5010 Select HCFA - Miscellaneous 837 Keying Requirements V1 (06 02 21)

Professional (HCFA) and Misc.
Medical Claim Forms
Version 1
Professional (HCFA) and Misc. Medical Claim Forms

1
Proprietary and Confidential

5010 Keying Requirements
Revision Log
New
Date of
Revision Details of Revision Revised By:
Revision
Number
1.0 Initial Draft Ginger Barnes
Change Management Revision Log

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Request Title/Description
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2

TABLE OF CONTENTS
**Table of contents contains hyperlinks: Hold done the CTRL key and click with your mouse on one of the topics below to be taken directly to that portion of the manual.
HCFA – Miscellaneous Medical Keying Requirements

 Field 1 - Medicare, Medicaid, Champus, Champva, Group Health, Plan, FECA BLK Lung, Other
 Field 1a – Insured’s I.D. Number
 Field 2 - Patient’s Name-First Name
 Field 2 - Patient’s Name-Last Name
 Field 3 - Patient’s Birth Date
 Field 3 - Patient Sex
 Field 4 - Insured’s Name (First and Last)
 Field 5 – Patient’s Address
 Field 5 – Patient’s City
 Field 5 – Patient’s State
 Field 5 – Patient’s Zip
 Field 5 – Patient’s Telephone
 Field 6 – Patient Relationship to Insured
 Field 7 – Insured’s Address
 Field 7 – Insured’s City
 Field 7 – Insured’s State
 Field 7 – Insured’s Zip
 Field 8 – Patient Status: Marital
 Field 8 – Patient Status: Employment
 Field 8 - Patient Status: Student
 Field 9 – Other Insured's Name (First and Last)
Professional (HCFA) and Misc. Medical Claim Forms 3

 Field 9a - Other Insured s Policy or Group Number
 Field 9b - Other Insured’s Date of birth Other Insured’s Sex
 Field 9c - Employer s Name or School Name
 Field 9d - Insurance Plan Name or Program Name
 Field 10a – Is Patient Condition Related to: Employment
 Field 10b – Is Patient Condition Related to: Auto Accident?
 Field 10b - Place (State)
 Field 10c - Is Patient Condition Related to: Other Accident?
 Field 10d - Reserved for Local Use
 Field 11 - Insured's Policy Group or FECA Number
 Field 11a - Insured’s Date of Birth
 Field 11a - Insured’s Sex
 Field 11b - Employer's Name or School Name
 Field 11c - Insurance Plan Name or Program Name
 Field 11d – Is There Another Health Benefit Plan?
 N/A – Primacy Code
 Field 12a – Patient's or Authorized Person's Signature
 Field 12b - Release of Information Date
 Field 13 – Insured’s or Authorized Person’s Signature
 Field 14 – Date of Current: Illness
 Field 14 - Date of Current: Injury (Acc.)
 Field 14 - Date of Current: Pregnancy (LMP)
 Field 15 – If Patient has had same or Similar Illness. Give first date.
 Field 16 – Dates Patient unable to work in current occupation
 Field 17 – Name of Referring Physician or other Source
 Field 17a - ID Number of Referring Physician
 Field 17b – NPI (HCFA 1500)

 Field 18 – Hospitalization Dates Related to Current Services
 Field 19 – Reserved for Local Use
 Field 20 – Outside Lab? Yes No $Charges
 Field 21 - Diagnosis or Nature of Illness or Injury? 01-12
 Field 21 - Qualifier
 Field 22 – Medicaid Resubmission Code
 Field 23 – Prior Authorization Number
 Field 24 – NDC # - National Drug Control #
 Field 24a – Date(s) of Service From
 Field 24a - Date(s) of Service To
 Field 24b - Place of Service
 Field 24b - Place of Service (Claim Level)
 Field 24c – EMG (HCFA 1500)
 Field 24d - Procedures, Services or Supplies (CPT/HCPCS)
 Field 24d - Procedures, Services or Supplies (Modifier 1-4)
 Field 24e - Diagnosis Code (Pointer)
 Field 24f - $ Charges
 Field 24g - Days or Units
 Field 24h - EPSDT Family Plan
 Field 24i - EMG
 Field 24j – Rendering Provider NPI (HCFA 1500)
 Field 24j - COB
 Field24k - Reserved for Local Use
 Field 24k - Comments/Remarks (MM Only)
 Field 25 – Federal Tax ID Number
 Field 25 - Federal Tax ID Number (MM Only)
 N/A - FSA Rollover Indicator (MM Only)

 N/A - FSA Rollover Amount (MM Only)
 Field 26 – Patient Account No
 Field 27 – Accept Assignment (Medicare)
 Field 28 – Total Charges
 Field 29 – Amount Paid
 Field 30 – Balance Due
 N/A – Rendering Provider ID# - NPI (HCFA 1500) (Claim Level)
 Field 31 – Signature of Physician Last Name or Supplier including degrees or credentials
 Field 31 - Signature of Physician First Name or Supplier
 Field 31 - Signature of Physician or Supplier Indicator
 Field 31 – Date of Physician Signature
 Field 32 - Name of Facility where services were rendered
 Field 32 – Address of Facility where Services were rendered.
 Field 32 - City of Facility where services were rendered.
 Field 32 - State of Facility where services were rendered.
 Field 32 - Zip Code of Facility where services were rendered
 Field 32a – NPI (CMS and HCFA 1500)
 Field 32b – NPI (CMS and HCFA 1500)
 Field 33 - Physician’s or Supplier’s Billing Name
 Field 33 – Physician’s or Supplier’s Address
 Field 33 – Physician’s or Supplier’s City
 Field 33 – Physician’s or Supplier’s State
 Field 33 – Physician’s or Supplier’s Zip Code
 Field 33 - Physician’s, Supplier’s Phone Number
 Field 33 - GRP#
 Field 33 - PIN #
 Field 33a – NPI (HCFA 1500)

 Field 33b – NPI (HCFA 1500)
 N/A - Referral Number (MM Only)
 N/A – ESRD (End Stage Renal Disease)
 Attachment Codes
HCFA-Miscellaneous Medical COB Keying Requirements
 CBH COB Field Name Variation List (CBH Common Claim and Proclaim Prints Only)
 COB Field Name Variation List & Guidelines
 COB Sorting & Matching Criteria
 EOB Determination Guidelines
 Medicare Reason Amount (detail)
 Medicare Reason Amount (claim)
 Medicare Reason Code (Detail)
 Medicare Reason Code (claim)
 Medicare vs Commercial EOB Criteria
 Other Insurance Paid Amount (Claim)
 Other Insurance Charges (Detail)
 Other Insurance Charges (Claim)
 Other Insurance Disallowed Amount (Detail)
 Other Insurance Disallowed Amount (Claim)
 Other Insurance Coinsurance and Copayment Amount (Detail)
 Other Insurance Coinsurance and Copayment Amount (Claim)
 Other Insurance Applied Toward Deductible Amount (Detail)
 Other Insurance Applied Toward Deductible Amount (Claim)
 Other Insurance Paid Amount (Detail)
 Other Insurance Paid Amount (Claim)
 Primacy Code

HCFA-Miscellaneous Medical Anesthesia Keying Requirements
 Field 24g - Days or Units
 Field 24g - Anesthesia Minutes
HCFA-Miscellaneous Medical Durable Medical Equipment (DME) Keying Requirements
 Field 24f - $ Charges

 Field 24f - $ Charges Rental Price
 Field 24f - $ Charges Purchase Price
 Field 24g – Time Qualifier
 Field 24g – Units or Quantity
HCFA-Miscellaneous Medical Medicaid Claim Processing Keying Requirements
 Medicaid Paid Amount – Detail Level

 Hierarchical Level Information
 Medicaid Primacy Info
 Medicaid Claim Filing Code
 Medicaid Submitter ID
 CBH Medicaid Claims
 Kennett Mailroom Medicaid Claims
 Medicaid Payment Verbiage
HCFA-Miscellaneous Medical Pre-Price Claim Processing Keying Requirements
 Pre-Pricing –Detail Level

 Pre-Pricing – Claim Level
 Pre-Pricing – Vendor ID Number
 Healthlink Participating Status

 Pre-Pricing Vendor ID Table
HCFA-Miscellaneous Medical Texas Members with Autism Diagnosis Keying Requirements
 Guidelines for Nutritional Supplements

 Field 21 - Diagnosis or Nature of Illness or Injury (01-12)
 Field 24D - Procedures, Services or Supplies (CPT/HCPCS)
HCFA-Miscellaneous Medical Keying Requirements – Additional Documentation
 Additional Keying Information

 Appendix “A”: Assignment Field Verbiage
 Appendix “B”: Durable Medical Equipment (DME) Listing
 Appendix “C”: Information to be captured in claim level remarks
 Appendix “C.1”: CBH Information to be captured in claim level remarks
 Appendix “D”: Relationship Code Mapping
 Appendix “E”: Place of Service Translation Table
 Appendix “G”: Cigna Verbiage
 Appendix “H”: Diagnosis Code Chart—Vision Claims
 Appendix “I”: Diagnosis Code vs. Verbiage Logic
 Appendix “J”: Century Logic
 Appendix “K”: Group vs Facility Logic
 Appendix “L”: Other Insured Insurance Plan Name or Program Name
 Appendix “M”: Cigna Attachment Code List
 Appendix “N”: EOB Determination Guidelines
 Appendix “O”: COB Field Name Variation List
 Appendix “P” CBH Common Claim and Proclaim Print COB Match Criteria
 Appendix “Q”: Medicare vs. Commercial EOB Criteria

 Appendix “R”: COB Sorting/Matching Criteria
 Appendix “S”: Claim Sorting Criteria
 Appendix “T”: Claim Splitting Criteria
 Appendix “U”: Renaissance Claims Keying Requirements
 Appendix “V”: Example of Provider Name Formats
 Appendix “V.1”: Sample HCFA 1500 Claim Form
 Appendix “V.2”: Sample CMS 1500 Claim Form
 Appendix W: Inpatient Codes

EDI
Gateway’s
Required
ANSI Common
to ANSI
HCFA-MM Claim Form Loop Claim Record
Submit Element
Field # Field Name Current Requirements Segment Field Name,
to EDI Number
Data Element Size, Claim
Gateway
or Detail
Level
1 Medicare Cigna Business Requirements 2000B Gateway OI-
Medicaid  Key if present SBR EDI Info: QUALIFIER(2
Champus SBR09 SNIP 4 000B)
Champva edits in
Group Health place to
Plan EDI Requirements: ECHCF: reject when ECR Field
FECA BLK Lung Valid 5010 Values – Claim/ used & not names:
Other - 12 - Preferred Provider Organization (PPO) echcf:SubscriberI needed E2-
- 13 - Point of Service (POS) nfo/ and reject INSURANCE-
- 14 - Exclusive Provider Organization (EPO) hcfd:insuranceInf when TYPE(2320)
- 15 - Indemnity Insurance o/ needed &
- 16 - Health Maintenance Organization (HMO) hcfd:FilingIndicat not used. XCCR field
- Medicare Risk orCode Should not name :
- 17 - Dental Maintenance Organization be used C00-SB-INS-
- AM - Automobile Medical after TY-CD
- BL - Blue Cross/Blue Shield mandated
- CH - Champus use of
- CI - Commercial Insurance Co. National
- DS - Disability PlanID.
- FI - Federal Employees Program
- HM - Health Maintenance Organization
- LM - Liability Medical
- MA - Medicare Part A
- MB - Medicare Part B
- MC - Medicaid
- OF - Other Federal Program (Use code OF
- when submitting Medicare Part D
- claims)
- TV - Title V
- VA - Veterans Affairs Plan
- WC - Workers’ Compensation Health Claim
- ZZ - Mutually Defined
- 71 - Use Code ZZ when Type of Insurance is not known.
Gateway Rule
- No specific rules
1a Insured’s I.D. X Cigna Business Requirements: Loop 2010BA EMPLOYEE-

Number  Key if present, and use this number to attempt an eligibility match. NM1 SSN PIC

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
NM101 = IL 66 X (20)
Eligibility Matching Criteria: NM102 = 1 CLAIM LEVEL
CBH Proclaim  Populate from eligibility lookup based on the insured’s id, Name and date of birth information NM108 = MI 67
Field Name:  If an eligibility record is returned, compare last name in the eligibility record to the insured last name on the claim. NM109 Xnet Field
EMP SSN  If an exact match is made, send the information returned in the eligibility record. Name:
 If an exact match is not made, key / send the insured information from the claim. Gateway (SSN) EE
CBH Common  If the insured was not located in the eligibility lookup or an exact match is not made, key / send the insured information ECHCF: EDI Info: SSN
Claim Field on claim. Claim/echcf:Subs SNIP 4 edit (AMI) EE ID
Name: criberInfo/ucfd:Pri rejects
EE SSN  If not present, use the insured name information from field 4 and the insured date of birth information from field 11a to attempt an maryIdentifer/ucf: when ECR Field
EE ID eligibility match. If a match is made, use the ID obtained within eligibility as the Insured ID. Identifier subscriber E2-EMPLE-
 Whether or not an eligibility match is made, if an ID is present in field 1a, this number should be output as the Insured ID if greater id is same SSN
than 2 digits and less than or equal to 19 as
 Insured’s I.D. Number: Key as many digits are present on the claim—must be greater than 2 and less than or equal to 19 Group/Polic
 Insured’s ID Number can be alphanumeric in any position within the ID. y number. Core WebDE:
 If missing or illegible, review the attachments to determine if the information is available prior to rejecting for missing or illegible InsIDa+InsIDb
information.
 If not present on claim, 2 digits or less, greater than 19 digits, and/or no match found in eligibility, reject claim. Select
WebDE:
od_id_number
Remove suffix from the Customer ID on the initial claim submission for newborn claims.
XCCR: M05-
Newborn claims are defined as a claim in which the date of service (earliest) on the claim is within 30 days of patient’s date of birth. PARTY-REF-
TY-CD
 Newborn claims submitted with a Customer ID that includes a suffix, should be submitted without the suffix on the initial claim
submission.
 Newborn claims submitted with an SSN or AMI without a suffix, should be transmitted as received
 Newborn claims returned with a 277CA reject should be returned with the appropriate reject letter.
EDI Requirements
 If # is 2 digits or less, greater than 19 digits, illegible or blank, reject up front
 Alphanumeric field.
 Remove special characters
Auditing Guide:
If the AMI or customer ID is blank, illegible or invalid and the procedure code on the claim is ‘99404’, send the default ‘CBH99.’ For
all other procedure codes received in the CBH PO box, if the AMI or customer ID is blank or invalid, reject upfront. Claims received
in the CBH PO Box with an illegible AMI or customer ID will be sent with the default ‘CBH99’.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
2 Patient’s Name- X Cigna Business Requirements Loop 2010CA PATIENT-

