IGI Presentation

1
Profession Claim example 837 Professional ASC
x12N (004010x098A1)
Sita Kapoor Infotech Global Inc. 100 Franklin
Square Dr. Somerset, NJ 08873 sk_at_igiusa.com
September 24, 2003
2
Claim Information, in English
SUBSCRIBER/PATIENT Ted Smith ADDRESS 236 N.
Main St., Miami, FL 33413 TELEPHONE
NUMBER 305-555-1111 SEX Male DOB 05/01/19
48 GROUP 12312-A SSN 000-22-1111 DESTINATI
ON PAYER ACS BENEFITS SERVICES PAYOR ADDRESS P
O Box 2181, Somerset, NJ 08853 PAYER ID
NUMBER 00520
3
Claim Information, in HCFA 1500
4
Claim Information, in English
BILLING PROVIDER/SENDER Michael
Brenett ADDRESS ASSAD, WASSAD NJ
12121212 TIN 111753453 RENDERING
PROVIDER Michael Brenett Payer Provider
ID 52054 UPIN ID C68426 PATIENT ACCOUNT
NUMBER SM-192619 CASE Office Visit DOS03/21/200
3. POSOffice SERVICES RENDERED Office first
visit 40.00 Next CPT Code 15.00 Next CPT
Code 35.00
5
Claim Information, in HCFA 1500
V1506
6
Claim Information, in x12
BHT00190020030923200309231933CH REF870040
10X098DA1 NM1412IGI HOSPITAL NURSING
HOME46Z9988 PERICMNJYTE9089463571 NM1
402BCBS4600520 HL1201 NM1851BERNE
TTMICHAEL24111753453 N3ASSAD N4WSDSADNJ
12121212 REF1C52054
7
Claim Information, in x12
HL21220 SBRP18ACS BENEFITS
SERVICES16 NM1IL1SMITHTEDMI00022111
1 N32316 N. MAIN STREET N4MIAMIFL33413 DMG
D819480501M REF1G12312-A NM1PR2ACS
BENEFITS SERVICESPI00520 N3P O BOX
2181 N4SOMERSETNJ08853 CLMSM1926195522
1YAYAC DTP431D820030321 HIBFV1506 NM1
821BERNETTMICHAELZZ52054 PRVPEZZ282N0
0000X REF1GC68426 LX1 SV1HC9921340UN14
01Y0 DTP472RD820030321-20030321 LX
2 SV1HC9921440UN1151Y0 DTP472D
820030321 LX3 SV1HC9921540UN1301Y
0 DTP472RD820030321-20030323
8
Provider Information
HL1201 NM1851BERNETTMICHAEL241117534
53 N3ASSAD N4WSDSADNJ12121212 REF1C52054
52054
C68426
9
Subscriber Information
HL21220 SBRP18ACS BENEFITS
SERVICES16 NM1IL1SMITHTEDMI00022111
1 N32316 N. MAIN STREET N4MIAMIFL33413 DMG
D819480501M NM1PR2ACS BENEFITS
SERVICESPI00520 N3P O BOX
2181 N4SOMERSETNJ08853
10
Subscriber Information
HL21220 SBRP18ACS BENEFITS
SERVICES16 NM1IL1SMITHTEDMI00022111
1 N32316 N. MAIN STREET N4MIAMIFL33413 DMG
D819480501M REF1G12312-A NM1PR2ACS
BENEFITS SERVICESPI00520 N3P O BOX
2181 N4SOMERSETNJ08853
11
Patient Information
The Subscriber is the Patient The Patient Loop
will not be mapped
12
Subscriber Payer Information
HL21220 SBRP18ACS BENEFITS
SERVICES16 NM1IL1SMITHTEDMI00022111
1 N32316 N. MAIN STREET N4MIAMIFL33413 DMG
D819480501M REF1G12312-A NM1PR2ACS
BENEFITS SERVICESPI00520 N3P O BOX
2181 N4SOMERSETNJ08853
13
Claim Information
CLMSM19261985111YAYAC DTP431D82003
0321 HIBFV1506 NM1821BERNETTMICHAEL24
52054 PRVPEZZ282N00000X REF1GC68426
Original
14
Claim Information
V1506
Office Visit
Original
CLMSM19261985111YAYAC DTP431D82003
0321 HIBFV1506 NM1821BERNETTMICHAEL24
52054 PRVPEZZ282N00000X REF1GC68426
Original
15
Service Line Information
LX1 SV1HC9921340UN1061Y0 DTP47
2RD820030321-20030321 LX2 SV1HC9921440UN
1061Y0 DTP472D820030321 LX3 SV1
HC9921540UN2061Y0 DTP472RD82003
0321-20030323
16
EDI Claim in the x12N format
BHT00190020030923200309231933CHREF8700401
0X098DA1NM1412IGI HOSPITAL NURSING
HOME46Z9988PERICMNJYTE9089463571NM140
2BCBS4600520HL1201NM1851BERNETTM
ICHAEL24111753453N3ASSADN4WSDSADNJ12121
212REF1C52054HL21220SBRP18000221111AC
S BENEFITS SERVICESMBNM1IL1SMITHTEXS
MI000221111N32316 N. MAIN STREETN4MIAMIFL33
413REF873053331111DMGD819480501MNM1PR2A
CS BENEFITS SERVICESPI00520N3P O BOX
1181N4SOMERSETNJ08853CLM115474855221Y
AYACPDTP431D820030321HIBFV1506NM
1821BERNETTMICHAEL2452054PRVPEZZ282N0
0000XREF1GC68426LX1SV1HC9921340UN140
1Y0DTP472RD820030321-20030321LX2SV1
HC9921440UN1151Y0DTP472D820030
321LX3SV1HC9921540UN1301Y0DTP
472RD820030321-20030323
17
EDI Transaction Control Segments
18
Control Envelopes

