FMMIS 837P Professional Health Care Claim and Professional Encounter Claim Companion Guide

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FMMIS 837 Professional Health Care Claim and Professional Encounter Claim Companion Guide
005010X222A2
Version 4.0

Effective April 29, 2025

Florida Medicaid Management Information System Fiscal Agent Services Project

Introduction

The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid and all other health insurance payers in the United States comply with the EDI standards for health care as established by the Secretary of Health Services. The ANSI X12N implementation guides have been established as the standards of compliance for claim transactions.
The following information is intended to serve only as a companion guide to the HIPAA ANSI X12N implementation guides. The use of this guide is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This companion guide supplements, but does not contradict any requirements in the X12N implementation guide. Additional companion guides/trading partner agreements will be developed for use with other HIPAA standards, as they become available.
Additional information on the Final Rule for Standards for Electronic Transactions can be found at http://aspe.hhs.gov/admnsimp/final/txfin00.htm. The HIPAA Implementation Guides can be accessed at http://www.wpc-edi.com/hipaa/HIPAA_40.asp.

Purpose

This is the technical report document for the ANSI ASC X12N 837 Health Care Claims (837) transaction for professional claims. This document provides a definitive statement of what trading partners must be able to support in this version of the 837. This document is intended to be compliant with the data standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associated rules.
The 837 Professional transaction is the electronic correspondent to the paper CMS-1500 claim forms; therefore, any claim types submitted on the CMS-1500 forms correlate to the 837 Professional transaction, if data is submitted electronically.
All required segments within the 837 Professional transactions must always be sent by the submitter and received by the payer. Optional information is sent when it is necessary for processing. Segments that are conditional are only sent when special criteria are met. Although required segments in the incoming transaction may not be used during claims processing, some of these data elements are returned in other transactions such as the Unsolicited Claim Status (277U Transaction Set) and the Remittance Advice (835 Transaction Set).

Implementation Timeline for the HIPAA 5010 Standard

Per Federal mandate, beginning on January 1, 2012, any electronic transaction files submitted by providers to a payer must be in the new HIPAA standard 5010 X12 format.
In the interest of providing a needed transition period between the current HIPAA 4010 standard and the incoming HIPAA 5010 standard, starting on July 11, 2011, Florida Medicaid accepts electronic medical transactions in both the current 4010 X12 and the new 5010 X12 format.
In line with the Federal mandate, this transition period ends on December 31, 2011, and all files submitted after that date must be in the new 5010 X12 standard format.

Transmission and Data Retrieval Methods

Gainwell Technologies supports several types of data transport depending upon the trading partner's need. Providers and their representatives can submit and receive data via the Web Portal and Value Added Networks (VANs)/Switch Vendors for interactive transactions.

Web Portal: Transaction files are uploaded/downloaded in the Trade Files menu on the secure Web Portal.
Value Added Networks (VANs) or Switch Vendors: VANs or Switch Vendors typically support interactive transactions through a dedicated connection to the fiscal agent. VANs sign a contract with the State and have unique, VAN specific communication arrangements with the fiscal agent. A list of approved vendors is listed on the fiscal agent Web Portal.

Detailed information to assist with EDI related processes are available on the Provider Public Web Portal at http://www.mymedicaid-florida.com.
Information available includes:

Trading Partner Testing Procedures (Ramp Manager) for all new trading partners, or trading partners adding a new transaction; and
Web Upload/Download instructions for submitters uploading/downloading via the secure Web Portal.

File/System Specifications

EDI only accepts Windows/PC/DOS formatted files. Any file transmitted to EDI must be named in accordance to standard file naming conventions, including a valid three character file extension.
EDI allows for the upload/download of zipped or compressed files. Any data file contained within the zipped file must contain a valid three character file extension. The recommended extension is
.txt or .dat. Zipped files must not contain directory folders or structures and should contain only individual files.
Note: Only one X12 transaction file is permitted in each zipped file. Any data file that is 5MB or larger is required to be zipped or compressed before transmitting it to EDI.
The Web Portal is designed to support the following Internet browsers:

Internet Explorer, version 6 or later;
Firefox, version 1.5 or later; and
Opera, version 8.5 or later.

Transaction Limitations

A single Trading Partner may send up to 60 transactions per minute via batch or interactive methods. Batch files should contain no more than 5000 transactions per file.
If a higher transaction volume is needed, please contact our EDI Operations department at 1-866- 586-0961 or email your inquiries to flediteam@gainwelltechnologies.com.

System Availability

Connection will be available 24 hours a day, 7 days a week outside of the regularly scheduled system maintenance windows, and unless there are unforeseen technical difficulties.
Batch acknowledgement and response files will be available for retrieval for 60 days. If a batch file is needed after 60 days, please contact our EDI Operations department at 1-866-586-0961 or email your inquiries to flediteam@gainwelltechnologies.com.

Connection Issues and Resolutions

TLS V1.2 Security Protocol

To avoid a connection error, the TLS V1.2 security encryption protocol must be enabled for each request.
Sample C# line entry:
System.Net.ServicePointManager.SecurityProtocol = SecurityProtocolType.Tls | SecurityProtocolType.Tls11 | SecurityProtocolType.Tls12 | SecurityProtocolType.Ssl3;

Transmission Responses

For every transaction received, there is an expected response. The available responses are an Interchange Acknowledgement (TA1) and the Functional Acknowledgement (997/999).
Once a transaction is received, it goes through a front end compliance check called a TA1. The TA1 is a means of replying to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. The TA1 is a single segment and is unique in the sense that this single segment is transmitted without the GS/GE envelope structure. The TA1 segment provides the capability for the receiving trading partner to notify the sending trading partner of problems that were encountered in the interchange control structure.
Once the transaction has passed the front end compliance check it then goes through a syntax compliance edit. This edit verifies the compliance within the ANSI X12 syntax according to the HIPAA Implementation Guides. The transaction receives a Functional Acknowledgement (997/ 999) to provide feedback on the transaction. The 997 functional acknowledgement contains accepted or rejected information. If the transaction contains any syntactical errors, the segments and elements in which the error occurred are reported in a rejected acknowledgement. If the transaction contained no syntactical errors, a positive 997 response is generated and the transaction is passed on for processing.
Note: The 997 will be replaced with the 999 effective December 11, 2015.

EDI Support

The Gainwell EDI Operations Team is available to support trading partners and providers that exchange transactions electronically. Support functions include:

Enrollment processing for trading partners requesting to submit transactions electronically;
Provide assistance to billing agents, clearinghouses and software vendors;
Identifying and troubleshooting technical issues; and
Data Exchange help.

