ANSI 5010 Claim Format

ANSI 5010 is the newest standard adopted to transmit medical information securely and with as much detail as possible.

Reading this information was never truly meant for human eyes to process, but for quick information it is good to know the basics and you can generally pick out what you are looking for and what you are looking at.

Here is an example claim with two transactions (1 transaction containing an NDC) for one payer/carrier for one patient sent in ANSI 5010 837P format :

(Below the example I will break down what this information is and how it relates to the claim)

((Also note that this information is purely fictional and is pulled from Medisoft's Tutorial Data, any relationship or similarities to actual persons are completely coincidental and unintended))

ISA*00*          *00*          *ZZ*SENDERIDISA06*ZZ*RECEIVERIDISA08*120219*0910*|*00501*000000001*1*P*:

GS*HC*SENDERCODE*RECEIVERCODE*20120219*0910*1*X*005010X222A1

ST*837*0001*005010X222A1

BHT*0019*00*11AAAA*20120219*0910*CH

NM1*41*2*PRACTICE NAME*****46*SENDERID

PER*IC*FIRST LAST*TE*8003334747

NM1*40*2*CCB MEDICAID*****46*RECEIVERID

HL*1*1*20*1

NM1*85*2*HAPPY VALLEY MEDICAL CLINIC*****XX*1234567891

N3*5222 E. BASELINE RD.

N4*GILBERT*AZ*85234

REF*EI*123456789

NM1*87*2

N3*1944 N. KLUGE DR.*SUITE 8381

N4*GILBERT*AZ*85234

HL*1*1*22*1

SBR*P*18*25BB******CH

NM1*IL*1*YOUNGBLOOD*MICHAEL*C***MI*USAA236678

N3*73982 N. 28TH AVE.

N4*PHOENIX*AZ*85044

DMG*D8*19620705*M

NM1*PR*2*U.S. TRICARE*****PI

CLM*17*5007.5***11:B:1*Y*A*Y*Y**OA:EM

DTP*439*D8*20100101

HI*BK:8472*BF:73730*BF:3469

NM1*82*1*HINCKLE*WALLACE****XX*9876543210

PRV*PE*PXC*PROVITAXON

LX*1

SV1*HC:99000:::::HANDLING FEE*8*UN*1***1:2:3

DTP*472*D8*20120219

REF*6R*100

LX*1

SV1*HC:J0490:::::BENADRYL HCL, UP TO 50 MG.*4999.5*UN*1***1:2:3

DTP*472*D8*20120219

REF*6R*99

LIN**N4*12345678901

CTP****50*UN

SE*9999*0001

GE*9999*1

IEA*9999*000000001

FILE HEADER INFORMATION-
This information is normally defined at the clearing house or carrier direct where you are sending the claim file.  Checking for an EDI Companion guide would detail what information needs to be sent here; normally the entire file will be rejected if this information is incorrect.  (In Revenue Manager this information is defined under Configure->Receivers->Header Information &Transaction Set drop-downs)

ISA*00*          *00*          *ZZ*SENDERIDISA06*ZZ*RECEIVERIDISA08*120219*0837*|*00501*000000001*1*P*:	ISA Loop
GS*HC*SENDERCODE*RECEIVERCODE*20120219*0837*1*X*005010X222A1	GS Loop
ST*837*0001*005010X222A1	ST Loop
BHT*0019*00*11AAAA*20120219*0837*CH	ST Loop

Submitter Name & Contact Information

This information will be dependent on the clearing house or carrier direct's requirements; but will normally be the userID or Submitter Number, the contact information is required to be sent, but I have yet to meet someone that has been contacted via this information.  (In Revenue Manger this information is defined under Configure->Receivers->Header Information)

NM1*41*2*PRACTICE NAME*****46*SENDERID	1000A Loop
PER*IC*FIRST LAST*TE*8003334747	1000A Loop

Receiver Name

This information will be the clearing house or carrier direct where you are sending the claim file.  This information will be in the EDI Companion guide normally. (In Revenue Manger this information is defined under Configure->Receivers->Header Information)

NM1*40*2*CCB MEDICAID*****46*RECEIVERID	1000B Loop
HL*1*1*20*1	2000A Loop

Billing Provider's Name & Contact Information

This information will be defined and pulled from Medisoft's Practice information if the rendering provider is set to file claim as group.  Otherwise the individual provider's information would replace the information seen here.  This would relate to the information in Box 33 on a HCFA Paper claim.