• Control Envelopes
• ISA / IEA
• Interchange envelope
• GS / GE
• Functional group envelope
• ST / SE
• Transaction set envelope

19
Functions of the Transaction Set (ST/SE) Control
Envelope
(One Business Document)
20
Control Envelope
EDI Transaction Set with Control Envelope

01
02
ST

Transaction Set
EDI Data - Claim 1

02
SE

01
21
Transaction Set (ST/SE) Control Envelope
ST8371234 BHT00190020030923200309231933C
H REF87004010X098DA1 NM1412IGI HOSPITAL
NURSING HOME46ZZZ98576 PERICMARYTE73
22710600 NM1402BCBS46980005420 HL1
201 NM1852IGI HOSPITAL NURSING
HOME24980S57F237 cont SE141234 ST837
1235 BHT00190020030923200309231933RP REF
87004010X098DA1 NM1412IGI HOSPITAL
NURSING HOME46ZZZ98576 PERICMARYTE7322
710600 NM1402BCBS46980005420 HL12
01 NM1852IGI HOSPITAL NURSING
HOME24980S57F237 cont SE141235
22
Functional Group (GS/GE) Control Envelope
To Payer A Claims Payable
Functional Groups
EQUALS
To Payer A Claims Reporting
Transaction Sets
23
Control Envelope
GS
01
04
03
02

F U N C T I O N A L



05
06
07
08




ST
EDI Data Claims (charges)
Trans Set
SE
ST
Trans Set
EDI Data Claims (reporting)
SE
01
02

GE

24
Functional Group (GS/GE) Control Envelope
GSHCZZ5760052020030923193320030923X004010X
098A1 ST8371234 BHT001900200309232003
09231933CH REF87004010X098DA1 NM1412IGI
HOSPITAL NURSING HOME46ZZZ98576 PERIC
MARYTE7322710600 SE10001234
ST8371235 BHT00190020030923200309231933R
P REF87004010X098DA1 NM1412IGI HOSPITAL
NURSING HOME46ZZZ98576 PERICMARYTE73
22710600 SE261234 GE220030923
25
Interchange (ISA/IEA) Control Envelope
To Payer A Claims Payable
Interchange
Functional Groups
To Payer A Member Enrollment
Transaction Sets
26
Control Envelope
ISA








01
04
03
02
05
06
07
08
I N T E R C H A N G E









09
12
11
10
13
14
15
16
GS
ST
F U N C T I O N A L G R O U P
EDI Data HCFA SET 1
Trans Set
SE
ST
EDI Data HCFA SET 2
Trans Set
SE
GE
ST
GS
EDI Data Eligibility Info 1
Trans Set
GE
SE
IEA