The providers may reach EDI staff Monday through Friday 8:00 a.m. to 5:00 p.m. EST (Eastern Standard Time) at the EDI Helpdesk, (866) 586-0961.

Control Segment Definitions for Florida Medicaid 837 Transactions

Note the page numbers listed below in each of the tables represent the corresponding page number in the X12N 837 HIPAA Implementation Guide [837_5010_x223].

X12N EDI Control Segments

ISA - Interchange Control Header Segment IEA - Interchange Control Trailer Segment GS - Functional Group Header Segment GE - Functional Group Trailer Segment ST - Transaction Set Header
SE - Transaction Set Trailer
TA1 - Interchange Acknowledgement

ISA – Interchange Control Header Segment

Communications transport protocol interchange control header segment. This segment within the X12N implementation guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header record.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
C.3	N/A	ISA	Interchange Control Header Segment
C.4	N/A	ISA01	Authorization Information Qualifier	00, 03	00 – No Authorization Information Present ENCOUNTER – 03 – Additional Data Identification
C.4	N/A	ISA02	Authorization Information		[space fill] ENCOUNTER – MCO Medicaid ID + [space fill]
C.4	N/A	ISA03	Security Information Qualifier	00	00 – No Security Information Present
C.4	N/A	ISA04	Security Information		[space fill]
C.4	N/A	ISA05	Interchange ID Qualifier	ZZ	ZZ – Mutually Defined
C.4	N/A	ISA06	Interchange Sender ID		Trading Partner ID supplied by Florida Medicaid, left justified space filled. ENCOUNTER – Encounter Specific Trading Partner ID, left justified, space filled.
C.5	N/A	ISA07	Interchange ID Qualifier	ZZ	ZZ – Mutually Defined
C.5	N/A	ISA08	Interchange	77027	77027 left justified and

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
			Receiver ID		space filled. Florida Medicaid Sender ID.
C.5	N/A	ISA09	Interchange Date		The date format is YYMMDD.
C.5	N/A	ISA10	Interchange Time		The time format is HHMM.
C.5	N/A	ISA11	Repetition Separator	^	^
C.5	N/A	ISA12	Interchange Control Version Number	00501	00501 – Control Version Number
C.5	N/A	ISA13	Interchange Control Number		Interchange Unique Control Number – Must be identical to IEA02
C.6	N/A	ISA14	Acknowledgement Requested	1, 0	1 – Acknowledgement Requested 0 – No Acknowledgement Requested
C.6	N/A	ISA15	Usage Indicator	P	P – Production Data
C.6	N/A	ISA16	Component Element Separator	:	: – Component Element Separator

IEA – Interchange Control Header

Communications transport protocol interchange control trailer segment. This segment within the X12N implementation guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
C.10	N/A	IEA	Interchange Control Trailer
C.10	N/A	IEA01	Number of Included Functional Groups		Number of included Functional Groups
C.10	N/A	IEA02	Interchange Control Number.		Must be identical to the value in ISA13

GS – Functional Group Header

Communications transport protocol functional group header segment. This segment within the X12N implementation guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
C.7	N/A	GS	Functional Group Header
C.7	N/A	GS01	Functional ID Code	HC	HC – Health Care Claim (837)
C.7	N/A	GS02	Application Sender’s Code		Trading Partner ID supplied by Florida Medicaid.
C.7	N/A	GS03	Application Receiver’s Code	77027	77027 Florida Medicaid Sender ID.
C.7	N/A	GS04	Date		The date format is CCYYMMDD.
C.7	N/A	GS05	Time		The time format is HHMM.
C.7	N/A	GS06	Group Control Number		Group Control Number – Must be identical to GE02.
C.8	N/A	GS07	Responsible Agency Code	X	X – Responsible Agency Code
C.8	N/A	GS08	Version/ Release/ Industry Identifier Code	005010X222A1	Version/ Release/ Industry Identifier Code

GE – Functional Group Trailer

Communications transport protocol functional group trailer segment. This segment within the X12N implementation guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
C.9	N/A	GE	Functional Group Trailer
C.9	N/A	GE01	Number of Transaction Sets Included		Number of Included Transaction Sets
C.9	N/A	GE02	Group Control Number		Must be identical to the value in GS06.

ST – Transaction Set Header

Communications transport protocol transaction set header segment. This segment within the X12N implementation guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the claim header record.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
70	N/A	ST	Transaction Set Header

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
70	N/A	ST01	Transaction Set Identifier Code	837	837 = Health Care Claim
70	N/A	ST02	Transaction Set Control Number		Transaction Control Number Increment by 1 when multiple transaction sets are submitted. Must be identical to SE02.
70	N/A	ST03	Implementation Convention Reference		Must be identical to the value in GS08.

SE – Transaction Set Trailer

Communications transport protocol transaction set trailer. This segment within the X12N implementation guide indicates the end of the transaction set and provides the count of transmitted segments [including the beginning (ST) and ending (SE) segments]. This segment may be thought of traditionally as the claim trailer record.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
496	N/A	SE	Transaction Set Trailer
496	N/A	SE01	Number of Included Segments		Total number of segments included in Transaction Set including ST and SE.
496	N/A	SE02	Transaction Set Control Number		Must be identical to the value in ST02.

Valid Delimiters

The delimiters documented below are used for Florida Medicaid, unless otherwise requested by a trading partner.

Definition	ASCII	Decimal	Hexadecimal
Segment Separator	~	126	7E
Element Separator	*	42	2A
Compound Element Separator	:	58	3A
Repetition Separator	^	94	5E

X12N 837 Business Scenarios – Inbound Transaction

This section contains Payer-specific business rules and limitations for the 837 Professional transaction.

Subscriber, Insured = Recipient in the Florida Medicaid Eligibility Verification System:

The Florida Medicaid Eligibility Verification System does not allow for dependents to be enrolled under a primary subscriber, rather all enrollees/members are primary subscribers within each program or Managed Care Organization.

Provider Identification = NPI or Medicaid ID (Providers without an NPI only):

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandated the implementation of a National Provider Identifier (NPI). Most health care providers must register with the National Plan and Provider Enumeration System and receive a unique NPI. The intent of the HIPAA regulations was to require all health plans to convert their claims processing systems to use only the NPI for claims processing and reporting for providers required to obtain an NPI. Because of the complexities of this conversion by health care plans and providers, the use of the NPI has not yet been strictly enforced. However, Medicaid claims submitted on and after January 1, 2011, have new requirements for the use of the NPI.
Beginning on January 1, 2011, the NPI is required on all electronic transactions and paper claims from providers who qualify for an NPI. Florida Medicaid still accepts transactions containing the Provider’s Medicaid ID, but any qualifying claims that lack the NPI are denied.
Starting on May 1, 2011, Florida Medicaid no longer accepts electronic claim transactions (837, 837I, and 837P) containing the Florida Medicaid ID submitted by providers who qualify for an NPI. Any electronic claims sent by qualifying providers on or after May 1, 2011 that contain the provider’s Florida Medicaid Provider ID are denied, even if they also contain the NPI.
Please note that paper claims are not affected by this change.
For all non- healthcare providers where an NPI is not assigned, the claim must contain the Florida Medicaid Provider Number with the appropriate loops within the REF segment where REF01 equals G2.

