Typically, the element separator is an asterisk (*). This option is required.
Segment terminator*	Enter the segment terminator character in the Setting column to the right of this option. The segment terminator is a character used to separate each segment in a control segment. Typically, the segment terminator is a tilde (~). This option is required.
Repetition separator*	Enter the repetition separator character in the Setting column to the right of this option. The repetition separator is a character used to separate repeated occurrences of a simple data element or a composite data structure. This value must be different than the element separator, component element separator, and the segment terminator. Typically, the repetition separator is a chevron (^), which is the recommended delimiter. The default setting is the ^. This option is required.

Limits

Option	Setting
Claims per submission limit*	Enter the claims per submission limit in the Setting column to the right of this option. The claims per submission limit is the maximum number of claims that can be submitted in an entire 837 electronic file. This option is required. Typically, the claims per submission limit are defined by the clearinghouse and/or direct payer. The default setting is 10,000.
CLM segment limit per transaction set*	Enter the CLM segment limit per transaction set in the setting field to the right of this option. The CLM segment limit per transaction set is the maximum number of claim/encounter (CLM) transactions that can be sent in a ST/SE Transaction Set. This option is required. Typically, the CLM segment limit per transaction set cannot exceed 5000. However, the CLM segment limit per transaction set is defined by the clearinghouse and/or direct payer. The default setting is 5000.
Number of transactions sets per file*	Enter the number of transactions sets per file in the Setting column to the right of this option. The number of transactions sets per file is the maximum number of payers who can be included in one file, which is the ISA/IEA Envelope. This option is required. Typically, the number of transactions sets per file is defined by the clearinghouse and/or direct payer. The default setting is 1000.
Number of functional groups per file*	Enter the number of functional groups per file in the setting field to the right of this option. The number of functional groups per file is the maximum number of claim types (HCFA, UB, and ADA) that can be included in one electronic file. This option is required and should always be set to 1, because only one claim form type (HCFA, UB, or ADA) can be selected on the 837 Electronic File Creation window when the 837 electronic file is created. The default setting is 1.

File Options

Option	Setting
Default file name (see below)*	Enter the default file name in the Setting column to the right of this option. This option is not required. The default file name needs to be descriptive to distinguish electronic claim files for this submitter profile from other electronic files for other submitter profiles. When electronic claims are processed for this submitter profile, the default file name entered here automatically appends to the file path in the Send Filename field on the 837 Electronic File Creation window. In addition to the default file name, dates and counters can be added to the to the file name. Refer to the field definition that follows for an explanation of valid date formats and the symbol used to include a counter. For example, if you enter the following text for the default file name (NYMedicareYYYYDDMM##), then the default file name would be NYMedicare2003160303. The system checks for invalid file name characters. Invalid file name characters are: \ / : * ? " <
Date values entered in one of the following formats will automatically be replaced with the appropriate date values: YYYYMMDD, YYYYDDMM, MMDDYYYY, DDMMYYYY, MMDDYY, DDMMYY, YYMMDD, YYDDMM A counter can be inserted with the # symbol.	This field is informational only and refers to the previous field definition Default file name (see above). When one of the valid date formats is used, a dash (-) can be used as a separator between the day, month, and year (YYYY-DD-MM). When the counter symbol (#) is included as part of the default file name, it will increment by 1 each time an electronic claim file for this submitter profile is created. The counter resets each day, unless a value greater than zero is entered in the field below, The default file name is maximum counter. Once the counter reaches the maximum counter value, the counter will reset. In addition, if multiple counter symbols are used, they will act as placeholder values for the counter and will convert to leading zeros.
Default file name max counter (Blank or zero value resets counter each day)*	Enter the default file name maximum counter in the Setting column to the right of this option. The default file name, maximum counter, is a value greater than zero, which controls when the counter set in the default file name resets. For example, if the default file name maximum counter is set at 50, then the counter in the default file name will reset after 50 electronic claim files are created for this submitter profile. The best practice is to leave this setting blank or enter a zero value to reset the counter each day. This option is not required.