First Name  Populate from dependent eligibility lookup based on the insured’s id, patient name and patient date of birth information NM1 98 FIRST-NAME
 Multiple ways to make patient match: NM101=QC 1065 PIC X(25)
CBH Proclaim 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match NM102=1 CLAIM LEVEL
Field Name: 2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name NM104 = FN
PAT-NAME and DOB) NM105 = MI 1036 (First) ECR Field
3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step 1037 name:
children or spouse using maiden name) (Middle) E2-PAT-
CBH Common 4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last ECHCF: FIRST-NAME
Claim Field name and dob) could be using nick names or shortened version of first name Claim/echcf:Patie
Name:  If the dependent was not located in the eligibility lookup, key the patient information on claim. ntInfo/ucfd:FirstN Xnet Field
PAT FNAME  Multiple names returned by eligibility look-up - key as shown on claim ame Name:
 No names returned by eligibility look-up - key as shown on claim
PAT MNAME  If unable to populate from eligibility look-up (i.e. blank, illegible or incomplete DOB) - key as shown on claim. XCCR :
M00-FRST-NM Xnet Field
 If a ( / ) is present, consider as a comma and parse name using existing name rules.
Name:
 Do not key punctuation.
PAT FNAME
 Do not key prefixes (Mr., Ms., etc.)
 If middle name is present, key middle name Core WebDE:
 If middle name is not present, but middle initial is present, key middle initial PatFirst,
 If name is hyphenated, key as two words with no hyphen PatMid
 If the word “SAME” is present in the Patient’s Name field, duplicate the Insured’s first name.
 If there is only one name in box 2, assume it to be the patient’s first name and duplicate the Insured’s last name. Select
 If names are divided by commas, use the following parsing rule to determine: last name, first name middle initial. WebDE:
 If missing or illegible, review the attachments to determine if the name is available prior to rejecting for missing or illegible od_pat_name
information. _f,
 If first name is not present and does not populate in eligibility table, reject claim. od_pat_name
 To help identify the Patient Name when not clearly indicated refer to the below list of terms commonly submitted as the Patient _m
Name.
May be identified by but not limited to:
o Patient Name
o Patient
o Pat Name
o Pat
Newborn Requirements:
 If patient is identified as a newborn, the patient’s first name must be output as:
o “Newborn”

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
o “Baby Boy”
o “Baby Girl”
o “Twin A”
o “Twin B”
 If the patient is a newborn and one of the above names are not indicated in this field, please change the name based off of the
below criteria:
o If the newborn does not have a gender identified in Field 3, output “Newborn”
o If the newborn indicates a M for male in Field 3, output “Baby Boy”
o If the newborn indicates a F for female in Field 3, output “Baby Girl”
o If the newborn has an identical birthday as another newborn with the same last name, DOB, output “Twin A” or “Twin
B”
 Newborn patients are identified by having one of the following characteristics :
o Date of Birth is less than 31 days
o First name is submitted as ‘newborn’, ‘baby boy’, ‘baby girl’, etc.
EDI Requirements
 If patient first name is blank, reject up front.
 Remove special characters.
Auditing Guide:
 In Xnet, if the Insured’s and Patient’s name are the same and the Patient Relationship is 18, the Insured’s information is output for
both the Insured and the Patient.
2 Patient’s Name- Cigna Business Requirements: Loop 2010CA PATIENT-

Last Name  Populate from dependent eligibility lookup based on the insured’s id, patient name and patient date of birth information NM1 LAST-NAME
 Multiple ways to make patient match: NM101=QC PIC X(35)
CBH Proclaim 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match NM102=1 CLAIM LEVEL
Field Name: 2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name NM103= LN 1035
PAT-NAME and DOB) ECR Field
3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step ECHCF: name : E2-
children or spouse using maiden name) Claim/echcf:Patie PAT-LAST-
4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last ntInfo/ucfd:FirstN NAME
CBH Common name and dob) could be using nick names or shortened version of first name ame
Claim Field  If the dependent was not located in the eligibility lookup, key the patient information on claim.
Name:  Multiple names returned by eligibility look-up - key as shown on claim XCCR : Xnet Field
PAT LNAME  No names returned by eligibility look-up - key as shown on claim M00-LAST-NM- Name:
PAT GEN  If unable to populate from eligibility look-up (i.e. blank, illegible or incomplete DOB) - key as shown on claim. ORG-NM PAT LNAME
 If a ( / ) is present, consider as a comma and parse name using existing name rules.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Do not key punctuation.
 Do not key prefixes (Mr., Ms., etc.) Core WebDE:
 If suffix is present, key (Jr., III, etc.). PatLast
 If name is hyphenated, key as two words with no hyphen
 If there is only one name in box 2, duplicate the Insured’s last name. Select
 If the word “SAME” is present in the Patient’s Name field, duplicate the insured’s last name. WebDE:
 To help identify the Patient Name when not clearly indicated refer to the below list of terms commonly submitted as the Patient od_pat_name
Name. _l
 May be identified by but not limited to:
 Patient Name
 Patient
 Pat Name
 Pat
EDI Requirements
Auditing Guide:
3 Patient Birth X Cigna Business Requirements Loop 2010CA EMPLOYEE-

Date  Populate from dependent eligibility lookup based on the insured’s id, patient name and patient date of birth information DMG DATE-OF-
 Multiple ways to make patient match: DMG01=D8 1250 BIRTH PIC
CBH Proclaim 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match DMG02 1251 X(08) CLAIM
Field Name: 2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name LEVEL
PAT-DOB and DOB) ECHCF:
3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step Claim/echcf:Patie
children or spouse using maiden name) ntInfo/ucfd:Demo ECR field :
CBH Common 4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last graphicsInfo/ucfd: E2-EMPLE-
Claim Field name and dob) could be using nick names or shortened version of first name BirthDate DOB
Name:  If the dependent was not located in the eligibility lookup, key the patient information on claim.
PAT DOB  Date must be valid XCCR : Xnet Field
 Do not key slashes (/), dashes (-), or special characters. M00-BRTH-DT Name:
 If date is future, send as a future date PAT DOB
 If date is blank, and the word “SAME” is present in the Patient’s Name field, duplicate the Insured’s date of birth (F11a).
 If century is not included on the claim, logic must create century. Core WebDE:

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If century does not equal 19, 20 or 21 default DOB to ‘1900101’ If patient date of birth is not present (blank), illegible, or has invalid PatDOB
century code output “19000101”.
Insured = Patient Data Fields : Address, Gender, DOB Fields Select
 When Patient = Insured only Insured data loop is sent. WebDE:
 Insured data (as submitted on the claim) should be sent in Insured loop od_pat_dob
 When Insured data is incomplete (Address, Gender, DOB and Relationship), and data is present in Patient fields, populate Insured
data loop with Patient data submitted on the claim
 If both Insured and Patient data (Address, Gender, DOB and Relationship) is missing in any of these fields on the claim and an
exact match was found on ID in eligibility, populate missing data fields in Insured loop with Insured data information found in
eligibility file
 If Insured Data fields are blank, Patient data fields are blank, and no eligibility data found in eligibility file (on exact match), populate
data fields with defaults as defined
EDI Requirements
 Format date in CCYYMMDD format.
 If blank, default to “19000101”.

3 Patient Sex X Cigna Business Requirements Loop 2010CA PATIENT-
 Populate from dependent eligibility lookup based on the insured’s id, patient name and patient date of birth information DMG SEX PIC
CBH Proclaim  Multiple ways to make patient match: DMG03 1068 X(01) CLAIM
Field Name: 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match F = FEMALE LEVEL
SEX 2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name M = MALE
and DOB) U = UNKNOWN ECR Field :
3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step E2-PAT-SEX
CBH Common children or spouse using maiden name) ECHCF:
Claim Field 4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last Claim/echcf:Patie
Name: name and dob) could be using nick names or shortened version of first name ntInfo/ucfd:Demo Xnet Field
PAT SEX  If the dependent was not located in the eligibility lookup, key the patient information on claim. graphicsInfo/ucfd: Name:
 If blank, or if both are marked, send U Gender PAT SEX
 Valid values are F for female and M for male, and U for unknown.
Insured = Patient Data Fields : Address, Gender, DOB Fields XCCR : Core WebDE:
 When Patient = Insured only Insured data loop is sent. M00-GENDER- PatSex
 Insured data (as submitted on the claim) should be sent in Insured loop CD
 When Insured data is incomplete (Address, Gender, DOB and Relationship), and data is present in Patient fields, populate Insured Select
data loop with Patient data submitted on the claim WebDE:
 If both Insured and Patient data (Address, Gender, DOB and Relationship) is missing in any of these fields on the claim and an od_pat_sex
eligibility file

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
EDI Requirements
 Key if present
 If blank, default to “U"
4 Insured’s Name X Cigna Business Requirements: Loop 2010BA EMPLOYEE-

(First and Last)  Populate from eligibility lookup based on the insured’s id, Name and date of birth information NM1 LAST-NAME
 If the insured was not located in the eligibility lookup or an exact match is not made, key / send the insured information on claim. NM101=IL 98 PIC X(35)
Match Criteria: NM102=1 1065 CLAIM LEVEL
CBH Proclaim  If an eligibility record is returned, compare last name in the eligibility record to the insured last name on the claim. NM103 = LN 1035 EMPLOYEE-
Field Name:  If an exact match is made, send the information returned in the eligibility record. NM104 = FN 1036 FIRST-NAME
EMP-NAME  If an exact match is not made, key / send the insured information from the claim. PIC X(25)
 If the insured was not located in the eligibility lookup or an exact match is not made, key / send the insured information on claim. ECHCF: CLAIM LEVEL
Example: Claim/echcf:Subs EMPLOYEE-
CBH Common Last Name returned in eligibility record: Johnson criberInfo/ucfd:La GENERATIO
Claim Field Insured last name on Claim: John stName N PIC X(10)
Name:  Johnson and John is not an exact match, key / send insured information from the claim. CLAIM LEVEL
EE LNAME
Hyphenated name match criteria: Claim/ ECR field :
EE FNAME  If an exact match is made to one of the last names, send the information returned in the eligibility record. echcf:SubscriberI E2-EMPLE-
 If an exact match is not made to one of the last names, key / send insured information from the claim. nfo/ FIRST-NAME
EE MNAME Example: ucfd:FirstName E2-EMPLE-
Last name returned in eligibility record: Smith LAST-NAME
Insured last name on claim: Smith-Jones XCCR :
 Smith returned in eligibility record, is a match to Smith on claim form, send information returned in the eligibility record. M00-FRST-NM Xnet Field
Example: M00-LAST-NM- Name:
Last name returned in eligibility record: Jones ORG-NM EE FNAME
Insured last name on claim: Smith-Johnson EE LNAME
 Jones returned in eligibility record, is not a match to Smith or Johnson, key / send information from the claim.
 If a ( / ) is present, consider as a comma and parse name using existing name rules. Core WebDE:
 Do not key punctuation. InsLast,
 Do not key prefixes (Mr., Ms., etc.) InsFirst,
 If suffix is present, key (Jr., III, etc.) after the last name. ???
 If middle initial is present, key first name followed by a space, then middle initial.
 If name is hyphenated, key as two words with no hyphen Select
 If the word “SAME” is present, duplicate the patient’s first and last name. WebDE:
 If insured name is blank, and patient relationship is Self, duplicate patient name. od_ins_name
 If there is no insured name and there is no patient name or the word “SAME” does not exist and the insured was not located in the _l,

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
eligibility look-up, reject claim od_ins_name
 If missing or illegible, review the attachments to determine if the information is available prior to rejecting for missing or illegible _f,
information. od_ins_name
_m
EDI Requirements:
 If there is no name, reject up front
Auditing Guide:

5 Patient’s X Cigna Business Requirements Loop 2010CA PATIENT-
Address  If we get a match on the member ID based on patient name and patient DOB, plug the address fields from the dependent eligibility N3 ADDRESS-1
table N301 = Addr1 166 PIC X(35)
CBH Proclaim  Multiple ways to make patient match: N302 = Addr2 166 CLAIM LEVEL
Field Name: 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match PATIENT-
PAT-ADDR 2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name Length of ADDRESS-2
and DOB) Address has PIC X(35)
PAT-ADDR-2 3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step increased to 55 CLAIM LEVEL
children or spouse using maiden name) characters.
4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last ECR Fields:
CBH Common name and dob) could be using nick names or shortened version of first name ECHCF: E2-PAT-
Claim Field  If the dependent was not identified as a match to the eligibility file, key the patient address information from the claim Claim/ ADDR-1
Name:  If the dependent is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and echcf:PatientInfo/ E2-PAT-2
PAT ADDR key what is on the claim. ucfd:AddressInfo/
 If address contains two lines, key both lines. ucfd:AddressLine Xnet Field
o Street address & suite #'s will be populated in Address 1 if both a physical and PO box address are present. 1 Name:
o PO box will populated in Address 2. PAT ADDR
Claim/
o If only PO box is present will be populated in Address 1.
echcf:PatientInfo/ Core WebDE:
o If data is present in address 2, then address 1 cannot be blank. If second line of address is present and first is not, move ucfd:AddressInfo/ PatAdr1 or
second line up to first line. ucfd:AddressLine InsAdr1,
 If the word “SAME” is present in the patient’s address, city, state or zip, duplicate insured’s address, city, state and zip. 2 PatAdr2 or
 If patient address is incomplete or missing from the claim form, output the Insured’s address, city, state and zip as listed on the InsAdr2
claim form. XCCR :
 Use Insured's Address - If the Patient address is missing or incomplete (any fields missing) populate with the Insured address M00-ADDR-LN1 Select
information. If the Insured information is also missing or incomplete, reject the claim back to the submitter for missing address line. M00-ADDR-LN2 WebDE:
 If missing or illegible, review the attachments to determine if the information is available prior to rejecting for missing or illegible od_pat_addr,
information. od_pat_addr_

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If the patient address and insured address are not present and an eligibility match could not be made, member mail will be treated 2
as dead mail (Misc. Med)
Insured = Patient Data Fields : Address, Gender, DOB Fields

 When Patient = Insured only Insured data loop is sent.
 Insured data (as submitted on the claim) should be sent in Insured loop
 When Insured data is incomplete (Address, Gender, DOB and Relationship), and data is present in Patient fields, populate Insured
 If both Insured and Patient data (Address, Gender, DOB and Relationship) is missing in any of these fields on the claim and an
eligibility file
 If Insured Data fields are blank, Patient data fields are blank, and no eligibility data found in eligibility file (on exact match), reject
back to the submitter
EDI Requirements
 Remove special characters.
Auditing Guide:
 Cigna International claims may have a defaulted address of 300 Bellevue Parkway, Wilmington, DE 19809.
 Do not count errors for standard Postal abbreviations being keyed for Street, Lane, Drive, Boulevard, Avenue etc… as long as the
abbreviation is keyed correctly.