NM1*85*2*HAPPY VALLEY MEDICAL CLINIC*****XX*1234567891	2010AA Loop-NM1 Seg
N3*5222 E. BASELINE RD.	2010AA Loop-N3 Seg
N4*GILBERT*AZ*85234	2010AA Loop-N4 Seg
REF*EI*123456789	2010AA Loop-REF Seg

Billing Provider's Pay-To Address Information

This information will be defined and pulled from Medisoft's Practice Information's Pay-To tab.  Because of new requirements with ANSI 5010, a physical address must be sent for the Billing Provider in loop 2010AA and then an additional address can be added such as a PO Box or another separate payment address can in loop 2010AB, if you would prefer not to have payments sent to the Billing Provider's physical address.  Normally the payment address must be on file with both the carriers and the clearing house where you are sending the claim.

NM1*87*2	2010AB Loop-NM1 Seg
N3*1944 N. KLUGE DR.*SUITE 8381	2010AB Loop-N3 Seg
N4*GILBERT*AZ*85234	2010AB Loop-N4 Seg
HL*1*1*22*1	2000B Loop
SBR*P*18*25BB******CH	2000B Loop

Patient and Contact Information

This information will be pulled from the patient's information in Medisoft.  This loop will repeat until all the patients and their claims and transactions have been processed.

NM1*IL*1*YOUNGBLOOD*MICHAEL*C***MI*USAA236678	2010BA Loop-NM1 Seg
N3*73982 N. 28TH AVE.	2010BA Loop-N3 Seg
N4*PHOENIX*AZ*85044	2010BA Loop-N4 Seg
DMG*D8*19620705*M	2010BA Loop-DMG Seg

Claim's Carrier/Payer

This will be the claim's current payer. (ex if the claim has Medicare as primary insurance and BCBS for secondary insurance; if this was the primary claim, this would show Medicare's information, otherwise for secondary claims this would show BCBS' information.)

NM1*PR*2*U.S. TRICARE*****PI

2010BB Loop-NM1 Seg

Beginning of Claim

This is the beginning of the claim for this patient.  Claims will have a transaction limit of 6, so after 6 transactions have been processed a new claim loop of 2300 will repeat if there are more pending transactions for this patient.

CLM*17*5007.5***11:B:1*Y*A*Y*Y**OA:EM	2300 Loop-CLM Seg
DTP*439*D8*20100101	2300 Loop-DTP Seg
HI*BK:8472*BF:73730*BF:3469	2300 Loop-HI Seg

Rendering Provider's Information

This information will be pulled from the Assigned Provider of the claim. (Note: this does not mean the transaction line's assigned provider necessarily; this will depend on how you "Create Claims" in Medisoft; Assigned Provider radio will pull from the Assigned Provider of that Case, where Attending Provider will group and create claims based on the Assigned Provider at the Transaction line.)  This loop will be omitted if the Billing Provider is the Rendering Provider (ex. Provider is filing claim as Individual).  (Note: This NPI would relate to box 24j on a Paper HCFA claim.)

NM1*82*1*HINCKLE*WALLACE****XX*9876543210	2310B Loop-NM1 Seg
PRV*PE*PXC*PROVITAXON	2310B Loop-PRV Seg

First Transaction on Claim

This is the first transaction's information broken down.

LX*1	2400 Loop-LX Seg
SV1*HC:99000:::::HANDLING FEE*8*UN*1***1:2:3	2400 Loop-SV1 Seg
DTP*472*D8*20120219	2400 Loop-DTP Seg
REF*6R*100	2400 Loop-REF Seg

Second Transaction on Claim

The transaction loop will repeat until all the transaction lines on the claim have been processed.

LX*1	2400 Loop-LX Seg
SV1*HC:J0490:::::BENADRYL HCL, UP TO 50 MG.*4999.5*UN*1***1:2:3	2400 Loop-SV1 Seg
DTP*472*D8*20120219	2400 Loop-DTP Seg
REF*6R*99	2400 Loop-REF Seg

NDC Information for Second Transaction on Claim

Additional information, such as the NDC information, will sometimes be added between the transaction entries and will apply to the transaction directly above it.

LIN**N4*12345678901	2410 Loop-LIN Seg
CTP****50*UN	2410 Loop-CTP Seg

File Footer Information

Once all the transactions, claims, and patients have been processed, this information will be added to signify the end of the claim file.

SE*9999*0001	SE Loop
GE*9999*1	GE Loop
IEA*9999*000000001	IEA Loop