Interchange Control Header [Header Loop ISA Segments]

Option	Setting
Create one ISA segment per payer	Activate this option to create a new ISA segment for each payer. It is recommended to leave this setting blank.
Authorization info qualifier ID [ISA01]*	Select one of the pre-loaded options in the drop-down list in the Setting column to the right of this option. This option is required. The recommended setting for this option is No authorization information present (00). If Additional data identification (03) is selected, the option that follows is required.
Authorization info [ISA02]*	Enter the authorization information in the Setting column to the right of this option. This option is dependent on the selection in the previous option. If Additional data identification was selected, then this option automatically becomes required.
Security info qualifier ID [ISA03]*	Select one of the pre-loaded options in the drop-down list in the Setting column to the right of this option. This option is required. The option that follows is dependent on the selection made here. The recommended setting for this option is No security information present (00).
Security info [ISA04]*	Enter the security information in the Setting column to the right of this option. This option is dependent on the selection in the previous option. If Password was selected, then this option automatically becomes required.
Interchange ID qualifier [ISA05]*	Enter the interchange ID qualifier in the Setting column to the right of this option. This option is required and is provided to you by the clearinghouse and/or direct payer.
Interchange sender ID [ISA06]*	Enter the interchange sender ID in the Setting column to the right of this option. This option is required and is provided to you by the clearinghouse and/or direct payer.
Interchange ID qualifier [ISA07]*	Enter the interchange ID qualifier in the Setting column to the right of this option. This option is required and is provided to you by the clearinghouse and/or direct payer.
Interchange receiver ID: Use elec trans ID from payer master OR [below]	Activate this option to draw information from the Payer master file to fill the ISA08 Interchange receiver ID field.
Interchange receiver ID [ONLY if line ABOVE is unchecked] [ISA08]*	Enter the interchange receiver ID in the Setting column to the right of this option. This option is required and is provided to you by the clearinghouse and/or direct payer.
Increment Interchange Counter [ISA13]	Activate this option to increment the ISA13 segment by the number of claims submitted in your 837 electronic file. This process occurs after the 837 electronic file generation and the claim request status are updated to Archive. If this option is not activated, the ISA13 segment is set to 000000001 every time the file is generated. This option has been added to the Submitter Profile Listing report as ISA13 Counter Ind.
Interchange Counter Value [ISA13]	Enter a value to set as the initial value for the ISA13 counter. The default setting is 0.
Request acknowledgment [ISA14]*	Activate this option to send a TA1 Request acknowledgment in the file (file element ISA14) and a response is transmitted back to the submitter. This option is not required.

Functional Group Header [Header Loop GS Segments]

Option	Setting
Application sender code [GS02]*	Enter your application sender code in the setting field to the right of this option. The Application sender code is a required option and is provided to you by the clearinghouse and/or direct payer.
Application receivers code: Use elec trans ID from payer master OR below	Activate this option by selecting the setting field to the right of the option. When this option is activated, the application draws information from the Payer master file to fill the GS03 Application receiver code field.
Application receivers code [ONLY if line ABOVE unchecked] [GS03]*	Enter the application receiver code in the Setting column to the right of this option. The application receiver code is a required option and is provided to you by the clearinghouse and/or direct payer.
Break claim file based on submitter ID (GS02)	Select the applicable options: Use Standard Submitter Logic (default setting) Multiple Submitters Per File/Separate GS Headers Multiple Submitters Per File/One GS Header The recommended setting for this option is to leave the field blank.

Begin Hierarchical Transaction [Header Loop BHT Segments]

Option	Setting
Transaction set purpose code (BHT02) must equal ‘00’ (Original)*	Activate this option to populate the BHT02 element position in the 837 file with 00. BHT02 defines the transmission status of the batch being transmitted in the 837 ST/SE segment. A ‘00’ setting indicates that the batch is an Original. The default value is checked.
Transaction set purpose code (BHT06) must equal ‘CH’ (Chargeable)*	Activate this option to populate the BHT02 element position in the 837 file with CH. BHT02 defines the transmission status of the batch being transmitted in the 837 ST/SE segment. A CH setting indicates that the batch is a Re-issue. Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. The default value is checked.

Option

Setting

Transaction set purpose code (BHT02) must equal ‘00’ (Original)*

Activate this option to populate the BHT02 element position in the 837 file with 00. BHT02 defines the transmission status of the batch being transmitted in the 837 ST/SE segment. A ‘00’ setting indicates that the batch is an Original. The default value is checked.

Transaction set purpose code (BHT06) must equal ‘CH’ (Chargeable)*

Activate this option to populate the BHT02 element position in the 837 file with CH. BHT02 defines the transmission status of the batch being transmitted in the 837 ST/SE segment. A CH setting indicates that the batch is a Re-issue. Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. The default value is checked.