5 Patient’s City Cigna Business Requirements Loop 2010CA PATIENT-
 If we get a match on the member ID based on patient name and patient DOB, plug the address fields from the dependent eligibility N4 CITY PIC X
CBH Proclaim table N401 19 (30) CLAIM
Field Name:  Multiple ways to make patient match: LEVEL
PAT-CITY 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match ECHCF:
2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name Claim/ ECR Fields:
and DOB) echcf:PatientInfo/ E2-PAT-CITY
CBH Common 3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step ucfd:AddressInfo/
Claim Field children or spouse using maiden name) ucfd:City Xnet Field
Name: 4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last Name:
PAT CITY name and dob) could be using nick names or shortened version of first name XCCR Field: PAT CITY
 If the dependent was not identified as a match to the eligibility file, key the patient address information from the claim M00-CITY-NM
 If the dependent is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and
key what is on the claim.
 If the word “SAME” is present in the patient’s address, city, state or zip, duplicate insured’s address, city, state and zip.
 If patient address is incomplete or missing from the claim form, output the Insured’s address, city, state and zip as listed on the
claim form.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Use Insured's Address - If the Patient address is missing or incomplete (any fields missing) populate with the Insured address
information. If the Insured information is also missing or incomplete, reject the claim back to the submitter for missing city field.
 If missing or illegible, review the attachments to determine if the information is available prior to rejecting for missing or illegible.
 If the patient address and insured address are not present and an eligibility match could not be made, member mail will be treated
as dead mail (Misc. Med)

 When Patient = Insured only Insured data loop is sent.
 Insured data (as submitted on the claim) should be sent in Insured loop
eligibility file
 If Insured Data fields are blank, Patient data fields are blank, and no eligibility data found in eligibility file (on exact match), reject
back to the submitter
EDI Requirements
Auditing Guide:
 Cigna International claims may have a defaulted address of 300 Bellevue Parkway, Wilmington, DE 19809.
5 Patient’s State Cigna Business Requirements Loop 2010CA PATIENT-

 If we get a match on the member ID based on patient name and patient DOB, plug the address fields from the dependent eligibility N4 STATE PIC
CBH Proclaim table N402 156 X(02) CLAIM
Field Name:  Multiple ways to make patient match: LEVEL
PAT-STATE 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match ECHCF:
2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name Claim/ ECR Field:
and DOB) echcf:PatientInfo/ E2-PAT-
CBH Common 3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step ucfd:AddressInfo/ STATE
Claim Field children or spouse using maiden name) ucfd:State
Name: 4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last
PAT STATE name and dob) could be using nick names or shortened version of first name XCCR Field: Xnet Field
 If the dependent was not identified as a match to the eligibility file, key the patient address information from the claim M00-STE-PROC- Name:
 If the dependent is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and CD PAT STATE
key what is on the claim.
 If the word “SAME” is present in the patient’s address, city, state or zip, duplicate insured’s address, city, state and zip. Core WebDE:
 If patient address is incomplete or missing from the claim form, output the Insured’s address, city, state and zip as listed on the PatSt or InsSt

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
claim form.
 Use Insured's Address - If the Patient address is missing or incomplete (any fields missing) populate with the Insured address Select
information. If the Insured state information is also missing or incomplete, default state to “XX”. WebDE:
 Do not reject for only missing state information in address line od_pat_state
 If missing or illegible, review the attachments to determine if the information is available.

eligibility file
EDI Requirements
 Default XX
 State must be a valid state abbreviation.
Auditing Guide:
5 Patient’s Zip Cigna Business Requirements Loop 2010CA PATIENT-ZIP

 If we get a match on the member ID based on patient name and patient DOB, plug the address fields from the dependent eligibility N4 PIC X(11)
CBH Proclaim table N403 116 CLAIM LEVEL
Field Name:  Multiple ways to make patient match:
PAT-ZIP 1) DOB can be off 1 digit (off on month, but the year and day may match or off on the year) you have name and address match ECHCF: ECR field:
2) If Name and DOB is a match – address is not a match – you can use that member (the ID pulled up the correct patient name Claim/ E2-PAT-ZIP
and DOB) echcf:PatientInfo/
CBH Common 3) Last name is not a match but first name, dob matches (the ID pulled up the correct patient first name and dob) (could be step ucfd:AddressInfo/ Xnet Field
Claim Field children or spouse using maiden name) ucfd:PostalCode Name:
Name: 4) First name is not a match, dob matches and last name matches and gender is a match (the ID pulled up the correct patient last PAT ZIP
PAT ZIP name and dob) could be using nick names or shortened version of first name XCCR Field:
 If the dependent was not identified as a match to the eligibility file, key the patient address information from the claim M00-POSTL-CD. Core WebDE:
 If the dependent is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and PatZip1+PatZi
key what is on the claim. p2 or

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Zip code must be equal to 5 or 9 numeric digits, no spaces. InsZip1+InsZi
 If the word “SAME” is present in the patient’s address, city, state or zip, duplicate insured’s address, city, state and zip. p2
 Do not send Patient Zip if patient name is missing
 If patient address is incomplete or missing from the claim form, output the Insured’s address, city, state and zip as listed on the Select
claim form. WebDE:
 Use Insured's Address - If the Patient address is missing or incomplete (any fields missing) populate with the Insured address od_pat_zip
information. If the Insured zip code information is also missing or incomplete, default 99999
 Do not reject for only missing zip code information in address line

eligibility file
EDI Requirements
 If blank, default 99999
 If greater than or less than 5 or 9, default 99999
Auditing Guide:
5 Patient’s Cigna Business Requirements N/A N/A N/A

Telephone Not required, do not key.
6 Patient Cigna Business Requirements If Self box is RELATIONSH

Relationship to  Key if present. checked: IP-TO-
Insured  If multiple relationships are marked and the insured and patient are the same, default to 21 and the patient and insured data. Loop 2000B EMPLOYEE
Self  If multiple relationships are marked and the insured and patient are the different, default to 21 and the patient and insured data. SBR 1069 PIC X(02)
Spouse  If insured and patient are the same and self is marked on the claim, key 18 (translated to 21) and the insured data. SBR02 = 18 CLAIM LEVEL
Child  If insured and patient are different and self is marked on the claim, output 21 and the patient and insured data. (self)
Other  If insured and patient are the same and relationship is marked as 01, 19, 21 or other valid dependent code, output relationship as ECR field:

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
listed on claim and the insured and patient data. If Spouse, Child, E2-
CBH Proclaim  If insured and patient are different and relationship is blank on the claim, output 21 and the patient and insured data. or Other box is RELATIONSH
Field Name:  If insured and patient are the same and relationship is blank on the claim, output 21 and the patient and insured data. checked: 1069 IP-TO-EMPLE
 See Appendix D for valid values (translator will accept these values). Loop 2000C
 If two boxes are marked, but do not match, default to 21. PAT Xnet Field
 If two boxes are marked but one is handwritten, use the handwritten box as relationship. PAT01 Name:
CBH Common REL TO EE
Claim Field Miscellaneous Medical
Name:  When a Miscellaneous Medical claim form is submitted that has no designated area for the Insured patient relationship to be listed, Valid values for
REL TO EE and the patient information section is not completed, the patient relationship code should be keyed as 18 or self, and the Insured PAT01: Core WebDE:
01 – Spouse PatRel
837 loop information should be output.
19 – Child
21 – Unknown Select
EDI Requirements
WebDE:
 HCFA form has boxes for Spouse, Child and Other. The corresponding ANSI values for these are 01, 19, and 21 respectively.
ECHCF: Loop
 If no patient relationship and patient = insured, key patient relationship code of 18 (translated to 21) and the Insured information
Claim/ 2000B.SBR02
within the Insured ANSI loop. If it does not match, default to 21.
echcf:SubscriberI X12_2000B_S
 Default to 21 if blank or two boxes do not match
nfo/ BR_RELATIO
hcfd:EnrollmentIn NCODE
fo/
hcfd:Relationship Loop
To Subscriber 2000C.PAT01
od_pat_rel
Claim/
echcf:PatientInfo/
hcfd:EnrollmentIn
fo/
hcfd:Relationship
ToSubscriber
XCCR field:
C00-PATNT-
RELSHP-CD
7 Insured’s Cigna Business Requirements Loop 2010BA EMPLOYEE-
Address  Populate from eligibility lookup using the insured’s address. N3 ADDRESS-1
 If the insured is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and key N301 = Addr1 166 PIC X(35)
CBH Proclaim what is on the claim. N302 = Addr2 166 CLAIM LEVEL
Field Name:  If the insured was not located in the eligibility lookup, key what is on the claim. EMPLOYEE-
EMP-ADDR  Key if present. ECHCF: ADDRESS-2
 If address contains two lines, key both lines. Claim/ PIC X(35)

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
EMP-ADDR-2  If data is present in address 2, then address 1 cannot be blank. If second line of address is present and first is not, move second echcf:SubscriberI CLAIM LEVEL
lineup to first line. nfo/
 If the word “SAME” is present in the insured’s address, duplicate patient’s address, city, state and zip. ucfd:AddressInfo/ ECR field:
CBH Common  If data submitted on the claim is different from what is in eligibility, and eligibility is address is complete, send what was generated ucfd:AddressLine E2-EMPLE-
Claim Field from the eligibility lookup. 1 ADDR-1
Name:  If Insured address is incomplete or missing from the claim form, output the Patient’s address, city, state and zip as listed on the E2-EMPLE-
EE ADDR claim form. Claim/ ADDR-2
 Use Patient's Address - If the Insured address is missing or incomplete (any fields missing) populate with the Patient address echcf:SubscriberI
information. If the Patient information is also missing or incomplete, reject the claim back to submitter for missing address nfo/
information. ucfd:AddressInfo/ Xnet Field
 If missing or illegible, review the attachments to determine if the information is available prior to rejecting for missing or illegible ucfd:AddressLine Name:
information. 2 EE ADDR
 If the patient address and insured address are not present and an eligibility match could not be made, member mail will be treated
as dead mail (Misc. Med) XCCR field :
Insured = Patient Data Fields : Address, Gender, DOB Fields M00-ADDR-LN1 Core WebDE:
 When Patient = Insured only Insured data loop is sent. M00-ADDR-LN2 InsAdr1,
 Insured data (as submitted on the claim) should be sent in Insured loop InsAdr2
data loop with Patient data submitted on the claim Select
 If both Insured and Patient data (Address, Gender, DOB and Relationship) is missing in any of these fields on the claim and an WebDE:
exact match was found on ID in eligibility, populate missing data fields in Insured loop with Insured data information found in od_ins_addr,
eligibility file od_ins_addr_
 If Insured Data fields are blank, Patient data fields are blank, and no eligibility data found in eligibility file (on exact match), reject 2
back to submitter
EDI Requirements
Auditing Guide:
 Do not count errors for standard Postal abbreviations being keyed for Street, Lane, Drive, Boulevard, Avenue etc… as long as the
abbreviation is keyed correctly.

7 Insured’s City Cigna Business Requirements Loop 2010BA EMPLOYEE-
 Populate from eligibility lookup using the insured’s address. N4 CITY PIC
CBH Proclaim  If the insured is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and key N401 19 X(30) CLAIM
Field Name: what is on the claim. LEVEL
EMP-CITY  If the insured was not located in the eligibility lookup, key what is on the claim.
 Key if present. ECHCF: ECR field:

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If the word “SAME” is present in the insured’s address, city, state or zip, duplicate patient’s address, city, state and zip. Claim/ E2-EMPLE-
 Must be a minimum of two characters. If less than two characters, do not output. echcf:SubscriberI CITY
CBH Common  If data submitted on the claim is different from what is in eligibility, and eligibility is address is complete, send what was generated nfo/
Claim Field from the eligibility lookup. ucfd:AddressInfo/ Xnet Field
Name:  If Insured address is incomplete or missing from the claim form, output the Patient’s address, city, state and zip as listed on the ucfd:City Name:
EE CITY claim form. EE CITY
 Use Patient's Address - If the Insured address is missing or incomplete (any fields missing) populate with the Patient address XCCR field :
information. If the Patient information is also missing or incomplete, reject the claim back to the submitter for missing city M00-CITY-NM
information. Core WebDE:
 If missing or illegible, review the attachments to determine if the information is available prior to rejecting for missing or illegible. InsCity
 If the patient address and insured address and there is no eligibility match, member mail will be treated as dead mail (Misc. Med)
Select
Insured = Patient Data Fields : Address, Gender, DOB Fields WebDE:
 When Patient = Insured only Insured data loop is sent. od_ins_city
eligibility file
 If Insured Data fields are blank, Patient data fields are blank, and no eligibility data found in eligibility file (on exact match), reject
back to submitter
EDI Requirements
Auditing Guide:
7 Insured’s State Cigna Business Requirements Loop 2010BA EMPLOYEE-

 Populate from eligibility lookup using the insured’s address. N4 STATE PIC
CBH Proclaim  If the insured is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and key N402 156 X(02) CLAIM
Field Name: what is on the claim. LEVEL
EMP-STATE  If the insured was not located in the eligibility lookup, key what is on the claim. ECHCF:
 Key if present, up to two bytes. Claim/ ECR Field :
 If the word “SAME” is present in the insured address, city, state or zip, duplicate patient address, city, state and zip. echcf:SubscriberI E2-EMPLE-
 If data submitted on the claim is different from what is in the system, and eligibility is address is complete, send what was generated nfo/ STATE
CBH Common from the eligibility lookup. ucfd:AddressInfo/
Claim Field  If Insured address is incomplete or missing from the claim form, output the Patient’s address, city, state and zip as listed on the ucfd:State Xnet Field
Name: claim form. Name:

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
EE STATE  Use Patient's Address - If the Insured address is missing or incomplete (any fields missing) populate with the Patient address XCCR : EE STATE
information. If the Patient information is also missing or incomplete, default state to XX. M00-STE-PROC-
 Do not reject for only missing the state code in the address line CD
 If missing or illegible, review the attachments to determine if the information is available. Core WebDE:
insState
 When Patient = Insured only Insured data loop is sent. Select
 Insured data (as submitted on the claim) should be sent in Insured loop WebDE:
 When Insured data is incomplete (Address, Gender, DOB and Relationship), and data is present in Patient fields, populate Insured od_ins_state
eligibility file
with defaults as defined
EDI Requirements
 State must be a valid postal abbreviation.
 Default XX
Auditing Guide:
7 Insured’s Zip Cigna Business Requirements Loop 2010BA EMPLOYEE-

 Populate from eligibility lookup, using the insured’s address. N4 ZIP PIC
 If the insured is located in the eligibility lookup, but no address is present or incomplete, do not accept eligibility information and key N403 116 X(11) CLAIM
CBH Proclaim what is on the claim. LEVEL
Field Name:  If the insured was not located in the eligibility lookup, key what is on the claim. ECHCF:
EMP-ZIP  Key if present. Claim/ ECR field:
 Zip code must be equal to 5 or 9 numeric digits, no spaces. echcf:SubscriberI E2-EMPLE-
 If the word “SAME” is present in the insured address, city, state or zip, duplicate patient address, city, state and zip. nfo/ ZIP
CBH Common  If data submitted on the claim is different from what is in eligibility, and eligibility is address is complete, send what was generated ucfd:AddressInfo/
Claim Field from the eligibility lookup. ucfd:PostalCode Xnet Field
Name:  If Insured address is incomplete or missing from the claim form, output the Patient’s address, city, state and zip as listed on the Name:
EE ZIP claim form. XCCR: EE ZIP
 Use Patient's Address - If the Insured address is missing or incomplete (any fields missing) populate with the Patient address M00-POSTL-CD
information. If the Patient zip code information is also missing or incomplete, default zip code to 99999
 Do not reject claim for only missing zip code in address line Core WebDE:

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If missing or illegible, review the attachments to determine if the information is available. InsZip1+InsZi
p2
 When Patient = Insured only Insured data loop is sent. Select
 Insured data (as submitted on the claim) should be sent in Insured loop WebDE:
 When Insured data is incomplete (Address, Gender, DOB and Relationship), and data is present in Patient fields, populate Insured od_ins_zip
eligibility file
EDI Requirements
Auditing Guide:
8 Patient Status: Cigna Business Requirements N/A N/A N/A

Marital Not required, do not key.

Employment Not required, do not key.