Logical File Structure:

There can be only one interchange (ISE/IEA) per logical file. The interchange can contain multiple functional groups (GS/GE); however; the functional groups must be the same type.

Submitter:

Submissions by non-approved trading partners are rejected.

Claims:

Claims must be submitted in separate ISA/IEA envelopes.

Response/997 Functional Acknowledgement:

A response transaction is returned to the trading partner that is present within the ISA06 data element.
The Agency for Health Care Administration (Agency) provides a 997 Functional Acknowledgment for all transactions that are received.
You will receive this acknowledgment within 48 hours unless there are unforeseen technical difficulties. If the transaction submitted was translated without errors for a request type transaction, i.e., 270 or 276, you will receive the appropriate response transaction generated

from the request. If the transaction submitted was a claim transaction, e.g., 837, you will receive either the 835 or the unsolicited 277.
Note: The 835 and unsolicited are only provided weekly.
Note: The 997 will be replaced with the 999 effective December 11, 2015.

When NM108 = 24 or REF01 = EI:

If the NM108 equals 24 (Employer Identification Number (EIN) or the REF01 equals EI (EIN) within any loop, the value in the corresponding NM109 or REF02 must be in the format of XXXXXXXXX.
Note: Neither number should contain dashes or hyphens, as this causes the data element to exceed the maximum allowed number of characters.

Claims Allowed per Transactions (ST/SE envelope):

The HIPAA implementation guide states on the CLM (Claim Information) segment that the developers recommend that trading partners limit the size of the transaction (ST/SE) envelope to a maximum of 5,000 CLM segments.
Encounter files have a file size limit of 5,000 claims per ISA/IEA.

Document Level:

The Agency processes files at the claim level. It is possible based on where the error(s) occur within the hierarchical structure that some claims may pass compliance and others will fail compliance. Those claims that pass compliance are processed within the Florida Medicaid Management Information System (FMMIS). Those claims that fail compliance are reported on the 997.
Note: The 997 will be replaced with the 999 effective December 11, 2015.

Dependent Loop:

For the Agency, the subscriber is always the same as the patient (dependent). Claims containing data in the Patient Hierarchical Level (2000C loop) will not process correctly.

Compliance Checking:

Inbound 837 transactions are validated through Strategic National Implementation Process (SNIP) Level 4. In addition to Level 4, Level 7 patient (dependent) level occurs if 2000C patient loop is received. All other levels are validated within the FMMIS.

Identification of TPL:

For each claim at the header level, if loop 2320 (Other Subscriber Information) is present and SBR09 (Claim Filing Indicator) is not equal to MB (Medicare), 16 (HMO Medicare Risk), HM (HMO) or MC (Medicaid), the COB Payer Paid Amounts (AMT01=D) received in the 2320 loop(s) are summed together for the Payer Paid Amount.
Note: The 2320 loop can repeat multiple times per claim.

Private Transportation:

Private Transportation providers are currently required to submit start and stop time information on the claim. This information provides a means to distinguish between services submitted for the same recipient on the same day. The X12N 837 Professional transaction does not provide the capability for providers to submit start and stop times. Private Transportation claims use two modifiers instead of start and stop times.
The values are:

D	Diagnostic or therapeutic site other than P or H
E	Residential, domiciliary, custodial facility (nursing home, not a skilled nursing facility)
G	Hospital-based dialysis facility (hospital or hospital-related)

H	Hospital
I	Site of transfer (for example, airport or helicopter pad) between types of ambulance
J	Non-hospital-based dialysis facility
N	Skilled nursing facility (SNF)
P	Physician’s office (includes HMO non-hospital facility, clinic, etc.)
R	Residence
S	Scene of accident or acute event
X	Intermediate stop at physician’s office in route to the hospital (includes HMO non-hospital facility, clinic, etc.)

Note: Modifier X can only be used as a designation code in the second modifier position.
The Origin and Destination codes are billed together as a two-character modifier to create combinations that uniquely identify services billed on the same day. If the provider needs to utilize the same procedure code and origin/destination modifier for the same recipient on the same day, a second modifier is billed with the value of ‘76’ (Repeat Procedure by Same Physician).
Note about Round Trip: A round trip means that the patient was picked up, taken somewhere, and returned to the same place they were picked up. There are only two legs to a round trip, going out and coming back. If you made a trip with three legs (going out, going somewhere else, coming back) that is not a round trip.

1. To bill a round trip if you bill for a base rate and mileage:
  1. Round trips will need to supply a brief description for the purpose of the round trip in CR109, Loop 2300.
  2. Ambulance Pick-Up and Drop-Off locations are required for all ambulance and non-emergency transportation claims. The Pick-Up and Drop-Off locations will be sent in the following segments in Loop 2310E and 2310F: NM1, N3 and N4. Please see pages 7-8 and 7-11 of this companion guide for details of the segments.
  3. Bill only one line for mileage (unless you have a known exception). The modifier for origin and destination should reflect the pickup point and the stop point (e.g., Home to Doctor is a modifier of RP). Enter the total miles for the entire trip.
  4. If you bill a base rate, you will send that line item once. For wheelchair-van and stretcher van, submit total charges of two times your base rate on this line item.
2. To bill a round trip if you bill for a base rate only:
  1. Round trips will need to supply a brief description for the purpose of the round trip in CR109, Loop 2300.
  2. Ambulance Pick-Up and Drop-Off locations are required for all ambulance and non-emergency transportation claims. The Pick-Up and Drop-Off locations will be sent in the following segments in Loop 2310E and 2310F: NM1, N3 and N4. Please see pages 7-8 and 7-11 of this companion guide for details of the segments.
  3. Bill only one line item for base rate. The modifier for origin and destination should reflect the pickup point and the stop point (e.g., Home to Doctor is a modifier of RP). For wheelchair-van and stretcher van, submit total charges of two times your base rate on this line item.

Note about Multi-Leg trips: A trip that had multiple segments and is not a round trip as described above, each segment must be billed as a separate line item.

