ANSI 835 BCBST IMPLEMENTATION GUIDE
SEGMENT ANALYSIS
VERSION 003 RELEASE 030
November 1999
OVERVIEW:
We have mapped private and BlueCare remittance data into an ANSI-835 document.
This document highlights how BCBST has populated specific ANSI segments.
PURPOSE:
The following pages are for reference and update information to the WEDI/Medicare
835 Implementation guide.
NOTE:
Not all segments are applicable to every remittance.
SEGMENTS:
X12 Segment Name:
Usage:
ISA12
ID 5
I11
5M
Interchange Control Version Number
ANSI Version Code 00300
X12 Segment Name:
Usage:
BPR16
DT 6
0513
6 C
0127
30 M
BPR Trace
Mandatory
Effective Entry Date
Effective Entry Date Check Remit date
X12 Segment Name:
Usage:
Note:
TRN02
AN 1
ISA Interchange Control Header
Mandatory
TRN Trace
Mandatory
Increase length of data sent in remittance # from 9 bytes to 16 for
HMO Blue/Wellport claims. Corporate claims remain 9 bytes.
BlueCare remits do not have remittance numbers.
Reference Number
Trace Number Remittance #
Page: 1
X12 Segment Name:
LX Assigned Number
Usage:
Mandatory
Note:
Added additional Lines of Business and increased length.
LX01
0554
Assigned Number
N0 1
6 M
Loop Number
LOB CODE
Tuesday/Wednesday Files
COR
MET
STS
MUN
THS
FES
FEH
LOB
HOSPITAL
PHYSICIAN
Corporate
Nashville Metro
State Employee
State Municipal
State Teacher
FEP Standard
FEP High
113
114
115
116
117
119
120
213
214
215
216
217
219
220
BC01
HM01
WP01
MR01
MR02
MR03
MR04
MR05
MG01
ST01
ST02
ST03
ST04
ST05
MR06
ST06
AB01
AS01
ST07
ST08
ST09
Blue Cross
HMO Blue
Wellport
Medicare Risk Beacon
Medicare Risk Caduceus
Medicare Risk Fort Sanders
Medicare Risk UT
Medicare Risk McMinn/Meigs
Metro Government
State 01 - Employees
State 02 - Teachers
State 03 – Local Govt
State 04 – POS - Employees
State 05 – POS - Teachers
Medicare Risk Sequatchie
State 06 – POS – Local Govt
Memphis
Southern Health
State Employees HMO
State Teachers HMO
State Government HMO
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
140
141
142
143
144
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
240
241
242
243
244
TCP
BCTP
VSKM
VSUT
THR2
BLR1
BLR3
BLR4
BLR5
TCHIP
TN Provider Network
Volunteer State - THP
Volunteer State - UT
BlueCare
BlueCare
BlueCare
BlueCare
BlueCare
118
121
122
123
124
125
126
127
128
218
221
222
223
224
225
226
227
228
Thursday Files
Friday Files
Page: 2
X12 Segment Name:
Usage:
Note:
REF01
ID 2
REF02
AN 1
REF03
1028
2 M
30 C
Reference Number Qualifier
TJ
Reference Number
Tax ID Number
Description
X12 Segment Name:
Usage:
Note:
TS301
AN 1
TS302
ID 1
TS303
DT 6
TS304
R 1
TS305
R 1
TS306
R 1
TS307
R 1
TS308
R 1
TS309
R 1
TS310
R 1
TS311
R 1
TS312
R 1
TS313
R 1
TS314
R 1
TS315
R 1
TS316
R 1
TS317
R 1
TS318
REF Reference Numbers
Optional
Added this field to produce Tax ID.
TS3 Transaction Statistics
Optional
Added 2 fields, Withhold Amount and Amount Discounted.
0127
Reference Number
30 M
Provider Number
1331
Facility Code
2 M
Type of Bill
0373
Date
6 M
Fiscal Period
0380
Quantity
15 M
Total Claims
0782
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
15 O
Monetary Amount
BCBSTN Provider #
BC/BS
Check Paid Date
Zero Fill
Total Charges
Total Non-Covered
Covered/Eligible
Disallowed Amount
Network Adjustment
Contractual Agreement
Deductible
Co-Insurance
COB
Other Adjustment
Paid Amount
Total Adjustment
Patient Owe
Page: 3
R 1
15 O
TS319
Monetary Amount
R 1
15 O
TS320 through TS324 not used at this time
X12 Segment Name:
Usage:
Note:
Withhold Amount
Amount Discount
CLP Claim Level Data
Mandatory
Expanded Patient Control Number to 20 bytes. Expanded claim
number to 12 bytes. Expanded DRG Code to 4 bytes. Added DRG
code to HMO Blue/Wellport hospital claims.