Student Not required, do not key.
9 Other Insured's X Cigna Business Requirements 2330A

Name NM1
(First and Last) Determination of when to send 9 and 9d NM101 = IL Xnet Field
 If it is determined that 9 or 9d are to be sent, 9 and 9d must be sent. (Note: If Medicaid, 9 and 9d must always be sent) NM102 = 1 Name:
CBH Proclaim  If it is determined that 9 or 9d are to be sent, and either field is blank, send defaults (XX) in the blank field. (person) 1035 OTHER-
Field Name:  When an EOB is present, send 9 and 9d. NM103 = Other INSUREDS-
N/A  If 9d has verbiage from Appendix L, send default of XX in field 9d. Insured’s Last 1036 FIRST-NAME
 If 9d has verbiage from Appendix G, send the Cigna verbiage in field 9d. Name or ‘XX’ OTHER-

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 When an EOB is not present, and 9 and 4 are different, send 9 and 9d (as long as field 9d does not contain verbiage from NM104 = Other INSUREDS-
CBH Common Appendix L or Appendix G. If 9d contains verbiage from Appendix L, or Appendix G, do not send 9 or 9d.) Field 9d must be Insured’s First last –NAME
Claim Field compared to attachments L and G before determination of sending 9 or 9d. Name or ‘XX’
Name:  When an EOB is not present and 9 and 4 are the same, do not send 9 or 9d. NM108 = MI We map
INSUR LNAME  When the term None or NA is listed in field 9, and field 9d is invalid, field 9 is to be ignored and no default values should be sent. NM109 = XX NM104 to first
 When the term None or NA is listed in field 9, and field 9d is populated with a valid term, field 9 should be sent using the default name and
INSUR FNAME values. 2320 NM105 from
 Field 9 should not be used in the name comparison between field 4 and field 9, whenever the terms None or NA are listed in field 9. OI 2330 A to last
INSUR MNAME  Do not key punctuation OI03 = Y name
 Do not key prefixes OI06 = I
 Key Suffix after LN if present ECR field:
 Key LN, FN, MI (Do not use MI on field 9 and 4 comparison. Compare LN and FN only). ECHCF: E2-OTH-
 If name is hyphenated, key as 2 words (name), no hyphens (example on claim: Smith-Jones, key as SMITH JONES) Claim/ INSUREDS-
 If a ( / ) is present, consider as a comma and parse name using existing name rules. echcf:ClaimCOBI LAST-NAME
 If the word “SAME” is present in the Other Insured’s Name field, duplicate the Insured’s first and last name. nfo/ E2-OTH-
hcfd:OtherSubscr INSUREDS-
Medicaid Claims Only: iberInfo/ FIRST-NAME
 If the claim is determined to be Medicaid, fields 9 and 9d must be output. The above rules only apply to Medicaid claims where hcfd:PersonIndic
directed. ator
 For Medicaid claims, key if present and if field 9 is blank, output the default of (XX) in the blank field. Core WebDE:
Claim/ OthLastName,
EDI Requirements echcf:ClaimCOBI OthFirstName
 Remove special characters. nfo/ +OthMid
hcfd:OtherSubscr
iberInfo/ Select
ucfd:Name (if WebDE:
PersonIndicator od_oth_ins_n
is 2) ame_f,
od_oth_ins_n
Claim/ ame_l
echcf:ClaimCOBI
nfo/ XCCR Field
hcfd:OtherSubscr name: M00-
iberInfo/ LAST-NM-
ucfd:LastName ORG-NM
and M00-FRST-
Claim/echcf:Clai NM.
mCOBInfo/hcfd:O
therSubscriberInf
o/ucfd:FirstName

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
(If
PeersonIndicator
is 1).
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfo/
ucfd:PrimaryIdent
ifier/ucf:Qualifier
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfo/
ucfd:PrimaryIdent
ifier/ucf:Identifier
9a Other Insured s Cigna Business Requirements Loop 2320

Policy or Group  Key as shown on claim. SBR Not mapped in
Number  If blank, output blank SBR03 127 ACR
Other Insured’s Loop 2330A Not mapped in

Date of birth EDI Requirements NM1 ECR
Other Insured’s  Remove special characters NM108 = ‘MI’ 66
Sex NM109 67 XCCR:
C30-GRP-
CBH Proclaim POL-NUM
Field Name: ECHCF:
N/A Claim/
echcf:ClaimCOBI
CBH Common nfo/
Claim Field hcfd:OtherSubscr
Name: iberInfo/
N/A hcfd:EnrollmentIn
fo/
hefc:GroupIdentifi
er

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfo/
ucfd:PrimaryIdent
ifier/ucf:Qualifier
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfo/
ucfd:PrimaryIdent
9b Other Insured’s Cigna Business Requirements N/A N/A N/A

Date of birth Not required, do not key. Field does not exist in a 5010 837.
Other Insured’s Below requirements are included in the event field data is required in the future:
Sex  If century is not included on the claim, logic must create century.
 If century does not equal 19, 20 or 21 default DOB to ‘1900101’
 If date of birth is not present (blank), illegible, or has invalid century code output “19000101”.
9c Employer s Cigna Business Requirements N/A N/A N/A

Name or Not required, do not key.
School Name
9d Insurance Plan Cigna Business Requirements OTHER-

Name or Loop 2330B INSURANCE-
Program Name Determination of when to send 9 and 9d NM101 = PR 98 CARRIER
 If it is determined that 9 or 9d are to be sent, 9 and 9d must be sent. NM102 = 2 1065 PIC X(35)
CBH Proclaim  If it is determined that 9 or 9d are to be sent, and either field is blank, send defaults (XX) in the blank field. NM103 = Plan 1035 CLAIM LEVEL
Field Name:  When an EOB is present, send 9 and 9d. Name (or default
N/A  If 9d has verbiage from Attachment L, send default of XX in field 9d. of XX) ECR field:
 If 9d has verbiage from Attachment G, send the Cigna verbiage in field 9d. NM108 = PI E2-OTH-INS-
 When an EOB is not present, and 9 and 4 are different, send 9 and 9d (as long as field 9d does not contain verbiage from NM109 = CARRIER
CBH Common Appendix L or Appendix G. If 9d contains verbiage from Appendix L, or Appendix G, do not send 9 or 9d.) Field 9d must be 000000000

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Claim Field compared to attachments L and G before determination of sending 9 or 9d.
Name:  When an EOB is not present and 9 and 4 are the same, do not send 9 or 9d. Xnet Field
INS CARRIER  Do not key punctuation ECHCF: Name:
 Do not key prefixes Claim/ INS CARRIER
 Key Suffix after LN if present echcf:ClaimCOBI
 Key LN, FN, MI (Do not use MI on field 9 and 4 comparison. Compare LN and FN only). nfo/ Core WebDE:
 If name is hyphenated, key as 2 words (name), no hyphens (example on claim: Smith-Jones, key as SMITH JONES) hcfd:OtherSubscr Od_oth_ins_pl
iberInfo/ an
hcfd:InsuranceInf
Medicaid Claims Only:
o/hcfdPayerInfo/ Select
 If the claim is determined to be Medicaid, fields 9 and 9d must be output. The above rules only apply to Medicaid claims where
ucfd:PersonIndic WebDE:
directed.
arot od_oth_ins_pl
 For Medicaid claims, key if present and if field 9d is blank, output the default of (XX) in the blank field. an
Claim/
echcf:ClaimCOBI XCCR: M00-
EDI Requirements nfo/ LAST-NM-
 Remove special characters. hcfd:OtherSubscr ORG-NM
 Defaults: XX or Cigna iberInfo/
hcfd:InsuranceInf
o/
hcfd:PayerInfo/
ucfd:Name
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfo/
hcfd:InsuranceInf
o/
hcfd:PayerInfo/
ucfd:PrimaryIdent
ifier/ucf:Qualifier
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfo/

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
hcfd:InsuranceInf
o/
hcfd:PayerInfo/
ucfd:PrimaryIdent
10a Is Patient Cigna Business Requirements 2300 ACCIDENT-

Condition  Key “Y” if present, otherwise leave blank. CLM INDICATOR-1
Related to:  If both ‘yes’ and ‘no’ is indicated, leave blank CLM11 C024 ACCIDENT-
Employment  If both ‘yes’ and ‘no’ is indicated and one is handwritten, give priority to handwritten option. CLM11-1 1362 INDICATOR-2
 If neither ‘yes’ nor ‘no’ is indicated (both boxes are blank), leave blank. CLM11-2 ACCIDENT-
CBH Proclaim INDICATOR-3
Field Name: EDI Requirements ECHCF: PIC X(03)
N/A  Valid Value = EM (Employment) Claim/ CLAIM LEVEL
 If “yes” valid value for CLM11-1 = ‘EM’ echcf:ClaimDetail
 Cannot send CLM11-2 if CLM11-1 is blank. s/ ECR field:
CBH Common  Cannot send CLM11-1 and CLM11-2 if they are the same. If they are the same, only send CLM11-1. Do not output CLM11-2 hcfd:RelatedCau E2-
Claim Field seInformation/ ACCIDENT-
Name: hcfd:RelatedCau IND-1
N/A seClode E2-
ACCIDENT-
XCCR Field: IND-2
C00-RELD- E2-
CAUSE1-CD ACCIDENT-
IND-3
We map
CLM11
CLM11-1
CLM11-2
CLM11-3
Core WebDE:
EmplInd
Select
WebDE:
X12_2300_CL
M_ACCIDENT
1

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
10b Is Patient Cigna Business Requirements 2300 ACCIDENT-
Condition  Key “Y” if present, otherwise leave blank. CLM C024 INDICATOR-1
Related to: Auto  If both ‘yes’ and ‘no’ is indicated, leave blank CLM11- 1 or ACCIDENT-
Accident?  If both ‘yes’ and ‘no’ is indicated and one is handwritten, give priority to handwritten option. CLM11-2 INDICATOR-2
 If neither ‘yes’ nor ‘no’ is indicated (both boxes are blank), leave blank. DTP01 = 439 1362 ACCIDENT-
CBH Proclaim DTP02 = D8 374 INDICATOR-3
Field Name: EDI Requirements DTP03 = First 1250 PIC X(03)
N/A  Valid Value = AA (Auto Accident) Date of Service CLAIM LEVEL
 If “yes” valid value for CLM11-1 = ‘AA’ (CCYYMMDD)
CBH Common  If Box 10b is checked and CLM11-1 is blank, then CLM11-1 = “AA” ECR field:
Claim Field  If Box 10b is checked and CLM11-1 <> blank, then CLM11-2 = “AA” ECHCF: E2-
Name:  ‘AA’ must be output with a DTP segment – Use content of field 14. If field 14 is not completed, default to first date of service on Claim/ ACCIDENT-
N/A the claim. echcf:ClaimDetail IND-1
 Cannot send CLM11-2 if CLM11-1 is blank. s/ E2-
 Cannot send CLM11-1 and CLM11-2 if they are the same. If they are the same, only send CLM11-1. Do not output CLM11-2 hcfd:RelatedCau ACCIDENT-
seInformation/ IND-2
hcfd:RelatedCau E2-
seClode ACCIDENT-
IND-3We map
XCCR Field: CLM11
C00-RELD- CLM11-1
CAUSE2-CD CLM11-2
CLM11-3
Core WebDE:
AutoInd
Select
WebDE:
X12_2300_CL
M_ACCIDENT
1 or
X12_2300_CL
M_ACCIDENT
2
10b Place (State) Cigna Business Requirements: 2300 PLACE-OF-
 Key if present CLM C024 ACCIDENT
CBH Proclaim  If no accident indicator is marked, do not send. CLM11-4 156 PIC X(02)
Field Name: CLAIM LEVEL

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
N/A EDI Requirements: ECHCF:
 If no accident indicator is marked, do not send Claim/ ECR field:
CBH Common  State must be a valid postal abbreviation echcf:ClaimDetail E2-PLACE-
Claim Field  If this is an auto accident, CLM-4 must be sent when CLM11-1 and CLM11-2 are used s/ OF-
Name:  Cannot send CLM11-1 and CLM11-2 if they are the same. If they are the same, only send CLM11-1. Do not output CLM11-2 hcfd:RelatedCau ACCIDENT
ACC COUNTRY seInformation/
hcfd:State
Core WebDE:
XCCR : Place
C00-RELD-
CAUSE-ACC- Select
STE WebDE:
od_acc_state
10c Is Patient Cigna Business Requirements 2300 ACCIDENT-
Condition  Key Y if present, otherwise leave blank. CLM C024 INDICATOR-1
Related to: EDI Requirements CLM11-1 or 1362 ACCIDENT-
Other Accident?  Valid Value = OA (Other Accident) CLM11-2 374 INDICATOR-
 Cannot send CLM11-2or CLM11-3 if CLM11-1 is blank. DTP01 = 439 1250 2ACCIDENT-
CBH Proclaim  OA must be output with a DTP segment – Use content of field 14. If field 14 is not completed, default to first date of service on the DTP02 = D8 INDICATOR-
Field Name: claim. DTP03 = First 3PIC X(03)
N/A  Cannot send CLM11-1 and CLM11-2 if they are the same. If they are the same, only send CLM11-1. Do not output CLM11-2 Date of Service CLAIM LEVEL
(CCYYMMDD)
CBH Common ECR field:
Claim Field ECHCF: E2-
Name: Claim/ ACCIDENT-
N/A echcf:ClaimDetail IND-1
s/ E2-
hcfd:RelatedCau ACCIDENT-
seInformation/ IND-2
hcfd:RelatedCau E2-
seClode ACCIDENT-
IND-3
XCCR: C00-
RELD-CAUSE3-
CD Core WebDE:
OthInd
10d Reserved for Cigna Business Requirements For each item: REMARKS-
Local Use  Key if present. 2300 CLM-DATA
NTE OCCURS 0

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
CBH Proclaim EDI Requirements NTE01=ADD 363 TO 10 TIMES
Field Name:  Map to NTE in loop 2300, without overlapping other NTE information. NTE02 352 PIC X(80)
CLAIM LEVEL
CBH Common NOTE: ECHCF:
Claim Field For Professional: Claim/ ECR field:
Name: All of these are appended together, IF PRESENT, in this order: echcf:ClaimDetail E2-
CLAIM LEVEL R s/ REMARKS-
EMARKS FSAAmt hcfd:ClaimNote/ CLM-DATA(1
Remarks (field 10d) ucf:Qualifier
RemarksGen_1 (1st 1/3 of claim form) XCCR: M30-
RemarksGen_2 (2nd 1/3 of claim form) NOTE-TXT
RemarksGen_3 (3rd 1/3 of claim form) Claim/
Remark2 (field 24k) echcf:ClaimDetail
Narr1, 2, 3, 4, 5 s/
hcfd:ClaimNote/
The NTE02 element has a max of 80 characters so we only pass the first 80. There can only be 1 NTE segment. ucf:Value
11 Insured's Policy Cigna Business Requirements: Loop 2000B

Group or FECA  Key as shown on claim. SBR SUBSCRIBER
Number  If illegible or blank, leave blank SBR03 -ACCOUNT-
NUMBER
EMR should recognize the following keywords as meaning “policy number” on Member Medical Claim Forms
ECHCF: ECR field:
• Account number when placed in the insured section of the claim form
Claim/ E2-SUBSCR-
• Policy number echcf:SubscriberI ACCT-
• Group account number nfo/ NUM(1)
• Group number hcfd:EntrollmentI
nfo/
 If a Member Claim Form and a HCFA and both present with different policy numbers listed, key the policy number from hcfd:GroupIdentifi Select
the Member Claim Form er WebDE:
od_ins_grp
EDI Requirements XCCR:
 Remove special characters C00-PATNT-
ACCT-NUM
11a Insured’s Date X Cigna Business Requirements Loop 2010BA EMPLOYEE-
of Birth  Populate from eligibility lookup. DMG DATE-BIRTH
 If the insured was not located in the eligibility lookup, key what is on the claim. DMG01 = D8 1250 PIC X(08)

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
CBH Proclaim  Key if present. DMG02 1251 CLAIM LEVEL
Field Name:  If invalid, illegible, blank or has invalid century code default to “19000101”. DMG02 =
N/A  If the relationship is SELF, output will populate DOB from patient “19000101”. ECR field:
Insured = Patient Data Fields : Address, Gender, DOB Fields (CCYYMMDD) – E2-EMPLE-
 When Patient = Insured only Insured data loop is sent. If invalid or blank. DOB
CBH Common  Insured data (as submitted on the claim) should be sent in Insured loop
Claim Field  When Insured data is incomplete (Address, Gender, DOB and Relationship), and data is present in Patient fields, populate Insured ECHCF: Core WebDE:
Name: data loop with Patient data submitted on the claim Claim/ InsDOB
EE DOB  If both Insured and Patient data (Address, Gender, DOB and Relationship) is missing in any of these fields on the claim and an echcf:SubscriberI
exact match was found on ID in eligibility, populate missing data fields in Insured loop with Insured data information found in nfo/ Select
eligibility file hcfd:Demographi WebDE:
 If Insured Data fields are blank, Patient data fields are blank, and no eligibility data found in eligibility file (on exact match), populate csInfo/ od_ins_dob
data fields with defaults as defined ucfd:BirthDate
EDI Requirements XCCR :