To bill a multiple leg trip if you bill for a base rate and mileage
1. Ambulance Pick-Up and Drop-Off locations are required for all ambulance and non-emergency transportation claims. The Pick-Up and Drop-Off locations will be sent in

the following segments in Loop 2310E and 2310F: NM1, N3 and N4. Please see pages 7-8 and 7-11 of this companion guide for details of the segments.

1. Bill one line item for each segment of mileage. The modifier for origin and destination should reflect the start point and the stop point.
2. All one line item for each segment of base rate. The modifier for origin and destination should reflect the start point and the stop point for that leg of the trip.
To bill a multiple leg trip if you bill for a base rate only:
1. Ambulance Pick-Up and Drop-Off locations are required for all ambulance and non-emergency transportation claims. The Pick-Up and Drop-Off locations will be sent in the following segments in Loop 2310E and 2310F: NM1, N3 and N4. Please see pages 7-8 and 7-11 of this companion guide for details of the segments.
2. Bill one line item for each segment of base rate. The modifier for origin and destination should reflect the start point and the stop point for that leg of the trip.

National Drug Code (NDC):

The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting/adjudication processes. In order for the Agency to fully realize the drug rebate savings for claims billed, an NDC Code for the billed drug is required effective January 1, 2007.

Attachments:

The PWK segment is used to indicate that supporting documents, or attachments for the claim, will be submitted. The ACN assigned to the attachment is created by the submitter. The preferred method is a combination of Medicaid provider ID and date of service. This alphanumeric combination is used to link the attachment to a claim and is defined in Loop 2300, Segment PWK06. It is not recommended to use the same ACN more than one time. Additionally, the ACN must not contain PHI. For the element summary, please refer to the Loop 2300 Attachments section of this guide and the Implementation Guide.
When claims are sent in via 837 files, the claims automatically go through EDI validation and are then are forwarded into the FMMIS claims system. Any claim indicating a claim attachment (ACN in the Loop 2300, Segment PWK06) will automatically go into a Suspended claim status. After the claims are suspended, the claims must be searched for in the Claims tab, and the corresponding attachment must be uploaded through the secure Web Portal.
Follow the Attachment Upload Process instructions below for using the Attachments panel.
Note: When uploading attachments, all documents within the file selected for upload must be associated to the claim that the ACN corresponds to.
Claims will continue to show as Suspended until each individual claim’s attachment(s) are uploaded. See the instructions below on how to search for a suspended claim. If no attachments are received after 21 days, the claims will deny.

Suspended Claim Search and Attachment Upload

After logging in to the secure Web Portal account, click Claims, then click search to begin the suspended claim search. After entering the claim information, select the corresponding claim type under Claim Type, then select Suspended under Status. Next, select the appropriate option for the suspended claim under Date of Service.

Note: If the claim is older than 12 months, select Date Range. The Date Range field will then allow users to type in a date range (only for exceptional claims).

A Search Results panel will display below the Claim Search panel. Select the desired claim.

Once the claim information displays, scroll down to the Supporting Documentation panel. When the Control Number, Transmission, and Report Type is listed, select the row of information and click add. The information will autofill. Next, click upload.

An Attachment Upload panel will open. Select the row that displays the ACN and Attachment Description. Click Browse…, then choose the desired claim attachment. Next, click upload attachment.

When files are uploaded successfully, the Upload Success panel will display a successful upload message followed by a tracking number.

Note: To submit multiple attachments for an individual claim, users must repeat the above steps in the Supporting Documentation and Attachment Upload panels. Users are no longer required to perform a Suspended Claim Search each time they wish to an upload attachment(s).

Exceptional Claim

Exceptional Claims are indicated on 837 transactions by entering the Delayed Reason code in the CLM20 of the 2300 Loop. The Exceptional Claim Form can be downloaded in the Exceptional Claim Request panel by clicking the link for Exceptional Claim Processing.
The Exceptional Claim form must be completed and submit as an attachment using the Supporting Documentation panel. In addition to the form, supporting documentation must be sent in as additional attachments to the claim.

Note: Refer to section 15 for Attachments process and section 16 for Suspended Claim Search and Attachment Upload process.

Medicare Part C Claims:

Medicare Part C (Medicare Advantage) claims should be submitted with the required Medicare Part C crossover form attached. Such claims that are submitted without an attachment will be processed by Florida Medicaid, but will be denied payment.
Any Medicare Part C claims received electronically via the Web Portal or batch submission that have been flagged as containing an attachment will temporarily suspend pending receipt of the noted attachment by Florida Medicaid. By default, if the attachment is not received within 21 days the original claim will be denied payment.

Transition from Special Feed to Encounter data for Rate Setting Initiative: FOR ENCOUNTERS:

A capitated relationship with a subcontracted service provider network where there is a downstream paid claim. In this scenario, the health plan is required to report the downstream paid amount for the service in SVD02 within the 2430 loop, and ‘05’ in CN101 within the 2300 loop of their X12 transactions. Example: a managed care provider.
A capitated relationship with a subcontracted service provider network where there is not a downstream paid claim. In this scenario, the health plan is required to report the health plan’s internally determined amount, calculated price, or allowed amount for the service in the SVD02 within the 2430 loop, and ‘06’ in CN101 within the 2300 loop of their X12 transactions. Example: a physician group.
To support the data reconciliation and encounter data completeness initiative, the health plans will be required to prepend 20 characters to the ‘line item control number’ (REF section of Loop 2400 with a ‘6R’ identifier) within their encounter X12 transaction submissions. The ‘line item control number’ to include the health plan’s prepend data will be returned within the Agency’s X12 835 response. See prepend specs below:

TPID (last three characters)	Region (2 characters)	Adjudication Date (YYMMDD)	Sequence Number (9 characters with leading zeros)	Network Provider Submitted Control Number (up to 30 characters)
999	99	999999	999999999	9999…

Example:
TPID	1001201
Region	02
Date	(September 2, 2019) 190902
Sequence of line process for the day	(351,892) 351892
Submitted from Network Provider	5897458732

Result: 201021909020003518925897458732

Maximum Billed Amount

The maximum billed amount allowed on a single physician/837P claim is (8,2) which could be represented as 999999.99. (One penny less than 1 million is the maximum that is allowed).

AMT_BILLED

Amount requested by the provider for services rendered.

NUMBER

For questions on bill amounts, please contact the EDI Operations department at 1-866-586-0961 or email flediteam@gainwelltechnologies.com for guidance.