Submitter Details [1000A Loop NM1 Segments]

Option	Setting
First name [NM104]*	Enter the first name in the Setting column to the right of this option. This option is dependent on the option selected in the Person or non-person option below. If Person is selected, then this option automatically becomes required.
Last name/Organization name [NM103]*	Enter the last name or organization name in the Setting column to the right. This option is required. If Person is selected in the Person or non-person option below, then enter the person’s last name. If Organization is selected, then enter the name of the organization.
Middle name [NM105]*	Enter the middle name of the person in the Setting column to the right of this option, if Person is selected in the Person or non-person option below. This option is not required.
Person or non-person [NM102]*	Select one of the pre-loaded options in the drop-down list in the Setting column to the right of this option. This option is required. The First name and Last name/Organization name options above are dependent on the selection made here.
Primary ID number: Use elec trans ID from payer master OR [below]	Activate this option to draw information from the Payer master file to fill the 1000A loop NM109 Primary ID number field.
Primary ID number [ONLY if line ABOVE is unchecked] [NM109]*	Enter the primary ID number in the Setting column to the right of this option. The primary ID number is provided to you by the clearinghouse and/or direct payer. This option is required.

Contact Information [1000A Loop PER Segments]

Option	Setting
Contact email [PER04/06/08]*	Enter the contact email in the Setting column to the right of this option. This option is not required.
Contact fax [PER04/06/08] (No Dashes)*	Enter the contact fax number, with no dashes, in the Setting column to the right of this option. This option is not required.
Contact name [PER02]*	Enter the contact name in the Setting column to the right of this option. This option is required.
Contact phone [PER04/06/08] (No Dashes)*	Enter the contact phone number, with no dashes, in the Setting column to the right of this option. This option is not required.
Contact phone ext [PER06/08]*	Enter the contact phone extension in the Setting column to the right of this option. This option is not required.

Service Facility

Option	Setting
Suppress service facility loop for place(s) of service [837I & 837D only]	Select the applicable option to suppress the claim-level Service Facility loop if the place of service is home, office, or outpatient. Valid options include: <none> Home [12] only Office [11] only Home [12] or Office [11] Outpatient [22] only Home [12] or Office [11] or Outpatient [22] This option can be overridden by the Suppress Facility Loop setting in the Electronic Claims sub-tab on the System tab of the Payer master file. For the 837P, the Suppress Facility option is disabled allowing the existing functionality to suppress the facility if the billing provider address is the same as the service location.

Option

Setting

Suppress service facility loop for place(s) of service [837I & 837D only]

Select the applicable option to suppress the claim-level Service Facility loop if the place of service is home, office, or outpatient. Valid options include:

<none>
Home [12] only
Office [11] only
Home [12] or Office [11]
Outpatient [22] only
Home [12] or Office [11] or Outpatient [22]

This option can be overridden by the Suppress Facility Loop setting in the Electronic Claims sub-tab on the System tab of the Payer master file. For the 837P, the Suppress Facility option is disabled allowing the existing functionality to suppress the facility if the billing provider address is the same as the service location.

Other Payer

Option	Setting
Default ID for Other Payers without eTrans IDs or NEIC numbers (NM109)*	Activate this option to insert the default NM109 value into the NM1 segment of the Other Payers for other payers that do not have eTrans IDs/NEIC numbers.

Common Options for the 5010 Format

Separators/Delimiters

Limits

File Options

Interchange Control Header [Header Loop ISA Segments]

Functional Group Header [Header Loop GS Segments]

Begin Hierarchical Transaction [Header Loop BHT Segments]

Submitter Details [1000A Loop NM1 Segments]

Contact Information [1000A Loop PER Segments]

Service Facility

Other Payer

Recommendations

Common Options for the 4010 Format

Exception Options for the 5010 Format

Common Options for the 5010 Format

Common Options for the 4010 Format

Set Up Submitter Profiles

Exception Options for the 5010 Format

Common Options for the 5010 Format

Separators/Delimiters

Limits

File Options

Interchange Control Header [Header Loop ISA Segments]

Functional Group Header [Header Loop GS Segments]

Begin Hierarchical Transaction [Header Loop BHT Segments]

Submitter Details [1000A Loop NM1 Segments]

Contact Information [1000A Loop PER Segments]

Service Facility

Other Payer

Common Options for the 4010 Format

Exception Options for the 5010 Format

Common Options for the 5010 Format

Common Options for the 4010 Format

Set Up Submitter Profiles

Exception Options for the 5010 Format