 If a match is found, use data from eligibility. M00-BRTH-DT
 Date must be valid and in CCYYMMDD format. Use standard calendar year to validate the date.
 Logic must recognize leap year (2/29).
 If century is not included on the claim, logic (Appendix J) must create century.
 If century does not equal 19, 20 or 21 default DOB to ‘1900101’
 If date of birth is not present (blank), illegible, or has invalid century code output “19000101”.
 Cannot be future date.
 If X12_2000B_SBR_RELATIONCODE = 18 then map Patient DOB
 If invalid, illegible or blank, default to “19000101”.
Auditing Guide:
In Xnet, if the Insured’s and Patient’s name are the same and the Patient Relationship is 18, the Insured’s information is output for both
the Insured and the Patient.
11a Insured’s Sex X Cigna Business Requirements 2010BA 1068 EMPLOYEE-

 Value must be output if Insured’s Date of Birth is being sent. DMG SEX
CBH Proclaim  Key if present. DMG03
Field Name:  If blank, or if both are marked, send as U. F = FEMALE ECR field:
N/A  Valid values are F for female and M for male, and U for unknown. M = MALE E2-EMPLE-
 If invalid or not present, output U. U = UNKNOWN SEX
 If the relationship is SELF, output will populate DOB from patient
CBH Common Insured = Patient Data Fields : Address, Gender, DOB Fields ECHCF: Core WebDE:
Claim Field  When Patient = Insured only Insured data loop is sent. Claim/ InsSex
Name:  Insured data (as submitted on the claim) should be sent in Insured loop echcf:SubscriberI
EE SEX  When Insured data is incomplete (Address, Gender, DOB and Relationship), and data is present in Patient fields, populate Insured nfo/ Select

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
data loop with Patient data submitted on the claim hcfd:Demographi WebDE:
 If both Insured and Patient data (Address, Gender, DOB and Relationship) is missing in any of these fields on the claim and an csInfo/ od_ins_sex
exact match was found on ID in eligibility, populate missing data fields in Insured loop with Insured data information found in ucfd:BirthDate
eligibility file
 If Insured Data fields are blank, Patient data fields are blank, and no eligibility data found in eligibility file (on exact match), populate XCCR:
data fields with defaults as defined M00-GENDER-
CD
EDI Requirements
 Key if present.
 If blank, invalid or both are marked, default U
 If X12_2000B_SBR_RELCODE = 18 then map from od_pat_sex.
Auditing Guide:
11b Employer's Cigna Business Requirements N/A N/A N/A

Name or School Not required, do not key.
Name
11c Insurance Plan Cigna Business Requirements Loop 2000B SUBSCRIBE

Name or  Key as shown on claim. SBR R-ACCOUNT-
Program Name  If illegible, leave blank SBR04 NAME
EDI Requirements: ECHCF:

 Key if present Claim/ ECR field:
 Remove special characters echcf:SubscriberI E2-SUBSCR-
nfo/ ACCT-NAME
 hcfd:EnrollmentIn
fo/ Select
hcfd:GroupName WebDE:
od_ins_plan
XCCR: Group
Plan Name
11d Is There Another Cigna Business Requirements Loop 2320 PAYER-
Health Benefit  Key 1 ( yes ) or 2 ( no ) depending on what is marked on the boxes. SBR RESPONSIBI
Plan?  Do not send if unmarked SBR01 = ‘S’ or LITY
‘P’
EDI Requirements E2-PAYER-

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Yes will map to “S” (Secondary) If 2320 SBR01 = RESPONSIBI
 No will map to “P” (Primary) S (COB won’t LITY
activate) then
2000B SBR01=P
If 2320 SBR01=P
then 2000B
SBR01=S
If 2320 SBR01=
T then SBR01=S
(Medicaid)
**NOTE: 2320
can never be P
for Facets
Medicaid claims
ECHCF:
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfoInfo/
hcfd:InsuranceInf
o/
hcfd:PayerSeque
nceCode
N/A Primacy Code Cigna Business Requirements 2320 1138 PRIMACY-

 If EOB is present and data is being output from EOB, output as “P”. SBR01 CODE
CBH Proclaim  If a Medicaid claim, output as “P” PIC X(01)
Field Name:  If EOB is present and data is not being output from EOB, output as “T”. If 2320 SBR01 is CLAIM LEVEL
N/A  If two EOBs are present, output as “T”. not P and the
 If no EOB is present, and data is being output from field 9d, output as “T”. EOB is Medicare, PAYER-
CBH Common  If no EOB is present, and no data is being output from field 9d, do not output. send RESPONSIBI
Claim Field 2320 LITY
Name: EDI Requirements SBR05 = ‘47’
PRIME CODE  Must be alpha. E2-PAYER-
 Remove special characters. **NOTE: 2320 RESPONSIBI

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
can never be P LITY
for Facets
Medicaid claims Xnet Field
Name:
PRIME CODE
ECHCF:
Claim/
echcf:ClaimCOBI
nfo/
hcfd:OtherSubscr
iberInfo/
hcfd:InsuranceInf
o/
hcfd:PayerSeque
nceCode
XCCR: C30-
PAYER-
RSPBLTY-CD
12(a) Patient's or Cigna Business Requirements: RELEASE-
Authorized  Key if present. INFO-
Person's  If ‘yes’, then send “Y” Loop 2300 1363 INDICATOR
Signature  If ‘no’, then send “I” CLM09
 If word ‘YES’ is present, consider ‘yes’ and send “Y”. Select
 If word ‘NO’ is present, consider ‘no’, and send “I”. ECHCF: WebDE:
 If the claim has a signature or the message “signature on file”, consider ‘yes’ and send “Y” Claim/ 2300.CLM09
echcf:SubscriberI =
 If there is no signature or message, consider ‘no’ and send “I”
nfo/ 1363 od_pat_auth_
 If blank, consider ‘no’ and send “I”
hcfd:InsuranceInf signed,
 If the words ‘SIGNATURE ON FILE’ or variations are present, or an actual signature is present consider ‘Yes’ and send “Y” o/
 If the words ‘PAY TO CLAIMANT’ or ‘PAID IN FULL’ are present, ‘PAY TO INSURED’ or ‘NO SIGNATURE ON FILE’ are present, hcfd:ReleaseOfIn 2320.OI06 =
consider ‘No’ and send “I”. formation 1363 X12_2320_SB
R_RELEASE
EDI Requirements XCCR field: C00- OFINFO
 If ‘yes’, then send “Y” RELS-OF-INFO-
 If ‘no’, then send “I” CD


12(b) Release of Cigna Business Requirements N/A N/A N/A
Information Date Not required, do not key.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
13 Insured’s or Cigna Business Requirements 2300 ASSIGNS-

Authorized  Key if present. CLM BENS-
Person’s  Refer to Appendix A for field verbiage. CLM08 1073 INDICATOR
Signature  If block 13 is blank, then send “N”. PIC X (01)
 If invalid (does not match list of valid verbiage), send “Y”. ECHCF: CLAIM LEVEL
CBH Proclaim  If a typed name is present, send “Y”. Claim/
Field Name:  If the words SIGNATURE ON FILE or variations are present, or an actual signature are present consider “Y”. echcf:SubscriberI ECR field:
PRV-ASSIGN-  If the words pay to claimant or paid in full are present , pay to insured or no signature on file are present , consider NO. If word YES nfo/ E2-ASSIGNS-
CODE is present consider “Y”. If word NO is present consider “N”. hcfd:InsuranceInf BENS-IND
o/
CBH Common Medicaid Claim Process: hcfd:BenefitsAssi
Claim Field  Transmit the Assignment of Benefit information for all Medicaid claims as “Yes” to direct payment to the Medicaid Agency. gnmentIndicator Xnet Field
Name: Name:
ASSIGN BENS EDI Requirements XCCR Field: ASSIGN
 Must be valid ANSI value. Y = Yes, N = No. C00-BEN- BENS
ASGMNT-IND (located under
the Claim
Data section)
Core WebDE:
AssignInd
Select
WebDE:
od_ins_auth_s
ig
14 Date of Current: Cigna Business Requirements 2300
Illness  Key if present. DTP01=431 or ONSET-DATE
 Date must be in CCYYMMDD format. 484 or 439 374
CBH Proclaim  If illegible, leave blank (QUAL) 1250 NO ECR field
Field Name:  Do not send if the “Date of Onset Illness” is greater than or the same as the Dates of Service in Field 24A. DTP02=D8
N/A  Do not key and output if the Date of Current illness is the same as the Date of Service (Field 24A) DTP03 Core WebDE:
DateOfCurrent
 If the date of current illness is not present or cannot be output, the qualifier will not be sent ECHCF:
CBH Common Claim/ Select
Claim Field  If QUAL is present and valid, key information echcf:ClaimDates WebDE:
Name:  QUAL must be three numeric digits / od_injury_dat

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
N/A  Valid QUAL codes include: hcfd:OnsetOfCurr e
o 431 – Onset of Current Symptoms or Illness entIllnessorSympt
o 484 – Last Menstrual Period omDate
 If QUAL code is on claim but is not on the valid code list, do not key
 If field 10a-c are marked N, date of current is present and will be output, and qualifier is either blank or invalid, default qualifier to XCCR Field:
431 M20-DT-VALUE
 If field 10a-c are marked Y, date of current is present and will be output, default qualifier to 439
EDI Requirements
 If any of the injury boxes (10A, B, C) = Yes, then send the date indicated in field 14, as the date of accident in DTP01 = 439.
 If the injury boxes in fields 10A,B, C are checked no or are blank, and field 14 contains a date, but does not indicate if due to illness,
injury or pregnancy, send the date indicated in field 14, as the date of illness in DTP01 = 431.
 Acute Manifestation Date (DTP01 = 453) is not mapped.
14 Date of Current: Cigna Business Requirements 2300 374 ACCIDENT-

Injury(Acc.)  Key if present. DTP01=439 1250 DATE PIC
 Date must be in CCYYMMDD format. DTP02=D8 X(8)
CBH Proclaim  If illegible, leave blank DTP03
Field Name: ECR field:
N/A EDI Requirements XCCR E2-
 Mandatory if 2300 CLM11-1, 2 or 3 equals AA or OA. ECHCF: Field: M20- ACCIDENT-
 If any of the injury boxes (10A, B,C) = Yes, then send the date indicated in field 14, as the date of accident in DTP01 = 439. Claim/ DT-VALUE DT
CBH Common  If the injury boxes in fields 10A,B, C are checked no or are blank, and field 14 contains a date, but does not indicate if due to illness, echcf:ClaimDetail
Claim Field injury or pregnancy, send the date indicated in field 14, as the date of illness in DTP01 = 431. s/ Core WebDE:
Name:  Acute Manifestation Date (DTP01 = 453) and Last Menstrual Period Date (DTP01= 484) are not mapped hcfd:AccidentInfo DateOfCurrent
N/A /
hcfd:AccidentDat Select
e WebDE:
X12_2300_DA
TEACCIDENT
AAOA
14 Date of Current: Cigna Business Requirements 2300 374 MATERNITY-
Pregnancy  Key if present. DTP01=484 1250 DATE PIC
(LMP)  Date must be in CCYYMMDD format. DTP02=D8 X(8)
DTP03
CBH Proclaim EDI Requirements ECR field:
Field Name:  If any of the injury boxes (10A, B, C) = Yes, then send the date indicated in field 14, as the date of accident in DTP01 = 439. ECHCF: E2-
N/A  If the injury boxes in fields 10A,B, C are checked no or are blank, and field 14 contains a date, but does not indicate if due to illness, Claim/ MATERNITY-
injury or pregnancy, send the date indicated in field 14, as the date of illness in DTP01 = 431. echcf:ClaimDates DT
CBH Common  Acute Manifestation Date (DTP01 = 453) and Last Menstrual Period Date (DTP01= 484) are not mapped. /

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Claim Field hcfd:LastMenstru XCCR Field:
Name: alPeriodDate M20-DT-
MATERNITY VALUE
DATE
15 If Patient has Cigna Business Requirements N/A N/A N/A

had Same or No longer keyed (not processed in 5010)
Similar Illness.
Give first date.
16 Dates Patient Cigna Business Requirements N/A N/A N/A
unable to work No longer keyed (not output in 5010)
in current
occupation
17 Name of Cigna Business Requirements Loop 2310A REFERRING-

Referring  Key if present. NM1 PHYSICIAN-
Provider  Name must be separated appropriately into first and last name fields NM101 = DN 98 LAST-NAME
or other Source  If unable to determine the first name, last name and credentials, refer to the Name Format Examples document for making the NM102=1 1065 PIC X(35)
determination of how to key. NM103 = LN 1035 CLAIM LEVEL
CBH Proclaim  DK, DN, DQ, P3 in field 17 should not be keyed as part of the Referring Physician Name. NM104 = FN 1036 REFERRING-
Field Name:  Example of when DK, DN, DQ, and P3 will be included in with the referring provider name. We are not going to assume it is not part NM105 = MI 1037 PHYSICIAN-
N/A of the last name or the first name. FIRST-NAME
ECHCF: PIC X(25)
Claim/ CLAIM LEVEL
CBH Common  If name cannot be parsed with accuracy, send entire name in last name field. echcf:RelatedPro XCCR REFERRING-
Claim Field  Do not use punctuation. Do not use name prefixes (Dr., Mr., Mrs., etc). vidersInfo/ Field: M00- PHYSICIAN-
Name:  If generational suffix is present, key (Jr., Sr., I., II., III., IV., V.) hcfd:ReferringPro LAST-NM- MIDDLE
REFER LNAME  Key last name, include generational suffix, space, include professional designation(s) and/or provider’s credentials as part of the viderInfo/ ORG-NM PIC X(25)
last name preceded by a space. ucfd:PersonIndic CLAIM LEVEL
REFER FNAME  Key middle initial in separate field and parse as a separate data element. ator M00-FRST-
 If individual name is not present, but group or facility name is present, output group or facility name . NM ECR field:
REFER MNAME  If individual name and group or facility name are both present, output individual name. Claim/ E2-
 If “None” or “N/A” is present, leave blank and do not pass. echcf:RelatedPro REFERRING-
 If neither are present, leave blank vidersInfo/ PRV-LAST-
 If after removing “DBA”, two names of the same type are present (i.e.: two individuals, two groups, or two facilities), key the hcfd:ReferringPro NAME
name after “DBA” viderInfo/ E2-
 If after removing “DBA”, two names of different types are present, apply the hierarchy for this field ucfd:LastName REFERRING-
Example: PRV-FIRST-
 If individual name is not present, but group or facility name is present, output group or facility name in last name field. Claim/ NAME
 If individual name and group or facility name are both present, output individual name. echcf:RelatedPro

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
vidersInfo/ Xnet Field
Individual vs. Organization Determination hcfd:ReferringPro Name:
 If any of the following terms are listed after the provider name in field 17, 31, and/or 33 on a HCFA or Miscellaneous Medical form, viderInfo/ REFER
key as an organization and not as an individual provider. ucfd:FirstName FNAME
Organization Abbreviations REFER
 APC MNAME
 ASC Claim/ REFER
 CORP echcf:RelatedPro LNAME
 Corporation vidersInfo/
 INC hcfd:ReferringPro
 LC viderInfo/ Core WebDE:
 LLC ucfd:MiddleName RefPrvFirst,
 LTD RefPrvMid,
 MAGD RefPrvLast+R
 PA (Note: See PA Exception Handling Guidelines and examples below) efSpec
 PC
 PLD Select
 PLLC WebDE:
 PSC od_refer_nam
 SC e_f,
od_refer_nam
 Above is a list of Organizations, if any of the above Organization abbreviations are presented at the END of an individual Provider e_m,
name, key as an Organization. (Key all in the last name field, where applicable) od_refer_nam
 ONLY key as Organization when these Organization abbreviations are the last thing presented after the name, with the exception of e_l
PA. See PA exception handling guidelines below
 Organization – Key all in the last name field
Example on Claim: Dr. Thomas L. Smith, M.D., PSC
Key all in the Last Name Field: Dr Thomas L Smith MD PSC (Organization)
PA Exception Handling Guidelines