01
02
27
Interchange (ISA/IEA) Control Envelope
ISA000000000001000000000001ZZE1576
3000520 2003091933U00401000000001
1T
GSHCE15760052020030923193320030923X004010X
098A1 ST8371234 BHT001900200309232003
09231933CH REF87004010X098DA1 NM1412IGI
HOSPITAL NURSING HOME46ZZZ98576 PERIC
MARYTE7322710600 SE10001234
ST8371235 BHT00190020030923200309231933R
P REF87004010X098DA1 NM1412IGI HOSPITAL
NURSING HOME46ZZZ98576 PERICMARYTE73
22710600 SE261234 GE220030923
IEA1000000001
28
EDI Claim in the x12N format
ISA000000000001000000000001ZZE1576
3000520 2003091933U00401000000001
1TGSHCE15760052020030923193320030923X0
04010X098A1ST83700001BHT001900200309232003
09231933CHREF87004010X098DA1NM1412DEWITT
HOSPITAL NURSING HOME46E1576PERICSUSAN
TE8709463571NM1402BCBS4600520HL120
1NM1852DEWITT HOSPITAL NURSING
HOME2457237N3P.O. BOX 32N4DE
WITTAR72042REF1C57237HL21220SBRP18XC
AV71748AR BLUE CROSS/BLUE SHIELDMBPATNM1
IL1DEBERRYWILLIAMSMIXCAV71748N390 SAM
DEBERRY RDN4DEWITTAR720420000DMGD819530817
MNM1PR2AR BLUE CROSS/BLUE SHIELDPI00520
N3P O BOX 2181N4LITTLE ROCKAR722030000CLM11
5474855221YAYACPDTP431D820030
726HIBK9895BF72981BFE9053BFV1506NM1DN1
BURLESONSTANW24D04410REF1BXNM1821GUS
TAVUSJOHNL2452054PRVPEZZ282N00000XREF1
GC68426NM1FA2DEWITT HOSPITAL NURSING
HOMEN3P.O. BOX 32N4DE WITTAR72042LX1SV1H
C9928255UN1221234Y0DTP472RD8
20030726-20030726HL31220SBRP18431356390A
MCO/AHA-1ST SOURCE REPRICIMBPATNM1IL1JA
MESKELLYMI431356390N3813 W
GIBSONN4DEWITTAR72042DMGD819721113FNM1PR
2AMCO/AHA-1ST SOURCE REPRICIPI00520N3P
O BOX 2181N4LITTLE ROCKAR722032181CLM1154754
55221YAYACPDTP431D820030726H
IBK7840BF78701NM1DN1GUSTAVUSJOHNL24C
68426REF1B52054NM1821GUSTAVUSJOHNL245
2054PRVPEZZ282N00000XREF1GC68426NM1FA2D
EWITT HOSPITAL NURSING HOMEN3P.O. BOX
32N4DE WITTAR72042LX1SV1HC9928255UN12
212Y0DTP472RD820030726-20030726HL
41220SBRP18HIP431310803-00BLUE ADVANTAGE
ADMINISTRATOMBPATNM1IL1PADGETTDELORES
MIHIP431310803-00N3P.O.BOX
56N4ETHELAR72048DMGD819400405FNM1PR2BL
UE ADVANTAGE ADMINISTRATOPI00520N3P.O.
BOX 1460N4LITTLE ROCKAR722030000CLM11547311
00221YAYACPDTP431D820030725HI
BK78902BF78701BF7936BFV1005NM1DN1GUSTA
VUSJOHNL24C68426REF1B52054NM1821GUSTA
VUSJOHNL2452054PRVPEZZ282N00000XREF1G
C68426NM1FA2DEWITT HOSPITAL NURSING
HOMEN3P.O. BOX 32N4DE WITTAR72042LX1SV1H
C99284100UN1221234Y0DTP472RD8
20030725-20030725HL51220SBRP18XCJ9900041
17AR BLUE CROSS/BLUE SHIELDMBPATNM1IL1
ESTESLARRYMIXCJ990004117NM1PR2AR BLUE
CROSS/BLUE SHIELDPI00520N3P O BOX
2181N4LITTLE ROCKAR722030000CLM853101198
221YAYACPDTP431D820030730HIBK4
1091BF3051NM1DN1TRACYWALLACELEE24E0292
0REF1B50594NM1821TRACYWALLACELEE24505
94PRVPEZZ282N00000XREF1GE02920NM1FA2DEW
ITT HOSPITAL NURSING HOMEN3P.O. BOX 32N4DE
WITTAR72042LX1SV1HC99223198UN12212