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X12N 837 Professional Loop and Data Element Specific Information for Florida Medicaid

This section specifies X12N 837 fields for which Florida Medicaid has specific requirements.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
71	N/A	BHT	Beginning Segment
71	N/A	BHT02	Transaction Set Purpose Code	00	00 – Original
72	N/A	BHT06	Transaction Type Code	CH, RP	CH – Chargeable (Use with Fee For Service Claim) ENCOUNTER - 'RP' - Reporting
74	1000A	NM1	Submitter Name
75	1000A	NM108	Identification Code Qualifier	46	46 – Electronic Transmitter Identification Number (ETIN)
75	N/A	NM109	Identification Code		Trading Partner ID supplied by FL Medicaid
76	1000A	PER	Submitter EDI Contact Information
77	1000A	PER01	Contact Function Code	IC	IC – Information Contact
77	1000A	PER02	Name		Required if different than the name contained in the Submitter Name (Loop 1000A, NM1 segment)
77	1000A	PER03	Communication Number Qualifier	EM, FX, TE	EM – Electronic Mail FX – Fax TE – Telephone
77	1000A	PER04	Communication Number		Email Address, Fax Number or Telephone Number (including the area code)
79	1000B	NM1	Receiver Name
79	1000B	NM103	Name Last or Organization Name		STATE OF FLORIDA MEDICAID
79	1000B	NM109	Identification Code		77027 – Florida Medicaid Payer ID
83	2000A	PRV	Billing Provider Specialty Information		ENCOUNTER – Provider ID Acquisition may require the taxonomy (see 2010AA below).
83	2000A	PRV01	Provider Code	BI	BI – Billing
83	2000A	PRV02	Reference Identification Qualifier	PXC	PXC – Health Care Provider Taxonomy Code
83	2000A	PRV03	Reference Identification		Provider Taxonomy Code

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
					Effective for Dates of Service 03/01/2022, and after, it is important to include the taxonomy. In most submissions, Medicaid's adjudication will be dependent upon the taxonomy. Required to Identify the Provider ID Acquisition.
87	2010AA	NM1	Billing Provider Name		ENCOUNTER – This loop should contain the NPI information for the Provider paid by the MCO. This information was previously sent in the 2010AB loop of the 4010X12 transaction set. Note: For MCO Plan ID submission location, see ISA01 and ISA02.
88	2010AA	NM101	Entity Identifier Code	85	85 – Billing Provider
89	2010AA	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)
90	2010AA	NM109	Identification Code		HIPAA National Provider Identifier
91	2010AA	N3	Billing Provider Address
91	2010AA	N301	Address Information		Physician Group provider submissions: For Dates of Service 03/1/2022, and after, the Address must match the service address on file with Medicaid.
92	2010AA	N4	Billing Provider City, State, ZIP code
93	2010AA	N403	Postal Code		Billing Provider 9-digit ZIP code. Physician Group provider submissions - For Dates of Service 03/1/2022 and after, must match the service location zip code on file with Medicaid.
94	2010AA	REF	Billing Provider Tax Identification
94	2010AA	REF01	Reference Identification Qualifier	EI, SY	EI – Employer ID (EIN) SY – Social Security Number (SSN)

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
94	2010AA	REF02	Reference Identification		If REF01=EI (EIN) If REF01=SY (SSN)
Subscriber Level Note: For Florida Medicaid, the insured and the patient are always the same person. Use this HL segment to identify the recipient and proceed to Loop 2300. Do not send the Patient Hierarchical Level (Loop 2000C). Claims received with the 2000C Loop may not process correctly.
114	2000B	HL	Subscriber Hierarchical Level
115	2000B	HL03	Hierarchical Child Code	22	22 – Subscriber
115	2000B	HL04	Hierarchical Child Code	0	0 – No Subordinate HL Segment in this Hierarchical Structure
116	2000B	SBR	Subscriber Information
116	2000B	SBR01	Payer Responsibility Sequence Number Code		Refer to the 837 Professional Implementation Guide for Valid Values (pg. 296).
118	2000B	SBR09	Claim Filing Indicator Code	MC	MC – Medicaid
119	2000B	PAT	Member Policy Number
120	2000B	PAT09	Pregnancy Indicator	Y	Y – Pregnancy Indicator when the recipient is pregnant to reflect exception from co-payment.
121	2010BA	NM1	Subscriber Name
122	2010BA	NM102	Entity Type Qualifier	1	1 – Person
122	2010BA	NM108	Identification Code Qualifier	MI	MI – Member Identification Number
123	2010BA	NM109	Identification Code		Florida Recipient 10-digit Medicaid ID
133	2010BB	NM1	Payer Name
134	2010BB	NM103	Name Last or Organization Name		STATE OF FLORIDA MEDICAID
134	2010BB	NM108	Identification Code Qualifier	PI	PI – Payer Identification
134	2010BB	NM109	Identification Code	77027	77027 – Florida Medicaid Payer ID
136	2010BB	N4	Payer City, State, ZIP code

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
136	2010BB	N4	N401 – City Name		Tallahassee
136	2010BB	N4	N402 – State or Province Code		FL
137	2010BB	N4	N403 – Postal Code		32301
140	2010BB	REF	Billing Provider Secondary Identification
140	2010BB	REF01	Reference Identification Qualifier	G2	G2 – Provider Commercial Code Note: This qualifier may only be used by non-healthcare providers who are unable to obtain an NPI ID (i.e. Med waivers)
141	2010BB	REF02	Reference Identification		Florida Medicaid Provider ID
157	2300	CLM	Claim Information
158	2300	CLM01	Claim Submitter’s Identifier		Patient Control Number Note: Value received is returned on the 835 Remittance Advice.
159	2300	CLM05-1	Facility Type Code		Enter the 2-digit Place of Service code at the claim header. Note: See the Medicaid Provider Reimbursement Handbook for a list of all of the valid values. Enter Place of Service code 99 for public transportation claims.
159	2300	CLM05-2	Facility Code Qualifier	B	B – Place of Service Codes for Professional or Dental Services
159	2300	CLM05-3	Claim Frequency Type Code	1, 7, 8	Valid values are as follows: 1 – Original Claim – Adjustment (Replacement of Paid Claim) – Void (Credit only). The ICN to credit should be placed in the REF02, where REF01=F8. Providers must use the most recently paid ICN when voiding

