HSU Computing, Inc

HIPAA 835 Analytics Table Mapping


EDI Interchange Control Table - EdiISA

Field Description Segment Data Element-Sub DE
ID Entry Identity
FolderName HIPAA 835/837 File folder location
FileName HIPAA 835/837 File name
AuthorInfoQualifier Authorization Information Qualifier ISA 01
AuthorInfo Authorization Information ISA 02
SecurityInfoQualifier Security Information Qualifier ISA 03
SecurityInfo Security Information ISA 04
SenderQualifier Interchange ID Qualifier ISA 05
Sender Interchange Sender ID ISA 06
ReceiverQualifier Interchange ID Qualifier ISA 07
Receiver Interchange Receiver ID ISA 08
Date Interchange Date ISA 09
Time Interchange Time ISA 10
Standard Standard or Repetition Separator ISA 11
Version Interchange Control Version Number ISA 12
ControlNumber Interchange Control Number ISA 13
AckRequired Acknowledgment Required ISA 14
Usage Test or Production flag ISA 15
ComponentSeparator Component Data Element Separator ISA 16
DataElementSeparator Data Element Separator
GSCount Functional Group Count
Created Entry Creation Time Stamp

EDI Functional Group Control Table - EdiGS

Field Description Segment Data Element-Sub DE
ID Entry Identity
ISAId Foreign key to EdiISA table
FunctionID Functional ID Code GS 01
SenderAppCode Application Sender Code GS 02
ReceiverAppCode Application Receiver Code GS 03
Date Functional Group Creation Date GS 04
Time Functional Group Creation Time GS 05
ControlNumber Functional Group Control Number GS 06
AgencyCode Responsible Agency Code GS 07
Version Version/Release ID Code GS 08
TSNo Transaction Set Count
Created Entry creation time stamp

HIPAA 835 Table - H835

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
GSId Foreign key to EdiGS Table
TSIdCode Transaction Set ID ST 01
TSControlNo Transaction Set Control Number ST 02
TSConventionReference Implementation Convention Reference ST 03
TSSegmentCount Segment count inside Transaction Set SE 01
PayerId Foreign key to Payer Table
PayeeId Foreign key to Payee Table
TxnHandlingCode Transaction Handling Code BPR 01
PaymentAmount Total Provider Payment Amount BPR 02
CreditDebitCode Credit/Debit Flag Code BPR 03
PaymentMethodCode Payment Method Code BPR 04
PaymentFormatCode Payment Format Code BPR 05
PayerDFINumberQualifier Payer Depository Financial Instition (DFI) ID Qualifier BPR 06
PayerDFINumber Payer DFI ID Number BPR 07
PayerAccountNumberQualifier Payer DFI Account Number Qualifier BPR 08
PayerAccountNumber Payer DFI Account Number BPR 09
OriginatingCompanyID Payer ID BPR 10
OriginatingCompanySupplementalCode Originating Company Supplemental Code BPR 11
PayeeDFINumberQualifier Payee DFI Number Qualifier BPR 12
PayeeDFINumber Payee DFI Number BPR 13
PayeeAccountNumberQualifier Payee DFI Account Number Qualifier BPR 14
PayeeAccountNumber Payee DFI Account Number BPR 15
PaymentDate Check Issue or EFT Effective Date BPR 16
TraceTypeCode Trace type code TRN 01
CheckOrEftNo Check or EFT Trace number TRN 02
PayerEIN Payer Number TRN 03
ReceiverID Receiver ID REF 02
VersionID Version ID REF 02
ProductionDate Production Date DTM 02
Created Entry created date