CLP01
AN 1
CLP07
AN 1
CLP08
ID 1
CLP09
ID 1
1028
38 M
0127
30 M
1331
2 O
1325
1 O
Claim Submitter’s ID
CLP11
ID 1
1352
4 O
Diagnosis Related Group
Code
Reference Number
Internal Control #
Facility Code
TOB Summary
Claim Frequency
TOB Frequency
Patient Control #
Claim Number
Place of Service
I = Inpatient
O = Outpatient
DRG Code
Page: 4
X12 Segment Name:
Usage:
Note:
CAS01
AN 1
1033
2 M
CAS Claims Adjustment (claim level)
Mandatory
Added Amount Discounted and Withhold Amount to Segment ID CO.
If the Withhold amount or discount amount is being sent, there will be
a second CO segments for the BlueCare remits.
Claims Adjustment Group Code
Code identifying the general category of payment adj.
Segment id - CO CONTRACTUAL
CAS01
CAS02
CAS03
CO
1
Deductible
(no Deductible for BlueCare)
CAS05
2
CAS06
Co-insurance
CAS08
41
CAS09
Network Adjustment
CAS11
A2
CAS12
Contract/Other Adjustment
CAS14
A2
CAS15
Total Adjustment
Segment id - CO CONTRACTUAL
Second Segment for BlueCare if needed
CAS01
CO
CAS02
104
CAS03
Withhold Amount
CAS05
88
CAS06
Amount Discounted
Segment id - PR PATIENT RESPONSIBILITY
CAS01
PR
CAS02
3
CAS03
Patient Owe
Segment id - NC DIS-ALLOWED CHARGES & NON-COVERED
CAS01
NC
CAS02
96
CAS03
Non-Covered
CAS05
A1
CAS06
Disallowed
Segment id - OA OTHER ADJUSTMENT
CAS01
OA
CAS02
B3
CAS03
Covered Amount/Eligible Amount
CAS05
22
CAS06
COB
Segment id - OA OTHER ADJUSTMENT (alternate segment if no claim level adjustments)
CAS01
OA
CAS02
93
CAS03
No Claim Level Adjustments
Page: 5
X12 Segment Name:
Usage:
Note:
NM101
ID 2
NM102
ID 1
NM108
ID 1
NM109
AN 2
2 M
1 M
0066
2 M
17 M
Entity Identifier Code
SJ = Servicing Provider information follows
Entity Type Qualifier
1 = Person
Identification Code Qualifier
BS = The Servicing Provider number is a Blue Shield Provider Number
Identification Code
Servicing Provider’s Blue Shield Number
X12 Segment Name:
Usage:
Note:
NM103
AN 1
NM104
AN 1
NM105
AN 1
NM108
ID 1
NM109
AN 2
35 C
25 O
25 O
0066
2 M
17 M
NM1 Individual or Organizational Name
Optional
Servicing Provider Number added for HMO Blue and Wellport claims.
NM1 Individual or Organizational Name
Mandatory
Patient Name expanded to 33 position for HMO Blue and Wellport
claims.
Name or Organization Name
Patient Last, First, Middle Initial
Name First
Not used
Name Middle
Not used
Identification Code Qualifier
Patient Number Change N and insured unique id number
Identification Code
Subscriber number
Page: 6
X12 Segment Name:
Usage:
Note:
REF01
ID 2
0128
2 M
REF02
REF Reference Numbers (claim level)
Optional
The claim number has been expanded to 12 bytes.
Reference Number Qualifier
Codes qualifying the Reference Number Valid Codes:
EA
N6
ZZ
Claim #
Network Type
Note Code/Description
Network Type
Tuesday/Wednesday Files
BLC
BPR
TPN
FEP
OTH
Thursday File
BPN
PCN
MET
SGN
BCN
HMO
SHP
OTH
X12 Segment Name:
Usage:
Note:
SVC04
R 1
SVC05
AN 1
0782
15 M
0234
30 O
Value
Blue Classic
Blue Preferred
Tennessee Preferred
FEP
Other – no network
Blue Preferred
Preferred Choice
Metro
Signature Network
Blue Classic
HMO Blue
Southern Health Plan
Others
SVC Service Information
Optional
Revenue Code added at the line item level for Wellport and HMO
Blue Hospital Claims.