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
					or adjusting. Consult your appropriate Reimbursement Handbook for additional guidelines for filing voids and adjustments. ENCOUNTER: Use 1 as a frequency code when resubmitting a denied claim.
161- 162	2300	CLM11-1 and CLM11-2	Related Causes Code	AA, EM, OA	AA– Auto Accident EM – Employment OA– Other Accident If the services being rendered are the result of an injury or accident, enter one of the standard two-character injury codes listed above in each Data Element if they apply. Otherwise, this field may be left blank
182	2300	PWK	Claim Supplemental Information. Indicates presence of attachment.		ENCOUNTER - Attachments are not permitted for Encounter Claims.
183	2300	PWK01	Report Type Code	EB	EB – Can be used for transmit of Coordination of Benefits or Medicare Secondary Payer and other codes available in the Implementation Guide.
184	2300	PWK02	Report Transmission Code		Use segment to indicate transmit of attachment.
185	2300	PWK05	Identification Code Qualifier	AC	AC – Attachment Control Number.
185	2300	PWK06	Identification Code		The ACN assigned to the attachment created by the submitter. The preferred method is a combination of Medicaid provider ID and date of service. Refer to the Attachments section of X12N 837P Business Scenarios - Inbound Transactions.
186	2300	CN1	Contract Information		ENCOUNTER – This information is required on all encounter claims. This refers to

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
					the contract between the plan and the provider paid by the plan.
186	2300	CN101	Contract Type Code		ENCOUNTER–Required – Use “09” for FFS. Use “05” for a capitation relationship when there is a downstream claim e.g., managed care provider. OR Use “06” for a capitation relationship when there is not a downstream claim e.g., a physician group. Refer to Implementation Guide for a list of valid values.
186	2300	CN102	Monetary Amount		ENCOUNTER – Required – If contract type (CN101= 05), then a downstream paid amount (the sum of SVD02 elements in the 2430 loop). If contract type (CN101 = 06), then the health plan’s internally determined amount, calculated price, or allowed amount (the sum of SVD02 elements in the 2430 loop). If contract type (CN101= 09), then Other Payer Amount Paid (the sum of SVD02 elements in the 2430 loop) Note: CN102 contains the total monetary amount the health plan paid the provider.
	2300	CLM20	Exceptional Claims Processing		Delay reason code. Note: There will be a delay before the claim will process and suspend. Once the claim has suspended for awaiting attachments, the submitter can download the Exceptional Claim form and submit as an attachment. Refer to the Exceptional Claim section of X12N 837P Business Scenarios - Inbound Transactions.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
194	2300	REF	Prior Authorization
194	2300	REF01	Reference Identification Qualifier	G1	G1 – Prior Authorization
195	2300	REF02	Reference Identification		Prior Authorization Number only if the services rendered required and received approved Prior Authorization from AHCA or a Peer Review Organization such as KePRO or First Mental Health.
196	2300	REF	Payer Claim Control Number
196	2300	REF01	Reference Identification Qualifier	F8	F8 – Original Reference Number Note: The f8 qualifier should only be used when voiding or adjusting a previously paid encounter. This qualifier should not be used for resubmission of denied encounters.
196	2300	REF02	Reference Identification		Enter the 13-digit ICN or 17-digit TCN assigned to the original claim submission. (ICN/TCN to be credit/voided).
202	2300	REF	Claim Identifier for Transmission Intermediaries		ENCOUNTER – This segment is to be used when resubmitting previously denied encounter claims for remediation. Note: Denied encounters cannot be voided or adjusted.
202	2300	REF01	Reference Identification Qualifier	D9	D9 – Claim Number ENCOUNTER – This will be sent when a previously denied claim is being resubmitted. Resubmission of previously denied claims must occur within 30 days of the original denial. Note: The D9 qualifier should only be used when resubmitting a denied encounter. This qualifier should not be used for adjustments or voids.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
203	2300	REF02	Reference Identification		The ICN of the most recent denied Encounter.
207	2300	K3	File Information
208	2300	K301	Fixed Format Information		MCO Receipt Date – Format CCYYMMDD
211	2300	CR1	Ambulance Transport Information
212	2300	CR104	Ambulance Transport Reason Code		Enter the Ambulance Transport Reason Code. Note: Refer to the 837 Professional Implementation Guide for the valid code values.
212	2300	CR105	Unit or Basis for Measurement Code	DH	DH – Miles
213	2300	CR106	Transport Distance		Florida Medicaid processes only the whole number when units are entered with decimals. Example: Units entered on the transaction 3.75 are processed as 3 units.
213	2300	CR109	Description		Description / clarification of the purpose of the ambulatory trip. Note: Only used on round-trip ambulatory claims.
214	2300	CR2	Spinal Manipulation Service Information
215	2300	CR208			Enter the corresponding Condition Code. Note: Refer to the 837 Professional Implementation Guide for the valid code values
223	2300	CRC	EPSDT Referral
223	2300	CRC01	Code Category	ZZ	ZZ – Mutually Defined Enter this for Child Health Check-Up Screening Referral Information.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
224	2300	CRC02	Certification Condition Indicator	Y, N	Y – Yes N – No For Child Health Check-Up screenings enter a Y if the patient is referred to another provider as a result of the screening. Enter N if no referral is made. If N is entered here, enter NU in 2300, CRC03.
224	2300	CRC03	Condition Code	AV, NU, S2, ST	Enter one of the following valid values. For Child Health Check-Up Exam Result: AV – Patient Refused Referral NU – Not Used (Patient Not Referred) S2 – Under Treatment ST – New Services Requested
257	2310A	NM1	Referring Provider Name
258	2310A	NM101	Entity Identifier Code	DN	DN – Referring Provider
258	2310A	NM102	Entity Type Qualifier	1	1 – Person
259	2310A	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)
259	2310A	NM109	Identification Code
260	2310A	REF	Referring Provider Secondary Identification
260	2310A	REF01	Reference Identification Qualifier	0B, G2	0B – State License Number G2 – Provider Commercial Number Note: The G2 qualifier should only be used for non-healthcare providers.
Detail Line Rendering Provider Name Note: If the 9-digit Zip code is required to identify the provider, then it must be entered in the service facility loop with the address; located at 2310C.
262	2310B	NM1	Rendering Provider Name

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
263	2310B	NM101	Entity Identifier Code	82	82 – Rendering Provider
264	2310B	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)
264	2310B	NM109	Identification Code
265	2310B	PRV	Rendering Provider Specialty Information
265	2310B	PRV01	Provider Code	PE	PE – Performing
265	2310B	PRV02	Reference Identification Qualifier	PXC	PXC – Health Care Provider Taxonomy Code
265	2310B	PRV03	Reference Identification		Note: Effective for Dates of Service 03/01/2022, and after, it is important to include the taxonomy. In most submissions, Medicaid's adjudication will be dependent upon the taxonomy.
267	2310B	REF	Rendering Provider Secondary Identification
267	2310B	REF01	Reference Identification Qualifier	0B, G2	0B – State License Number G2 – Provider Commercial Number Note: The G2 qualifier should only be used for non-healthcare providers.
269	2310C	NM1	Service Facility Location Name
270	2310C	NM101	Entity Identifier Code	77	77 – Service Location.
270	2310C	NM102	Entity Type Qualifier	2
270	2310C	NM103	Last or Organization Name
270	2310C	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI).
271	2310C	NM109	Identification Code
272	2310C	N3	Service Facility Location Address