Claim Payment Group Table - ClaimPmtGroups

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Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
Edi835Id Foreign key to Edi835 table
LineNumber Assigned number 2000 LX 01
TS3Present TS3 segment present in the loop 2000 2000
ProviderID Provider ID 2000 TS3 01
FacilityTypeCode Facility Type Code 2000 TS3 02
FiscalPeriod Fiscal Period Date 2000 TS3 03
TotalClaimCount Total Claim Count 2000 TS3 04
TotalClaimCharge Total Claim Charge Amount 2000 TS3 05
TotalMSPPayerAmount Total MS Payer Amount 2000 TS3 13
TotalNonLabChargeAmount Total Non-Lab Charge Amount 2000 TS3 15
TotalHCPCSReportedChargeAmount Total HCPCS Reported Charge Amount 2000 TS3 17
TotalHCPCSPayableAmount Total HCPCS Payable Amount2000 TS3 18
TotalProfessionalComponentAmount Total Professional Component Amount 2000 TS3 20
TotalMSPPatientLiabilityNetAmount Total MSP Patient Liability Met Amount 2000 TS3 21
TotalPatientReimbursementAmount Total Patient Reimbursement Amount 2000 TS3 22
TotalPIPClaimCount Total PIP Claim Count 2000 TS3 23
TotalPIPAdjustmentAmount Total PIP Adjustment Amount 2000 TS3 24
TS2Present TS2 segment present in the loop 2000 2000
TS201 Money Amount 2000 TS2 01
... Money Amount 2000 TS2 ...
TS219 Money Amount 2000 TS2 19

Claim Payment Table - ClaimPmts

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
ClaimPmtGroupId Foreign key to ClaimPmtGroup table
PatientControlNo Patient Control Number, Account Number 2100 CLP 01
ClaimStatusCode Claim Status Code 2100 CLP 02
ChargeAmount Total claim charge amount 2100 CLP 03
PaymentAmount Claim Payment Amount 2100 CLP 04
PatientResponsibleAmount Patient Responsible Amount 2100 CLP 05
FilingCode Claim Filing Indication Code 2100 CLP 06
PayerClaimControlNumber Payer Claim Control Number 2100 CLP 07
FacilityTypeCode Facility Type Code 2100 CLP 08
FrequencyCode Claim Frequency Code 2100 CLP 09
DRGCode DRG Code 2100 CLP 11
DRGWeight Adjudicated DRG Weight 2100 CLP 12
DischargeFraction Ajudicated Discharge Fraction 2100 CLP 13
AllowedAmount Allowed amount 2100 AMT (AU) 02
PatientNameId Patient, Foreign key to EntityNames table 2100 NM1 *1
InsuredNameId Insured Name, Foreign key to EntityNames table 2100 NM1 *1
CorrectedPatientOrInsuredNameId Corrected Patient/Insured Name, Foreign key to EntityNames table 2100 NM1 *1
ProviderNameId Service Provider, Foreign key to EntityNames table 2100 NM1 *1
CrossoverCarrierNameId Crossover Carrier for this claim, Foreign key to EntityNames table 2100 NM1 *1
CorrectPriorityPayerNameId Priority Payer, Foreign key to EntityNames table 2100 NM1 *1
OtherSubscriberNameId Other Subscriber, Foreign key to EntityNames table 2100 NM1 *1
RemarkCodes Not used
ServiceStartDate Claim Statement Period Start Date 2100 DTM (232) 02
ServiceEndDate Claim Statement Period Start Date 2100 DTM (233) 02
Contacts Administrative contact info 2100 PER 01..08
REFs REF segment data 2100 REF *2
DTMs DTM segment data 2100 DTM *2
AMTs AMT segment data 2100 AMT *2
QTYs QTY segment data 2100 QTY *2

Notes:


Service Line Payment Table

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
ClaimPmtId Foreign key to ClaimPmts table
AdjudicatedPC_Qualifier Adjudicated Procedure Code Qualifier 2110 SVC 01-1
AdjudicatedPC_Code Adjudicated Procedure Code 2110 SVC 01-2
AdjudicatedPC_Modifier1 Procedure Code Modifier 1 2110 SVC 01-3
AdjudicatedPC_Modifier2 Procedure Code Modifier 2 2110 SVC 01-4
AdjudicatedPC_Modifier3 Procedure Code Modifier 3 2110 SVC 01-5
AdjudicatedPC_Modifier4 Procedure Code Modifier 4 2110 SVC 01-6
AdjudicatedPC_Description Description 2110 SVC 01-7
ChargedAmount Line Item Charge Amount 2110 SVC 02
PaymentAmount Line Item Payment Amount 2110 SVC 03
NubcRevenueCode NUBC Code 2110 SVC 04
PaidUoS Unit of Service Paid Count 2110 SVC 05
OriginalPC_Qualifier Original Submitted Procedure Code Qualifier 2110 SVC 06-1
OriginalPC_Code Original Submitted Procedure Code 2110 SVC 06-2
OriginalPC_Modifier1 Submitted Procedure Code Modified 1 2110 SVC 06-3
OriginalPC_Modifier2 Submitted Procedure Code Modified 2 2110 SVC 06-4
OriginalPC_Modifier3 Submitted Procedure Code Modified 3 2110 SVC 06-5
OriginalPC_Modifier4 Submitted Procedure Code Modified 4 2110 SVC 06-6
OriginalPC_Description Description 2110 SVC 06-7
OriginalUoS Submitted Unit of Service Count 2110 SVC 07
ServiceStartDate Service Start Date 2110 DTM (150) 02
ServiceEndDate Service End Date 2110 DTM (151) 02
LineControlNo Line Item Control Number 2110 REF (6R) 02
AllowedAmount Line Item Allowed Amount 2110 AMT (B6) 02
RemarkCodes Remark Codes 2110 LQ 01,02
REFs REF Segment data 2110 REF *2
AMTs AMT Segment data 2110 AMT *2
QTYs QTY Segment data 2110 QTY *2

Payment Adjustment Table - PmtAdjustments

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
GroupCode Adjustment Group Code 2100, 2110 CAS 01...
ReasonCode Adjustment Reason Code 2100, 2110 CAS 02...
Amount Adjustment Amount 2100, 2110 CAS 03...
Quantity Adjustment Quantity 2100, 2110 CAS 04...
ClaimPmtId Foreign key to ClaimPmts table
ServiceLinePmtId Foreign key to ServiceLinePmts table

Payee Table

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
ProviderID Foreign key to Providers table
DeliveryMethod Report Transmission Code 1000B RDM 01
DeliveryName Mail to attention person's name 1000B RDM 02
DeliveryNumber URL or Email address 1000B RDM 03
Created Entry creation time stamp

Payer Table

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
EntityType Entity Type, Not used 1000A N1 01
Name Payer Name 1000A N1 02
PayerIdQualifier Payer ID Qualifier 1000A N1 03
PayerID Payer ID 1000A N1 04
SecondaryIDs Payer Additional IDs 1000A REF 01,02
Address Address Line 1000A N3 01
Address2 2nd Address Line 1000A N3 02
City City 1000A N4 01
State State 1000A N4 02
Zip Zip 1000A N4 03
Contacts Business Contact Info, Not used 1000A PER 01

Entity Names Table

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
SegmentID Segment ID NM1
EntityID Entity ID Code NM1 01
EntityType Entity Type Qualifier NM1 02
Last Last Name or Organization Name NM1 03
First First Name NM1 04
Middle Middle Name NM1 05
Suffix Name Suffix NM1 07
IdCodeQualifier Entity ID Code Qualifier NM1 08
IdCode Entity ID Code NM1 09

Provider Adjustment Table

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
Edi835Id Foreign key to Edi835 table
ProviderNPI Provider NPI PLB 01
FiscalPeriod Fiscal Period Date PLB 02
Reason Adjustment Reason Code PLB 03-1, ...
AdjustmentID Provider Adjustment ID PLB 03-2, ...
Amount Adjustment Amount PLB 04

Provider Table

Field Description Loop Segment Data Element-Sub DE
ID Table entry identity
EntityID Entity ID Code 1000B N1 01
EntityType Not used
LastName Provider Name 1000B N1 02
FirstName Not Used
MiddleName Not Used
SuffixName Not Used
NPIQualifier ID Code Qualifier 1000B N1 03
NPI ID Code 1000B N1 04
SecondaryIDs Other IDs 1000B REF 01,02
Address Address Line 1000B N3 01
Address2 2nd Address Line 1000B N3 02
City City 1000B N4 01
State State 1000B N4 02
Zip Zip Code 1000B N4 03
TINQualifier Not used
TIN Not used
Contact Not used
TaxonomyCode Not used
Created Entry creation time stamp