 PA - Presented last with another credential will be an organization
 Example on Claim: PAUL T. COOK, M.D., PA
 Key all in the Last name in Field: PAUL T COOK MD PA (Organization)
 PA - Presented alone will be considered a credential and keyed as an individual

 Example on Claim: PAUL T COOK PA
 Key - Last Name: COOK , First Name: PAUL, Credential: PA
 PA - Presented alone at the end of an organization will be considered as an organization

 Example on Claim: MEMORIAL HOSPITAL, PA

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Key as an Organization: MEMORIAL HOSPITAL PA
 PA – when presented with another credential, but does not fall at the end will be considered as an individual
 Example on Claim: PAUL T COOK PA MD
 Key - Last Name: COOK, First Name: PAUL, Credential: PA MD
EDI Requirements
17a ID Number of No longer keyed, does not output in 5010 N/A N/A N/A
Referring
Physician
(HCFA 1500)
17b Referring Cigna Business Requirements Loop 2310A REFERRING-
Provider NPI  Key if present. NM108 = XX 66 PROVIDER-
(CMS 1500)  Key NPI number information from NPI box on form, and a minimum of 2 characters exist. NM109 67 NATL-ID
 Key NPI if present even if more than 10 characters are listed, do not limit to only 10 characters.
CBH Proclaim  Name elements on NM1 required when sending NPI. If NPI is listed, and no name is present in field 17, do not send NPI. NM101=’DN’ XCCR ECR field:
Field Name:  First and last name if available NM102, 03, 04 Field: M05- E2-REFERR-
N/A  NPI Numbers should be keyed with no spaces. This applies to all NPI fields on all Medical form types. For example: from box 17 PARTY- PRV-NATL-ID
 NPI Number listed on the claim as: 89 97865345 REF-TY-
The NPI NM1 CD
 NPI Number should be keyed and output to Cigna as 8997865345
CBH Common segments should Xnet Field
Claim Field  The Luhn formula is applied to validate NPI information submitted. be sent with the Name:
Name:  If the NPI is incomplete or partially illegible, the NPI number will not be output. NM1 segments REFER NATL
REFER NATL ID EDI Requirements outlined in field ID
 NPI qualifier of XX should always be sent when sending NPI. 17.
 Remove special characters
 NPI Number should be keyed and output to Cigna with no spaces ECHCF: Select
 NPI is an alphanumeric field Claim/ WebDE:
 NPI must be a minimum of 2 characters in order to be compliant. echcf:RelatedPro X12_2310A_N
 Remove NPI data if the NPI first digit value on the claim is 0, 5, 6, 7, 8, 9 after the NPI goes through the Luhn formula (scrub it out vidersInfo/ M1_IDCODE
and send nothing) hcfd:ReferringPro
viderInfo/
ucfd:PrimaryIdent
ifier/ucf:Qualifier
Claim/

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
echcf:RelatedPro
vidersInfo/
hcfd:ReferringPro
viderInfo/
ucfd:PrimaryIdent
18 Hospitalization Cigna Business Requirements Loop 2300 Select
Dates Related to  Key as shown on claim DTP WebDE:
Current Services  If the service is inpatient and the field is blank, illegible or invalid, insert Date of Service From in Field 24a If the service is outpatient, DTP01=435
do not key admission date 096 For
Only key for inpatient service claims--Valid inpatient codes only: 11,18, 21, 22, 52, 65,66, 86 (updated 07/11/14) 2300.DTP01
 If the service is inpatient and the field is blank, illegible or invalid, insert Date of Service From in Field 24a (435):
od_hosp_date
EDI Requirements _fm
 Must be sent if services were provided as an inpatient.
For
2300.DTP01
(096):
od_hosp_date
_to
19 Reserved for Not required do not key (corrected claim information captured separately)
Local Use
CBH Proclaim
Field Name:
N/A
CBH Common
Claim Field
Name:
N/A
20 Outside Lab? Cigna Business Requirements: 2400
Yes No  Key as shown on claim PS1
$Charges  If illegible, leave blank PS102
EDI Requirements: ECHCF:

 Key if present Claim/
 Do not exceed 10 characters including reported or implied decimals places for cents echcf:ServiceLine
Info/
 hcfd:PurchasedS

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
erviceChargeAm
ount
21 Diagnosis or X Cigna Business Requirements 2300 PRINCIPAL-

Nature of Illness   Key if present. HI DIAGNOSIS
or Injury? 01-12  Key diagnosis codes in the order they are submitted. 1) PIC X(30)
 If diagnosis code A (01) is blank or illegible, send reject letter If diagnosis code A, default numeric diagnosis code to 000. HI01-1=BK or 1270 CLAIM LEVEL
CBH Proclaim  If diagnosis codes B through L (02-12) are illegible, leave blank ABK 1271 OTHER-
Field Name:  If diagnosis code A (01) is blank, and the claim is a Vision claim, based on the Vision Criteria below, default numeric diagnosis code
HI02-2 DIAGNOSIS
CAUSE-CODE to V720 or Z0100 2) PIC X(30)
 Default V720 for all claims with Date of service pre 10/1/2014 (ICD-9) HI02-1=BF or 352
ADD-CAUSE-1  Default Z0100 for all claims with Date of service on or post 10/1/2014 (ICD-10). ABF REMARKS-
ADD-CAUSE-2 HI02-2 DET DATA
ADD-CAUSE-3 CBH – Default Diagnosis Code: 3) OCCURS 1
ADD-CAUSE-4 HI03-1=BF or TO 12 TIMES
 When a HCFA (professional) or Misc. Med. claim is received with a 99404 CPT code (EAP) and the dx is missing or illegible (e.g. ABF PIC X(80)
situations where the EMR would populate 000), populate with below default. HI03-2
 Populate 799.9 as the default if the date of service is 09/30/15 and prior. 4) ECR field:
CBH Common  Populate R69 as the default if the date of service is 10/01/2015 and after. HI04-1=BF or E2-
Claim Field ABF PRINCIPAL-
Name:  If 99404 CPT code is present but multiple diagnosis codes are present and only one is missing or illegible, do not change 000 to HI04-2 DIAGNOSIS
PRIN DIAG 799.9. 5) 363
HI05-1=BF or 352
OTHER DIAG ABF Xnet Field
 Diagnosis code default code 000 should be keyed for dental claims being processed as medical. HI05-2 Name:
6) PRINC DIAG
HI06-1=BF or (for dx 01)
ICD-10 Diagnosis Rules: ABF OTHER DIAG
 If DX present/legible and ICD-10 version indicator is present, key as shown (pre and post 10/1/2014) HI06-2 (for dx 02-12)
 If DX is not present/legible (pre and post 10/1/2014), Send Reject Letter 7)
HI07-1=BF or Core WebDE:
ABF Diag1,
Identifying a vision claim: HI07-2 Diag2,
 A vision claim can be identified by the following pieces of information: 8) Diag3,
o Presence of a vision claim form or vision receipts (Misc. Medical only) HI08-1=BF or Diag4
o Rendering Provider (field 31) or Billing Provider (field 33) indicates Eye, Eyeglass, Eyeglasses, Vision, Ophthalmology, ABF Diag5
HI08-2 Diag6
Ophthalmologist, Optometry, Optometrist, or OD
9) Diag7
o Procedure Code (field 24d) indicates codes within the range of V2020 - V2799, Eyeglass, Eyeglasses, Contact Lens,
HI09-1=BF or Diag8
Contact Lenses ABF Diag9
o Diagnosis Code (field 21) indicates Eyeglass, Eyeglasses, Contact Lens, Contact Lenses

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
HI09-2 Diag10
 If narrative is present and the numeric diagnosis code is not, key narrative. Diagnosis code vs. verbiage criteria is reflected in 10) Diag11
Appendix I. HI010-1=BF or Diag 12
 Diagnosis cannot contain decimals. ABF
 Diagnosis code A (01) cannot be blank when there is another occurrence. HI010-2 Select
11) WebDE:
 ICD-9 and ICD-10 table will be used for validation of data capture quality. HI011-1=BF or od_diag1,
ABF od_diag2
EDI Requirements HI011-2 od_diag3,
 If diagnosis code is not present, and diagnosis description is, the description should be mapped to NTE02 and the diagnosis code 12) od_diag4
defaulted to 000 HI012-1=BF or od_diag5,
ABF Duplicate od_diag6,
 Remove special characters. HI012-2 diagnosis od_diag7,
 codes are od_diag8,
For each item: sent as a od_diag9,
1) Regardless of document type (HCFA, UB, MM, MH) if both ICD9 and IDC10 codes are present and every date of service is
2400 warning. od_diag10,
after 10/1/15 and qualifier is 0, output ICD qualifier as 0 and only send the ICD10 diagnosis codes. Scenario #1 NTE When it od_diag11,
2) Regardless of document types, (HCFA, UB, MM, MH) if both ICD9 and IDC10 codes are present, every date of service is NTE01=ADD goes as a od_diag12
after 10/1/15 and qualifier is 9, output ICD qualifier as 0 and only send the ICD10 diagnosis codes. Scenarios #1 and #4 NTE02 warning, it
3) Regardless of document types, (HCFA, UB, MM, MH) if both ICD9 and IDC10 codes are present, every date of service is causes XCCR field:
after 10/1/15 and qualifier is blank, output ICD qualifier as 0 and only send the ICD10 diagnosis codes. NOTE: BK is problem. If C35-CODE-
ICD-9 and ABK is we can VAL3
4) Regardless of document types, (HCFA, UB, MM, MH) if only ICD9 code(s) is present, every date of service is after 10/1/15
ICD-10 avoid
and qualifier is blank, reject the claim and send the ICD indicator letter. Scenario #5 keying it M30-NOTE-
5) Regardless of document types (HCFA, UB, MM, MH), if all diagnosis code fields are blank or illegible (i.e. nothing present or NOTE: BF is ICD- that would TY-CD
cannot be determined due to being illegible in diag1-12), reject the claim and send the Missing Diagnosis Code return letter. On 9 and ABF is be great.
HCFA/MM, exception would be Vision claims – if it meets the Vision requirements, send 000 for diagnosis code 1. On UB/MH, ICD-10
exception would be fields 69, 70 and 72 could have codes. This only applies to field 68. Scenarios #2 and #3. RX exception
ECHCF:
applies here that was outlined in CM
Claim/
6) Regardless of document types (HCFA, UB, MM, MH), if diagnosis code field 1 is illegible and a narrative is not present and echcf:ClaimDetail
other diagnosis codes are present, Reject the claim and send the Missing Diagnosis Code return letter. s/
7) Regardless of document type (HCFA, UB, MM, MH), if diagnosis code 1 is blank and a narrative is not present and other hcfd:HealthInform
diagnosis codes are present, do not output 000, move up all of the diagnosis codes up to the next open diagnosis field. ation/
Scenario #6 hcfd:PrincipalDia
8) In HCFA and in MiscMed, if diagnosis codes are moved up to the next open diagnosis field, pass the pointers per the gnosis/
hcfd:DiagnosisCo
examples so not to cause duplicates. Pointer scenarios deType
Claim/

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
1) Scenario 1: Misc Med Submissions Only: echcf:ClaimDetail
 If a Misc Med claim is submitted with both ICD9 and ICD10 DX codes AND the DOS is after 10/01/2015. Key ONLY s/
hcfd:HealthInform
the ICD10 codes and qualifier “0”.
ation/
 If qualifier is 9, and DOS is post 10/01/2015 output “0” hcfd:PrincipalDia
gnosis/
2) Scenario 2: HCFA (Field 21) hcfd:DiagnosisCo
 IF a HCFA is billed with NO DX code (at all), reject up front. Return with letter de
 Exception – EMR has rules for Vision and Prescription claims. If the claim is Prescription, business wants these keyed
Claim/
as they are today, with the default of 000 (example 7338520845). Keywords NDC#, RX#, CPT is default 99999 and
echcf:ClaimDetail
DX is blank – send default DX as 000 s/
hcfd:HealthInform
4) Scenario 4: HCFA/UB ation/
 If Qualifier is billed “9”, but DOS is after 10/01/2015 and DX codes are ICD10 – Change qualifier to “0” and key DX hcfd:OtherDiagno
codes as billed sis/
 Examples17338900136542 hcfd:DiagnosisCo
deType
5) Scenario 5: HCFA/UB Claim/
 No Qualifier is billed, DOS is after 10/01/2015 and DX code is ICD9 – Reject up front. Return with letter (ICD Indicator echcf:ClaimDetail
letter currently being used today) s/
 Example: 17338100756402, 7338507924 hcfd:HealthInform
ation/
hcfd:OtherDiagno
6) Scenario 6: HCFA/UB
sis/
 DX 1 is blank, DX 2 is populated – Move DX 2 to DX 1 and change the DX pointer as appropriate (i.e. from 2 to 1) hcfd:DiagnosisCo
 Example: 7338511849 de
ICD9 vs ICD10 Comparison (per CMS)

ICD-9 ICD-10
3-5 characters in length 3-7 characters in length
First digit may be alpha (E or V) or Digit 1 is alpha; digits 2 or 3 are numeric; digits 4-7 are alpha or numeric (alpha
numeric; digit 2-5 are numeric digits are not case sensitive)
 1st character is ALWAYS alpha
 2nd character is ALWAYS numeric
 Remaining 5 characters may be any combination of alpha/numeric

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
21 Qualifier Cigna Business Requirements: 2300 PRINCIPAL-
 When the below rules reference “EMR will reject upfront” this indicates that the EMR will identify these scenarios prior to submitting H101 = BK, or DIAGNOSIS-
the claims to the Gateway and send a return letter back to the submitter. The return letter will be sent for approval once a letter is ABK QUAL
approved through Cigna internal processes.
 If a claim is missed in the upfront identification process and should have been reject upfront but was sent through to the Gateway, NOTE: BK is
EMR will receive a 999 reject with a value of ‘1’ indicating “Required Data Element Missing in the IK403.” This will also trigger the ICD-9 and ABK is
corresponding reject letter. ICD-10
 The Gateway may also send a 277ca reject acknowledgement code A3:254 or A3:255 (Primary diagnosis code). Unique return
letters will be used to support these instances. The EMR must review the reason for the rejected diagnosis code and send out the ECR field:
appropriate letter corresponding to the ICD reject reason and requirements. E2-PRINCIPAL-
DIAGNOSIS
Updated ICD-10 EMR handling Rules
 Key identifier as shown
 If ICD 10 identifier is not present and the date of service is pre ICD-10 implementation, default to 9
 If ICD 10 identifier is not present and the date of service is on or post ICD-10 implementation, default to 0 (ICD-10)
 If the ICD version indicator shows a 0, pre ICD-10 Implementation, key as shown.
 If the ICD version indicator shows a 9, post ICD-10 Implementation, key as shown
 If a claim is submitted with both ICD 9 and ICD 10 version indicators, reject up front
 If a claim is submitted with a reference to both the ICD 9 and ICD 10 version indicator (10 and 9) on the same form
with one DOS, the EMR will reject upfront
 If the ICD version indicator is submitted with a 9 and a 0 on the same form with two or more DOS, the EMR will NOT
attempt to split the claim. The EMR will reject upfront
 If the ICD version indicator points to a 9 and 0 on the same form with two or more DOS, and the EMR only received
one page, they will not copy the claim or attempt to manually split the claim by diagnosis codes. The EMR will reject
up front
 If dates of service span the ICD 10 implementation date and there is not an ICD version indicator present, the EMR will reject
up front since it cannot determine which qualifier is appropriate.
 If dates of service span the ICD 10 implementation date and there is one ICD version indicator present, key as shown (999
reject will be sent back if the code is invalid)
Regardless of document types, (HCFA, UB, MM, MH) if only ICD10 codes(s) is present, every date of service is BEFORE 10/1/15 and
qualifier is blank, reject the claim and send the ICD indicator letter.
 Regardless of document type (HCFA, UB, MM, MH) if both ICD9 and IDC10 codes are present and every date of
service is prior to 10/1/15 and qualifier is 9, output ICD qualifier as 9 and only send the ICD9 diagnosis codes.
 Regardless of document type (HCFA, UB, MM, MH) if both ICD9 and IDC10 codes are present, every date of
service is prior to 10/1/15 and qualifier is 0, output ICD qualifier as 9 and only send the ICD9 diagnosis codes
 Regardless of document type (HCFA, UB, MM, MH) if both ICD9 and IDC10 codes are present, every date of