Y0DTP472RD820030730-20030730HL61220
SBRP18XCSL83633AR BLUE CROSS/BLUE
SHIELDMBPATNM1IL1FLYCYNTHIAMIXCSL
83633NM1PR2AR BLUE CROSS/BLUE
SHIELDPI00520N3P O BOX 2181N4LITTLE
ROCKAR722030000CLM115489875221YAYAC
PDTP431D820030801HIBK5920NM1DN1TR
ACYWALLACELEE24E02920REF1B50594NM1821
TRACYWALLACELEE2450594PRVPEZZ282N00000X
REF1GE02920NM1FA2DEWITT HOSPITAL NURSING
HOMEN3P.O. BOX 32N4DE WITTAR72042LX1SV1H
C9928375UN1221Y0DTP472RD8200308
01-20030801HL71220SBRP18XCAC77095AR
BLUE CROSS/BLUE SHIELDMBPATNM1IL1WRINKL
EKENNETHGMIXCAC77095N3BOX
471N4GILLETTAR720550000DMGD819401206MNM1
PR2AR BLUE CROSS/BLUE SHIELDPI00520N3P
O BOX 2181N4LITTLE ROCKAR722030000CLM1154810
35221YAYACPDTP431D820030728H
IBK9181BFE9289NM1DN1TRACYWALLACELEE24
E02920REF1B50594NM1821TRACYWALLACELEE
2450594PRVPEZZ282N00000XREF1GE02920NM1FA
2DEWITT HOSPITAL NURSING HOMEN3P.O. BOX
32N4DE WITTAR72042LX1SV1HC9928135UN12
212Y0DTP472RD820030728-20030728HL
81220SBRP18431-35-6390AMCO/AHA-1ST SOURCE
REPRICIMBPATNM1IL1JAMESKELLYMI431
-35-6390N3813 W GIBSONN4DEWITTAR72042DMGD8
19721113FNM1PR2AMCO/AHA-1ST SOURCE
REPRICIPI00520N3P O BOX 2181N4LITTLE
ROCKAR722032181CLM115384075221YAYAC
PDTP431D820030606HIBK4660NM1DN1TR
ACYWALLACELEE24E02920REF1B50594NM1821
TRACYWALLACELEE2450594PRVPEZZ282N00000X
REF1GE02920NM1FA2DEWITT HOSPITAL NURSING
HOMEN3P.O. BOX 32N4DE WITTAR72042LX1SV1H
C9928375UN1221Y0DTP472RD8200306
06-20030606HL91220SBRP18XCP990105122FIRS
T SOURCEMBPATNM1IL1SIEBERLESTERMI
XCP990105122N31206 S ADAMSN4DEWITTAR72042000
0DMGD819991104MNM1PR2FIRST
SOURCEPI00520N3PO BOX 2181N4LITTLE
ROCKAR720990000CLM115517155231YAYAC
PDTP431D820030815HIBK9895BF7295BF
E9053NM1DN1TRACYWALLACELEE24E02920REF1
B50594NM1821TRACYWALLACELEE2450594PRV
PEZZ282N00000XREF1GE02920NM1FA2DEWITT
HOSPITAL NURSING HOMEN3P.O. BOX 32N4DE
WITTAR72042LX1SV1HC9928255UN123123
Y0DTP472RD820030815-20030815HL10122
0SBRP18XCP990105122FIRST SOURCEMBPAT
NM1IL1SIEBERLESTERMIXCP990105122NM1PR2
FIRST SOURCEPI00520N3PO BOX
2181N4LITTLE ROCKAR720990000CLM115517275
231YAYACPDTP431D820030815HIBK9
895BF78609BF7872BF7295NM1DN1TRACYWALLAC
ELEE24E02920REF1B50594NM1821TRACYWALL
ACELEE2450594PRVPEZZ282N00000XREF1GE02
920NM1FA2DEWITT HOSPITAL NURSING
HOMEN3P.O. BOX 32N4DE WITTAR72042LX1SV1H
C9928375UN1231234Y0DTP472RD8
20030815-20030815HL111220SBRP18ASB4305410
001AR BLUE CROSS/BLUE SHIELDMBPATNM1IL1
WATSONKEITHMIASB4305410001NM1PR2AR
BLUE CROSS/BLUE SHIELDPI00520N3P O BOX
2181N4LITTLE ROCKAR722030000CLM115516275
231YAYACPDTP431D820030816HIBK2
554NM1DN1TRACYWALLACELEE24E02920REF1B
50594NM1821TRACYWALLACELEE2450594PRVPE
ZZ282N00000XREF1GE02920NM1FA2DEWITT
HOSPITAL NURSING HOMEN3P.O. BOX 32N4DE
WITTAR72042LX1SV1HC9928375UN1231Y
0DTP472RD820030816-20030816SE24000001G
E120030923IEA1000000001
29
Questions ?