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
272	2310C	N301	Address Information
273	2310C	N4	Service Facility Location City, State, ZIP code
273	2310C	N401	City Name
274	2310C	N402	State or Province Code
274	2310C	N403	Postal Code		Must be 9 digits.
275	2310C	REF	Service Facility Location Secondary Information
275	2310C	REF01	Reference Identification Qualifier	OB, G2, LU	0B – State License Number G2 – Provider Commercial Number LU – Location Number Note: The G2 qualifier should only be used for non-healthcare providers.
276	2310C	REF02	Reference Identification
Ambulance Pick-up Location
285	2310E	NM1	Ambulance Pick-Up Location		Note: For Ambulatory claims only.
285	2310E	NM101	Entity Identifier Code	PW	PW – Pickup Address
286	2310E	NM102	Entity Type Qualifier	2	2 – Non- Person Entity
287	2310E	N3	Ambulance Pick-Up Location Address
287	2310E	N301	Address Information		Note: If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, crossroad of State Road 34 and 45 or Exit near Mile marker 265 on Interstate 80.)
288	2310E	N4	Ambulance Pick-Up Location City, State, ZIP code
288	2310E	N401	City Name		Ambulance Pickup City
289	2310E	N402	State or Province Code		Ambulance Pickup State

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
289	2310E	N403	Postal Code		Ambulance Pickup Code
Ambulance Drop-Off Location
290	2310F	NM1	Ambulance Drop-Off Location		Note: For Ambulatory Claims Only
290	2310F	NM101	Entity Identifier Code 45		45 – Drop-Off Location
291	2310F	NM102	Entity Type Qualifier	2	2 – Non-Person Entity
292	2310F	N3	Ambulance Drop-Off Location Address
292	2310F	N301	Address Information		Street Address of Drop-Off Location
293	2310F	N4	Ambulance Drop-Off Location City, State and ZIP code
293	2310F	N401	City name		Ambulance Drop Off City
294	2310F	N402	State or Province Code		Ambulance Drop-Off State or Province
294	2310F	N403	Postal Code		Ambulance Drop-Off ZIP code
Other Subscriber Information ENCOUNTER -Loop 2320 (Other Subscriber Information) is required on all encounter claims. Note: For encounter claims, the MCO should always be reported as one of the other payers. For example, when there is TPL, the TPL is primary and the MCO is secondary. When there is no TPL, the MCO is primary.
299	2320	CAS	Claim Level Adjustments
301- 304	2320	CAS02, CAS05, CAS08, CAS11, CAS14, CAS17	Adjustment Reason Code	A1	All values from code source 139 are allowed. ENCOUNTER: A1 – MCO denied claim
295	2320	SBR	Other Subscriber Information
298	2320	SBR09	Claim Filing Indicator Code	16	16 – HMO Medicare Risk (required for Medicare Part C claims)
305	2320	AMT	Coordination of Benefits (COB) Payer Paid Amount
305	2320	AMT01	Amount Qualifier Code	D	D – Payer Amount Paid

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
305	2320	AMT02	Payer Paid Amount		Other Payer Amount Paid (TPL or MCO)
Other Payer Name ENCOUNTER – Loop 2330B (Other Payer Name) is required on all encounter claims Note: For encounter claims, the MCO should always be reported as one of the other payers. For example, when there is TPL, the TPL is primary and the MCO is secondary. When there is no TPL, the MCO is primary.
320	2330B	NM1	Other Payer Name
321	2330B	NM109	Identification Code		This number must be identical to at least one occurrence of the 2430-SVD01 to identify the other payer. Florida payer. Florida Medicaid captures third party payment amount(s) from the service line(s) in 2430-SVD02. Note: The 2320/2330 Loop(s) can repeat up to 10 times for a single claim and the 2430 Loop can repeat up to 25 times for a single detail. Effective January 1, 2020 due to the implementation of MBI replacing HICN, if a Medicare ID is used in NM109 in the Other Payer loop and if the Medicare ID is a HICN, then an error will post but will cause the claim to deny.
325	2330B	DTP	Claim Check or Remittance Date
325	2330B	DTP01	Date Claim Paid	573	573 – Other Payer or MCO Claim Adjudication Date
325	2330B	DTP02	Date Claim Paid	D8	D8 – Date Format (CCYYMMDD)
325	2330B	DTP03	Date Time Period		TPL or MCO Adjudication Date (CCYYMMDD)
350	2400	LX	Service Line Number
350	2400	LX01	Line Counter		Florida Medicaid accepts up to the HIPAA allowed 50 detail lines per claim.
351	2400	SV1	Professional Service
352	2400	SV101-1	Product/Service ID Qualifier	HC	HC – Health Care Financing

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
					Administration Common Procedural Coding System (HCPCS) Codes
353	2400	SV101-2	Procedure Code		Enter the procedure code for this service line. For Child Health Check-up (CHCUP) claims, enter the screening procedure code on the first service line. Enter procedure code 99998 for Public Transportation Claims.
355	2400	SV104	Quantity		Enter the Service Unit Count. Note: Submit whole numbers only.
357	2400	SV109	Emergency Indicator	Y	Y – Yes Enter Y if the services are known to be an emergency.
357	2400	SV111	EPSDT Indicator	Y	Y – Yes Enter Y when the recipient was referred for services as the result of a Child Health Check-up screening.
357	2400	SV112	Family Planning Indicator	Y	Y – Yes Enter Y if the services relate to pregnancy or if the services were for Family Planning.
373	2400	CRC	Ambulance Certification
374- 375	2400	CRC03- CRC07	Condition Indicator		Enter the Patient Condition Code. Use this Loop and Segment if Condition Code is different by line item, otherwise use CRC03 in the 2300 Loop if Condition Code applies to entire claim. Used only for Ambulance claims.
Ref – Line Item Control Number
401	2400	REF	Reference Information
401	2400	REF 01	Reference Ident Qual	6R	Provider control number