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
service is prior to 10/1/15 and qualifier is blank, output ICD qualifier as 9 and only send the ICD9 diagnosis codes
 If qualifier is 9, DX codes are ICD9 and DOS are after 10/01/15 – reject
 If qualifier is 0, DX codes are ICD10 and DOS is before 10/01/15 - reject
Miscellaneous Medical Forms:

Updated ICD-10 EMR handling Rules
 If the date of service is pre ICD-10 implementation, default to 9
 If the date of service is on or post ICD-10 implementation, default to 0 (ICD-10)
 If dates of service span the ICD 10 implementation date and the EMR will reject up front since it cannot determine which
qualifier is appropriate.
EDI Requirements:
 No special characters
 Default ‘9’ = ICD-9 reference
 Default ‘0’= ICD-10 reference
22 Medicaid Cigna Business Requirements: Loop 2300 Select

Resubmission  If field 22 (Resubmission code) contains a ‘7’ or reference of ‘corrected claim’ it can be considered a corrected claim—i.e. CLM WebDE:
Code output a 7 in loop 2300, CLM05-3 CLM05-03 CorrectedClai
 If illegible, leave blank m
. ECHCF:
EDI Requirements: Claim/ XCCR: C00-
 No special characters echcf:ClaimIdentif CLM-FREQ-
 Field can only output 1 character icationInfo/ CD
hcfd:ClaimFreque
 ncyCode
23 Prior Cigna Business Requirements LOOP 2300 TREATMENT-

Authorization  Key if present. REF01 = G1 128 AUTHORIZAT
Number  If code and verbiage are both present, key code first. REF02 = 127 ION-CODE
 If illegible or blank, leave blank TREATMENT PIC X(30)
CBH Proclaim EDI Requirements AUTHORIZATIO CLAIM LEVEL
Field Name:  Remove special characters. N CODE
N/A ECR field:
 ECHCF: E2-TREAT-

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
CBH Common Claim/ AUTHORIZE-
Claim Field echcf:ClaimDetail CODE
Name: s/
TRT AUTH hcfd:PriorAuthoriz Xnet Field
ationNumber Name:
TRT AUTH
XCCR field:
M15-DOC-REF-
ID Select
WebDE:
REF01 = G1:
od_prior_auth
REF01 = F8:
od_orig_ref
n/a MM Referral Number Not required, do not key. N/A N/A N/A
24 NDC # – Cigna Business Requirements For each item: N/A NDC-CODE

National Drug  Key if present. 2410
Control #  Numeric field up to 11 digits (not including N4) LIN – N4 Xnet Field
 If N4 is present at the beginning of the NDC # - remove SV1 Name:
CBH Proclaim  If NDC# is present, must output quantity amount and unit type CTP04 = NDC
Field Name:  Omit special characters and spaces. Quantity
N/A  The NDC number should be keyed at detail line level when submitted in conjunction with a CPT code. NDC will not replace the CPT CTP05-01 =Unit
code; a CPT code must still be present to key as a claim. This will not change the current correspondence RX process. This only or Basis of Core WebDE:
CBH Common Measurement NDC
applies to claims that are processed as claims and that have an NDC code listed in conjunction with the CPT code at the detail line
Claim Field
Name: level. ECHCF: We don’t use
N/A Claim/ this field in
EDI Requirements echcf:ServiceLine ECR.
 Remove special characters. Info/ E3-NDC-
 Output default quantity to 1 hcfd:DrugInfo/ CODE
 Output default unit to UN hcfd:DrugCode
XCCR field: S45-

DRUG-CD
24A Date(s) of X Cigna Business Requirements 2400 374 SERVICE-

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Service From  Key if present. DTP01=472 1250 FROM-DATE
 Date must be valid and in CCYYMMDD or CCYYMMDD-CCYYMMDD format. DTP02=D8 or 1251 PIC X(08)
CBH Proclaim  Use standard calendar year to validate the date. RD8 DETAIL
Field Name:  Logic must recognize leap year (2/29). DTP03 LEVEL
MED-BEGIN-  If century is not included on the claim, logic (Appendix J) must create century. SERVICE-TO-
DATE  Cannot be future date DATE
 If FROM date is blank and TO date has a value, copy from TO date ECHCF: PIC X(08)
CBH Common  If date is invalid or blank, and there is no TO Date available, reject claim. Claim/ DETAIL
Claim Field  If TO date is less than FROM date, reject claim echcf:ServiceLine LEVEL
Name:  If there is a valid date present on the first line, and there are additional lines present with a procedure code and charge amount Info/
MED/HOS present, but no date, use date from first line as the date for the additional lines. hcfdServiceRelat ECR field:
FROM  If a detail line has been crossed out, it should not be keyed. edDates/ E1-SERVICE-
 If a detail line has been crossed out, and corrected, the corrected information should be keyed. hcfd:ServiceDate FROM-DATE
 The date indicated on the receipt can be used as the DOS for miscellaneous medical s/ucf:BeginDate
 If the year is not present, assume the year by applying calendar year logic. E1-SERVICE-
24a Date(s) of TO-DATE
Service From Calendar Year Logic: XCCR field:
 If a claim is received in the month of April with 12/01 submitted as the service date, assume the year to be the C00-SVC-BEG-
(continued) previous year, due to this date not yet occurring in the current year. DT Xnet Field
 Use current year logic unless the date has not occurred in the current year, in that case, subtract one year Name:
from current. C00-SVC-END- MED/HOS
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, DT FROM
on the following detail lines, copy down the information from the completed detail lines where applicable.
Date Spanning Rules: CBH Only (PO Box Driven) Core WebDE:
 Medical equipment that are billed for the entire month can be date spanned. FromDate+To
Example: Date
 “Sept 2,5,9,12,15,21,27,30” , with one total charge (ex:$400.00) or “Jan 2006”
 Key with each line broken out into individual lines with the total charge divided, as in the below example: Select
Example: WebDE:
From Date: 09/02/10 To Date 09/02/10, Units: 1, Charge: $50.00 X12_2400_DT
From Date: 09/05/10 To Date 09/05/10, Units: 1, Charge $50.00 P_SERVI
From Date: 09/09/10 To Date 09/09/10, Units: 1, Charge $50.00 CEDATE
From Date: 09/12/10 To Date 09/12/10, Units: 1, Charge $50.00
Or From Date: 01/01/06 to 01/31/06

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
HAP Claims
 If a HAP Preferred Explanation of Pricing Sheet is received with a claim form, the entire document will continue to be processed as
Miscellaneous, and only the detail lines present on the claim form will be keyed.
 If a HAP Preferred Explanation of Pricing Sheet is received without a claim form, the document will continue to be processed as
Miscellaneous, and the detail lines present on the pricing sheet will be keyed.
 Both the HAP Preferred Explanation of Pricing Sheet and the claim form will continue to be considered non-attachments, and no
attachment indicator will be output.
EDI Requirements
 If date is invalid, illegible or blank, do not output claim.
 Valid century codes: 19, 20 ,21
 Date must be valid and in CCYYMMDD format
Do not key (/), (-) or special characters.

24A Date(s) of Cigna Business Requirements 2400 374 MED-HOS-
Service To  Key if present. DTP01=472 1250 SERV-THRU-
 Date must be valid and in CCYYMMDD format. DTP02=D8 1251 DET PIC
CBH Proclaim  Use standard calendar year to validate the date. DTP03 X(08) DETAIL
Field Name:  Logic must recognize leap year (2/29). LEVEL
MED-END-  If century is not included on the claim, logic (Appendix J) must create century.
DATE  Cannot be future date ECHCF: ECR field:
 If TO date is blank and FROM date has a value, copy from FROM Date. Claim/ E1-SERVICE-
 If the TO DATE is less than the FROM DATE, reject claim. echcf:ServiceLine FROM-DATE
CBH Common  If there is a valid date present on the first line, and there are additional lines present with a procedure code and charge amount Info/
Claim Field present, but no date, use date from first line as the date for the additional lines. hcfdServiceRelat E1-SERVICE-
Name:  If a detail line has been crossed out, it should not be keyed. edDates/ TO-DATE
MED/HOS  If a detail line has been crossed out, and corrected, the corrected information should be keyed. hcfd:ServiceDate ECR field:
THRU  If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on s/ucf:EndDate E3-PLACE-
the following detail lines, copy down the information from the completed detail lines where applicable. OF-SVC
 If the year is not present, assume the year by applying calendar year logic.
 Example: If a claim is received in the month of April with 12/01 submitted as the service date, assume the year
to be the previous year, due to this date not yet occurring in the current year. XCCR field: Xnet Field
 Use current year logic unless the date has not occurred in the current year, in that case, subtract one year C00-SVC-BEG- Name:
from current. DT MED/HOS
 If date is invalid or blank, and there is no FROM Date available, reject claim. THRU
C00-SVC-END-
DT

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Date Spanning Rules: CBH Only (PO Box Driven) Core WebDE:
 Medical equipment that are billed for the entire month can be date spanned. FromDate+To
Example: Date
 “Sept 2,5,9,12,15,21,27,30” , with one total charge (ex:$400.00) or “Jan 2006”
 Key with each line broken out into individual lines with the total charge divided, as in the below example: Select
Example: WebDE:
From Date: 09/02/10 To Date 09/02/10, Units: 1, Charge: $50.00 X12_2400_DT
From Date: 09/05/10 To Date 09/05/10, Units: 1, Charge $50.00 P_SERVICED
From Date: 09/09/10 To Date 09/09/10, Units: 1, Charge $50.00 ATE
Or From Date: 01/01/06 to 01/31/06
HAP Claims
EDI Requirements
 If date is invalid, do not output claim.
 If the TO DATE is less than the FROM DATE, do not output claim.
 Valid century codes: 19, 20 and 21
 Date must be valid and in CCYYMMDD format.
 Do not key (/), (-) or special characters.

24B Place of Service Cigna Business Requirements 2400 PLACE-OF-
 Key if present. SV1 SERVICE
CBH Proclaim  Refer to Appendix E for valid values and translations of codes and descriptions. SV105 1331 PIC X(02)
Field Name:  If invalid and cannot be translated, default place of service to 11 Loop 2300 1251 DETAIL
MED-  If a detail line has been crossed out, default to place of service 11 DTP01 =435 - LEVEL
LOCATION  If a detail line has been crossed out, and corrected, the corrected information should be keyed. ANSI Element

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on Number = 374 ECR field:
the following detail lines, copy down the information from the completed detail lines where applicable. DTP02 =DT - E3-PLACE-
CBH Common ANSI Element OF-SVC
Claim Field EDI Requirements Number = 1250
Name:  Place of service required, if blank default to place of service 11. DTP03 = Xnet Field
POS  Must be valid ANSI value. CCYYMMDDHH Name:
MM - ANSI POS
Situational Rule: Required when value is different than value carried in CLM05-1 in Loop ID-2300. If not required by this Element Number
implementation guide, do not send. = 1251 Core WebDE:
POServ
ECHCF:
Claim/ Select
echcf:ServiceLine WebDE:
Info/ od_place_ser
hcfd:PlaceOfServ
ice XCCR field:
C00-PLACE-
OF-SVC-CD
24B Place of Service Cigna Business Requirements 2300 PLACE-OF-

(Claim Level)  Output place of service from first detail line. SERVICE
 If first detail line is blank, default to place of service 11. 1331 PIC X(02)
CLM05-1 DETAIL
EDI Requirements SV105 (compare LEVEL
 Place of service from first detail line, required on claim level. second, third,
 Place of service required, use first detail line place of service, or if blank default to place of service 11. fourth, etc lines to ECR field:
 Must be valid ANSI value. line 1. If different E3-PLACE-
than line 1, then OF-SVC
key place of
service in SV105)
Select
ECHCF: WebDE:
Claim/ X12_2300_CL
echcf:ClaimIdentif M_FACILITYT
icationInfo/ YPECODE
hcfd:FacilityType
XCCR: C00-
PLACE-OF-
SVC-CD
24C EMG (CMS Cigna Business Requirements 2400 EMERGENCY

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
(CMS) 1500)  Key if present. SV1 -INDICATOR
 If an X is in this field, key as a Y. SV109=Y or 1073 PIC X(01)
CBH Proclaim  If blank or anything other than Y, leave blank. Blank DETAIL
Field Name:  If a detail line has been crossed out, it should not be keyed. LEVEL
N/A  If a detail line has been crossed out, and corrected, the corrected information should be keyed. ECHCF:
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on Claim/ ECR Field
the following detail lines, copy down the information from the completed detail lines where applicable. echcf:ServiceLine E3-
CBH Common Info/ EMERGENCY
Claim Field EDI Requirements hcfd:EmergencyI -IND
Name:  Pass either Y or blank. ndicator
EMG IND  Must send valid ANSI value of Y or blank.
XCCR: EDI-S00- Xnet Field
TY-OF-SVC-CD Name:
EMERG IND
Core WebDE:
Emg
Select
WebDE:
od_emg
24D Procedures, X Cigna Business Requirements 2400 C003 PRINCIPAL-
Services or  Key if present. SV1 PROCEDURE
Supplies  CPT/HCPCS must be five digits. SV101-1= HC -CODE PIC
(CPT/HCPCS)  If not present, less than 5 positions, or greater than 5 positions (excluding modifiers), default to 99999. SV101-2 235 X(40) DETAIL
 If the claim is determined to be a vision claim and a valid CPT4/Procedure code is not present on the claim form but one of the 234 LEVEL
CBH Proclaim procedure code descriptions indicated in “Diagnosis Code Chart—Vision Claims” in Appendix H is listed in the detail section of the For each item:
Field Name: document, key the corresponding CPT4 / Procedure code listed in the table 2400 REMARKS-
MED-CPT4-  If the procedure code description on the claim form must be an exact match to ‘Single Lenses’, ‘Bifocal Lenses’ or Trifocal Lenses’, NTE DET DATA
CODE for the corresponding default procedure code to be used. If “Lenses’ is the only word present, use the default for single lenses, NTE01=ADD 363 OCCURS 0
‘V2100’. NTE02 352 TO 10 TIMES
 If the word “Surcharge” exists, ignore the line, as long as other lines are present. PIC X(80)
CBH Common  If the word “Surcharge” exists, and it is the only line present, default to 99999. ECHCF:
Claim Field  If there are two CPT codes listed on the same line with one charge (separated by space, dash, slash—ex. 90833/99212), output Claim/ E2-
Name: total charge echcf:ServiceLine PRINCIPAL-
PROC CODE  If there is a valid CPT code with no charge amount listed, key the cpt code and output a zero charge amount Info/ PROC-CODE
 If there are two CPT codes listed on two different lines, output total charge amount hcfd:ServiceCode Leave blank
 If present and TAX, send ‘99199’ (per the AMA CPT 2000 Standard Edition book, this CPT code is defined as Special Info/hcfd:Value for
Service/Procedure/Report), and send “TAX” in the Remarks Section. Professional
 Apply current Tax line requirements and key tax lines when presented as a separate line item on a claim or invoice and when a XCCR : S00-