Monetary Amount
Total Paid (Some Lines of Business may be equal to zero.)
Product/Service ID
Revenue Code
Page: 7
X12 Segment Name:
Usage:
Note:
CAS01
AN 1
1033
2 M
CAS Claims Adjustment (line item level)
Optional
Added Amount Discounted and Withhold Amount to Segment ID CO.
If the Withhold amount or discount amount is being sent, there will be
a second CO segments for the BlueCare remits.
Claims Adjustment Group Code
Code identifying the general category of payment adj.
Segment id - CO CONTRACTUAL
CAS01
CAS02
CAS03
CO
1
Deductible
(No Deductible for BlueCare)
CAS05
2
CAS06
Co-insurance
CAS08
41
CAS09
Network Adjustment
CAS11
A2
CAS12
Contract Adjustment
CAS14
A2
CAS15
Total Adjustment
CAS16
N/A
CAS17
N/A
Segment id - CO CONTRACTUAL
Second Segment for BlueCare if needed
CAS01
CO
CAS02
104
CAS03
Withhold Amount
CAS05
88
CAS06
Amount Discount
Segment id - PR PATIENT RESPONSIBILITY
CAS01
PR
CAS02
3
CAS03
Patient Owe
Segment id - NC DIS-ALLOWED CHARGES & NON-COVERED
CAS01
NC
CAS02
96
CAS03
Non-Covered
CAS05
A1
CAS06
Disallowed
Segment id - OA OTHER ADJUSTMENT
CAS01
OA
CAS02
B3
CAS03
Covered Amount/Eligible Amount
CAS05
22
CAS06
COB
Page: 8
X12 Segment Name:
Usage:
Note:
REF01
ID 2
0128
2 M
REF02
AN 1
0127
30 C
Reference Number Qualifier
Codes qualifying the Reference Number Valid Codes:
QQ
Units
X12 Segment Name:
Usage:
Note:
REF01
ID 2
0128
2 M
REF02
AN 1
REF03
AN 1
0127
30 C
0352
80 O
REF Reference Numbers (line item level)
Optional
Units added for HMO Blue and Wellport Hospital claims.
REF Reference Numbers (line item level)
Optional
Increased note code to 3 bytes. Added the explanation of note for
BlueCare, HMO Blue and Wellport only.
Reference Number Qualifier
Codes qualifying the Reference Number Valid Codes:
ZZ
Note Code
Note Explanation
Page: 9
SUMMARY OF UPDATES
02-08-1996
CLP08
Place of Service (Hospital)
02-08-1996
CLP09
I = Inpatient
O = Outpatient (Hospital)
02-26-1996
BPR16
Check Remittance Date
03-26-1996
TS313
TS309
TS316
CAS08
CAS09
CAS11
CAS12
Patient Benefit (Hospital) removed
Allowed (Physician) removed
Blue Cross Benefit (Hospital) removed
71 & B3 (Hospital & Physician) removed
BS Benefit & Allowed Amount (Hospital & Physician) removed
100 (Hospital) removed
Patient Benefit (Hospital) removed
01-08-1997
LX01
LX01
01-20-1997
REF
REF01
REF02
11-14-1997
TRN
LX
TS3
CLP
CAS
NM1
REF
CAS
REF
FEP Standard
FEP High
Hospital 81
Hospital 91
Physician 82 Add
Physician 92 Add
Added new segment
Line Item level of physician only
ZZ
Note codes
Remittance number expanded.
Additional Lines of Business
Added Allowed Amount and Amount Discounted
Patient Control Number expanded, Claim number field expanded and
DRG number field expanded.
Claim level - added Amount Discounted and Withhold Amount
Patient Name field expanded.
Claim Number has been expanded to 16 bytes.
Line Item- Added amount discounted and Withhold Amount
Note code field expanded to 3 bytes and Notes Explanation field
added.
03-01-1998
REF
LX
Added provider tax id.
Expanded LOB codes to 3 bytes for all remits.
08-01-1998
NM1
Added Servicing Provider Segment
12-07-1998
CAS
SVC
Added value for OA.
Field 04 may not be equal to zero for all lines of business.
05-20-1999
REF
Added Network Type Values
10-01-1999
CLP
SVC
DRG added for Wellport and HMO Blue Hospital Claims
Revenue Code added for Wellport and HMO Blue Hospital
Claims
Units added for Wellport and HMO Blue Hospital Claims
REF
Page: 10
04/01/2000
Updated Network Types in REF segment.
Updated Line of Business Codes in LX segment.
Page: 11