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
401	2400	REF 02	Reference Ident		ENCOUNTER Only: Effective April 1, 2020, Required twenty (20) character prepend to the Line Item Control number (max - 50 characters) that contains the following: TPID (its last 3 characters) Region (2 characters) Adjudication Date (6 characters – YYMMDD) Sequence Number (9 characters) AND the remaining characters can be up to 30 characters (21 -50)
423	2410	LIN	Drug Identification
425	2410	LIN02	Product/Service ID Qualifier	N4	N4 – National Drug Code
425	2410	LIN03	Product Service ID		Enter National Drug Code in 5-4-2 format.
426	2410	CTP	Drug Quantity
426	2410	CTP04	Quantity		National Drug Unit Count
427	2410	CTP05-1	Unit or Basis for Measurement Code	UN	UN – Unit
Detail Line Rendering Provider Name Note: Required if the Rendering Provider NM1 information is different than that carried in the 2310B (claim) loop, or if the Rendering Provider information is different than the Billing Provider (2010 AA). If a ZIP code is required to identify the provider, then the 9-digit ZIP code must be entered in the service facility loop; 2310C.
430	2420A	NM1	Rendering Provider
432	2420A	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)
432	2420A	NM109	Identification Code
433	2420A	PRV	Rendering Provider Specialty Information
433	2420A	PRV01	Provider Code	PE	PE – Performing
433	2420A	PRV02	Reference Identification Qualifier	PXC	PXC – Health Care Provider Taxonomy Code
433	2420A	PRV03	Reference Identification		Note: Effective for Dates of Service 03/01/2022, and after, it is

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
					important to include the taxonomy. In most submissions, Medicaid's adjudication will be dependent upon the taxonomy.
434	2420A	REF	Rendering Provider Secondary Identification
434	2420A	REF01	Reference Identification Qualifier	G2	G2 – Provider Commercial Number Note: Non-healthcare providers must send this REF segment where REF01 = ‘G2’
435	2420A	REF02	Reference Identification		Enter FL Medicaid Provider ID
441	2420C	NM1	Service Facility Location Name
442	2420C	NM101	Entity Identifier Code	77	77 – Service Location
442	2420C	NM102	Entity Type Qualifier	2
442	2420C	NM103	Last or Organization Name
442	2420C	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)
442	2420C	NM109	Identification Code
444	2420C	N3	Service Facility Location Address
444	2420C	N301	Address Information
445	2420C	N4	Service Facility Location City, State, ZIP code
445	2420C	N401	City Name
446	2420C	N402	State or Province Code
446	2420C	N403	Postal Code		Must be 9 digits
447	2420C	REF	Service Facility Location Secondary Identification

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
447	2420C	REF01	Reference Identification Qualifier	G2, LU	G2 – Provider Commercial Number LU – Location Number Note: The G2 qualifier should only be used for non-healthcare providers.
448	2420C	REF02	Reference Identification
454	2420E	REF	Ordering and Referring Provider Identification
454	2420E	NM1	Ordering Provider
454	2420E	NM101	Ordering Provider	DK	DK – Ordering Provider
455	2420E	NM102		1
455	2420E	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)
456	2420E	NM109	Identification Code
458	2420E	N401	City Name
459	2420E	N402	State or Province Code
459	2420E	N403	Postal Code		Must be 9 digits
460	2420E	REF	Ordering Provider Name
460	2420E	REF01	Reference Identification Qualifier	G2	G2 – Provider Commercial Number Note: The G2 qualifier should only be used for non-healthcare providers.
461	2420E	REF02	Reference Identification		Enter FL Medicaid Provider ID
465	2420F	NM1	Referring Provider
466	2420F	NM101		DN	DN – Referring Physician
466	2420F	NM102		1
466	2420F	NM103	Last or Organizational Name
467	2420F	NM108	Identification Code Qualifier	XX	XX – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)
467	2420F	NM109	Identification Code

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
468	2420F	REF	Ordering Provider Name
469	2420F	REF01	Reference Identification Qualifier	G2	G2 – Provider Commercial Number Note: The G2 qualifier should only be used for non-healthcare providers.
469	2420F	REF02	Reference Identification		Enter FL Medicaid Provider ID
Line Adjudication information ENCOUNTER -Loop 2430 (name loop) Required on all encounter claims. Note: Other payer payment amounts are required to be entered at the detail level.
480	2430	SVD	Line Adjudication Information
480	2430	SVD01	Identification Code		This number should match one occurrence of the 2330B-NM109 identifying Other Payer.
481	2430	SVD02	Monetary Amount		Enter the Third Party Payment Amount (TPL) OR amount health plan paid to provider at the line item level only. This is also used for crossover detail paid amount. ENCOUNTER – If CN101 = 05, then SVD02 should be the downstream paid claim amount reported. If CN101 = 06, then SVD02 should be the health plan’s internally determined amount, calculated price, or allowed amount for the service reported. If CN101 = 09, then SVD02 should be the detail other payer paid amount OR amount health plan paid to provider.
Line Adjustment
484	2430	CAS	Line Adjustment
486- 488	2430	CAS02, CAS05, CAS08, CAS11, CAS14, CAS17	Adjustment Reason Code	1, 2, 66, A1	– Deductible – Coinsurance ENCOUNTER: A1 – MCO denied line item Other external code source values from code source 139 are allowed.

837 Professional Health Care Claim
Page	Loop ID	Reference	Name	Code/Value	Notes/Comments
486- 489	2430	CAS03, CAS06, CAS09, CAS12, CAS15, CAS18	Adjustment Amount		If Adjustment Group Code (CAS01) = PR and Adjustment Reason Code value is: enter the Medicare Deductible Amount enter the Medicare Coinsurance Amount

Frequently Asked Questions

This appendix contains a compilation of questions and answers relative to Florida Medicaid and its providers.
Please reference the following link:
http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_SubmissionInformation/tabId/66/D efault.aspx.
For more information concerning remediation of Encounter claims, please refer to the Managed Care Tip Sheets at the following link:
http://portal.flmmis.com/FLPublic/Provider_ManagedCare/Provider_ManagedCare_Support/tabId
/78/Default.aspx?linkid=tip

Note for SFTP submitters only:

The inbound file name should not be more than 40 characters in length including the extension and it should only contain valid characters A-Z, a-z, and 0-9. File names should not have any special characters (e.g., *, &, ^, %, $, #, @, !, ~) or non-printable ASCII characters.

If the file is received with a file name of more than 40 characters, the system will alter the inbound file name as required to process through the EDI System.
If the file is received with a file name containing special characters and/or non-printable ASCII characters, the file will not be processed.

Keywords: FMMIS 837 Professional Health Care Claim and Professional Encounter Claim Companion Guide, FMMIS 837, Professional Health Care Claim, Professional Encounter Claim, 837 professional, Companion Guide, Professional Health Care Claim and Professional Encounter Claim

FMMIS 837P Professional Health Care Claim and Professional Encounter Claim Companion Guide

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