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
dollar amount other than zero ($0.00) is present. Do not create a line item for tax if one is not present. EMER-IND
 Tax lines can be identified in any area (line, box, or field) stating “Tax” where there is a dollar amount other than zero ($0.00) Xnet Field
present. Name:
 If a zero ($0.00) dollar amount is presented for any tax item or line, do not key. PROC CODE
 If a J Code and an NDC Code are present on the same detail line, key the J Code and NDC Code, and handle as a medical claim.
 If only an NDC Code or Rx Number are present, handle as an Rx claim, and output as Correspondence Type RX.
 A CPT/HCPCS table will be used for validation of data capture quality.
 If a detail line has been crossed out, it should not be keyed. Core WebDE:
 If a detail line has been crossed out, and corrected, the corrected information should be keyed. ProcCd
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on
the following detail lines, copy down the information from the completed detail lines where applicable. Select
 Any 0.00 detail charge line that does not contain a five digit procedure code or a three digit revenue code, should not be keyed. WebDE:
od_code
HAP Claims
EDI Requirements
 If blank or less than or greater than 5 digits, default to 99999.
 If first position or procedure code is equal to alpha or numeric, use qualifier of HC in SV101-1.
 If first position is not alpha, then the qualifier is CJ, in SV101-1.
24D Procedures, Cigna Business Requirements 2400 C003 MED-

Services or  Key if present. SV1 PROCEDURE
Supplies  If twelve modifiers are present, key all twelve. SV101-3 1339 -CODE-
(Modifier 1-4)  Key modifiers in order that they are submitted. SV101-4 1339 MODIFIER-1
 If modifier is received as only 1 digit, do not send. SV101-5 1339 PIC X(02)
CBH Proclaim  A modifier table will be used for validation of data capture quality. SV101-6 1339 DETAIL
N/A  If a detail line has been crossed out, and corrected, the corrected information should be keyed. MED-
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on ECHCF: PROCEDURE
CBH Common the following detail lines, copy down the information from the completed detail lines where applicable. Claim/ XCCR: -CODE-
Claim Field echcf:ServiceLine MODIFIER-2

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Name: HAP Claims Info/ S00- PIC X(02)
PROC MOD  If a HAP Preferred Explanation of Pricing Sheet is received with a claim form, the entire document will continue to be processed as hcfd:ServiceCode PROC- MED-
Miscellaneous, and only the detail lines present on the claim form will be keyed. Info/ MDFR1-CD PROCEDURE
 If a HAP Preferred Explanation of Pricing Sheet is received without a claim form, the document will continue to be processed as hcfd:ModifierInfo/ -CODE-
Miscellaneous, and the detail lines present on the pricing sheet will be keyed. hcfd:ModifierCod S00- MODIFIER-3
 Both the HAP Preferred Explanation of Pricing Sheet and the claim form will continue to be considered non-attachments, and no e PROC- PIC X(02)
attachment indicator will be output. MDFR2-CD MED-
XCCR Field: PROCEDURE
EDI Requirements S05-DME-PROC- S00- -CODE-
 Do not send if only 1 digit. CD PROC- MODIFIER-4
 If there are modifiers with the same exact characters, do not send duplicates. Only send unique modifiers on a claim MDFR3-CD PIC X(02)
S00- ECR field:

PROC- E3-
MDFR4-CD REVENUE-
PROC-
MODIFIER-1
E3-
REVENUE-
PROC-
MODIFIER-2
E3-
REVENUE-
PROC-
MODIFIER-3
E3-
REVENUE-
PROC-
MODIFIER-4
Xnet Field
Name:
PROC MOD
Core WebDE:
ProcModA,
ProcModB,
ProcModC,
ProcModD

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Select
WebDE:
od_mod_1,
od_mod_2,
od_mod_3,
od_mod_4
24E Diagnosis Code Cigna Business Requirements 2400 DIAGNOSIS-
(Pointer)  Key if present. SV1 C004 POINTER-1
 If twelve pointers are present, key up to four. SV107-1 1328 PIC 9(02)
CBH Proclaim  Field may contain the actual diagnosis code, and a pointer should be used to match to the claim level diagnosis code (field 21). SV107-2 DIAGNOSIS-
Field Name:  If blank or invalid, default to 1. SV107-3 POINTER-2
N/A  If 01-04 , 01-03, etc. is present, each digit should be send individually (01 02 03 04, etc.), separated by a sub-element delimiter. SV107-4 PIC 9(02)
 If a detail line has been crossed out, it should not be keyed. IF DX APPLIES DIAGNOSIS-
 If a detail line has been crossed out, and corrected, the corrected information should be keyed. TO ALL SERV POINTER-3
CBH Common  If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on LINES, DO NOT PIC 9(02)
Claim Field the following detail lines, copy down the information from the completed detail lines where applicable. SEND POINTER. DIAGNOSIS-
Name: POINTER-4
DIAG POINT 1 HAP Claims ECHCF: PIC 9(02)
DIAG POINT 2  If a HAP Preferred Explanation of Pricing Sheet is received with a claim form, the entire document will continue to be processed as Claim/ DETAIL
DIAG POINT 3 Miscellaneous, and only the detail lines present on the claim form will be keyed. echcf:ServiceLine XCCR: LEVEL
 If a HAP Preferred Explanation of Pricing Sheet is received without a claim form, the document will continue to be processed as Info/
Miscellaneous, and the detail lines present on the pricing sheet will be keyed. hcfd:RelatedDiag S00-DIAG- ECR field:
 Both the HAP Preferred Explanation of Pricing Sheet and the claim form will continue to be considered non-attachments, and no nosisCodeInfo CD1-SEQ- E3-
attachment indicator will be output. (Note: ECHCF NUM DIAGNOSIS-
does not store POINTER-1
Crosswalk Pointer Chart: diagnosis code S00-DIAG- E3-
pointers. Instead CD2-SEQ- DIAGNOSIS-
EMR Keys: Represents: it matches the NUM POINTER-2
01 A pointer to the dx E3-
02 B code at the claim S00-DIAG- DIAGNOSIS-
03 C level and stores CD3-SEQ- POINTER-3
04 D that value at the NUM E3-
service line level.) DIAGNOSIS-
EDI Requirements S00-DIAG- POINTER-4
 Numeric only. CD4-SEQ-
 An issue was identified during 5010 PVS testing that identified the need for stricter requirements around aligning diagnosis pointers NUM Xnet Field
with appropriate diagnosis codes. Name:
 Output rules have been created that will move the diagnosis code pointer to match the diagnosis code and meet 5010 HIPAA DIAG POINT
compliance guidelines. 1

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
DIAG POINT
• NOTE: The solution will only move the pointer if it was aligned from with the diagnosis code when received. 2
• Duplicate diagnosis code pointers cannot be sent. DIAG POINT
• If duplicate is present, default service line to 1. 3
Below are the output rules to support this solution: Core WebDE:
Scenario 1: Ptr[0],
• Diag1 and Diag3 are keyed as indicated on claim Ptr[1],
• Ptr1 = 1 and Ptr2 = 3 (Pointers indicated 1, 3 on claim) Ptr[2],
• Diag3 is moved into Diag2 place so that Diag 1 and Diag 2 are now indicated Ptr[3]
• Ptr2 = 3 becomes Ptr2 = 2
• Final Result: Pointers will now indicate 1, 2 on output Select
WebDE:
Scenario 2: X12_2400_SV
• Diag1 and Diag 3 are keyed as indicated on claim 1_DIAGPOIN
• Ptr1 = 1 and Ptr2 = 2 (Pointers indicated 1, 2 on claim) TER1,
• Diag3 is moved up to Diag2 so that Diag 1 and Diag 2 are now indicated X12_2400_SV
• Ptr2 = 1 (default) since it does not match a Diag but the 1 is removed so there are no duplicate pointers 1_DIAGPOIN
• Final Result: Service line indicates Pointer =1 TER2
X12_2400_SV
Scenario 3: 1_DIAGPOIN
• Diag1 and Diag 3 are keyed as indicated on claim TER3,
• Ptr1 = 1, Ptr2 = 2 and Ptr3 = 3 (Pointers indicated 1, 2, 3 on claim) X12_2400_SV
• Diag3 is moved up to Diag2 so that Diag 1 and Diag 2 are now indicated 1_DIAGPOIN
• Ptr3 = 2 overrides Ptr2 = 2 so there are no duplicate pointers TER4
- Final result: Pointers now indicate 1, 2
Scenario 4:
 Diag1 and Diag 3 are keyed as indicated on claim
 Ptr1 = 1, Ptr 2 = 4 (Pointers indicated 1 and 4 on claim)
 Diag3 is moved up to Diag2 so that Diag 1 and Diag 2 are now indicated
 Ptr2 = 1 (default) since it does not match a Diag but the 1 is removed so there are no duplicate pointers
 Final Result: Service line indicates Pointer =1
Scenario 5:
 Diag1 and Diag 2 are keyed as indicated on claim
 Ptr1 = 1 and Ptr2 = 3 (Pointers indicated 1 and 3 on claim)
 Ptr2 = 1 (default) since it does not match a Diag but the 1 is removed so there are no duplicate pointers
 Final Result: Service line indicates Pointer =1

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 (Effective: EMR0841013)
New Scenario 6
 Diag 1 blank
 Diag 2 keyed as indicated on claim
 Ptr = 2
 Diag 2 is moved up to Diag 1
 Ptr 2 = 1
 Finale Result: Service line indicates Ptr 1
24F $ Charges X Cigna Business Requirements 2400 MEDICAL-

 Key if present. SV1 CHARGES
CBH Proclaim  If charge amount is blank, or zeroes, key a single zero (0). SV102 782 PIC 9(13)V99
Field Name:  If there are two CPT codes listed on the same line with one charge (separated by space, dash, slash—ex. 90833/99212), output DETAIL
MED-CHGD total charge ECHCF: XCCR: LEVEL
 If there is a valid CPT code with no charge amount listed, key the CPT code and output a zero charge amount Claim/ S00-SVC-
CBH Common  If there are two CPT codes listed on two different lines, output total charge amount echcf:ServiceLine CHRG- ECR field:
Claim Field  Apply current Tax line requirements and key tax lines when presented as a separate line item on a claim or invoice and when a Info/ AMT E3-MEDICAL-
Name: dollar amount other than zero ($0.00) is present. Do not create a line item for tax if one is not present hcfd:ServiceInfo/ CHARGES
CHARGE  Tax lines can be identified in any area (line, box, or field) stating “Tax” where there is a dollar amount other than zero ($0.00) hcfd:LineCharge
present Amount
 If a zero ($0.00) dollar amount is presented for any tax item or line, do not key Xnet Field
 If a detail line has been crossed out, it should not be keyed. Name:
 If a detail line has been crossed out, and corrected, the corrected information should be keyed. CHARGE
 If charge amount is illegible, reject and return to original submitter with return letter.
 Follow current process for detail lines containing zero charge lines. Output the term "Zero" in the claim level remark field.
 Any 0.00 detail charge line that does not contain a five digit procedure code or a three digit revenue code, should not be keyed. Core WebDE:
Charge
Charges with a greater value than $9,999,999.99
 Follow the process below when a claim with a value greater than $9,999,999.99 is received. Select
 Example: Claim is received for $11,000,000.00 with dates of service of 01-01-07 through 10-01-07 should be split as: WebDE:
 1st Claim - Date of service = 01-01-07 through 10-1-07, Total charge = $9,999,999.99 od_charges
 2nd Claim - Date of service = 01-01-07 through 10-1-07, Total charge = $1,000,000.01
 Example: Claim is received for $21,000,000.00 with dates of service of 09-01-07 through 02-01-08 should be split as:
 1st Claim - Date of service = 09-1-07 through 12-31-07, Total charge = $9,999,999.99

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 3rd Claim - Date of service = 01-01-08 through 02-02-08, Total charge = $1,000,000.02
 Example: Claim is received for $21,000,000.00 with dates of service of 1-1-07 through 10-1-07 should be split as:
 3rd Claim - Date of service = 1-1-07 through 10-1-07, Total charge = $1,000,000.02
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on
the following detail lines, copy down the information from the completed detail lines where applicable.
Miscellaneous Medical:
When presented with two separate columns with amounts, always key from the column that is the total amount for that detail line.
Example 1:
Rate column and Amount Column – 2 different amounts presented in each column -
Key from the Amount column as this is the total charge for that detail line.
Example 2:
Price/Ea. Column and a Total Column – 2 different amounts presented in each column –
Key from the Total Column as this is the total charge for that detail line.
HAP Claims
EDI Requirements
 Must be numeric.
 The EDI gateway does not allow for more than 7 characters to the left of the decimal point. Example - $9,999,999.99 would be
compliant at the gateway. An amount of 11,000,000.00 would NOT be compliant at the gateway.
24G Days or Units X Cigna Business Requirements 2400 MEDICAL-

 Key as shown on claim SV1 UNITS PIC
CBH Proclaim  If it is units, key as units SV103=MJ or UN 355 9(15) DETAIL
Field Name:  If it is minutes, key as minutes SV104 380 LEVEL
MED-NUM-PD  NOTE: Only change to minutes if it’s anesthesia claims
 If field is blank, then default units to 001. If anesthesia REMARKS-
 If “0” is present, default units to 001. claim: CLM -DATA
CBH Common  If units or minutes are greater than 3 digits, output “999”, and pass the actual number in the Remarks field. SV103 = MJ OCCURS 0

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Claim Field  If a detail line has been crossed out, it should not be keyed. 363 TO 10 TIMES
Name:  If a detail line has been crossed out, and corrected, the corrected information should be keyed. For each item: 352 PIC X(80)
UNITS  If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on 2300 CLAIM LEVEL
the following detail lines, copy down the information from the completed detail lines where applicable. NTE
NTE01=ADD ECR field:
Miscellaneous Medical Only NTE02 XCCR E3-MEDICAL-
HAP Claims field: UNITS
 If a HAP Preferred Explanation of Pricing Sheet is received with a claim form, the entire document will continue to be processed as ECHCF: S00-SVC-
Miscellaneous, and only the detail lines present on the claim form will be keyed. Claim/ UNIT-CNT
 If a HAP Preferred Explanation of Pricing Sheet is received without a claim form, the document will continue to be processed as echcf:ServiceLine Xnet Field
Miscellaneous, and the detail lines present on the pricing sheet will be keyed. Info/ Name:
 Both the HAP Preferred Explanation of Pricing Sheet and the claim form will continue to be considered non-attachments, and no hcfd:ServiceInfo/ UNITS
attachment indicator will be output. hcfd:UnitMeasure
mentCode . Core WebDE:
Business Requirements for anesthesia claims seen in “special processing” section Units
EDI Requirements Claim/ Select

 If minutes/units are blank, then default units to 001. echcf:ServiceLine WebDE:
 Maximum characters of 8 before the decimal and optionally 3 digits after the decimal Info/ od_days
 Must be numeric (special characters may be present) hcfd:ServiceInfo/
hcfd:Quantity Need to re-
evaluate
WebDE
mapping as
this
information
should be
reported as
‘MJ’, not ‘UN’.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
24H EPSDT Family Cigna Business Requirements 2400 Not mapped

Plan  Only key if present and the claim is a Medicaid claim SV1 in ACCR
 A Medicaid claim can be identified through the following process: SV1 11
 Use box 17, 24, 31, 32, 33 and attachments looking for common verbiage below. SV1 12 Not mapped in
 Medicaid agency identified in field 31 or 33 of a HCFA claim form. ECR
 Medicaid agency identified in field 1 of a UB92 claim form ECHCF:
 Medicaid agency identified in field 2 of a UB04 claim form Claim/
Common Verbiage used to Identify Medicaid claims for standard claim forms: echcf:ServiceLine Select
 HCFA/UB form accompanied by a cover letter indicating claim was submitted for payment by a Medicaid agency Info/ WebDE:
 Medicaid Reclamation Claim (watermark on claims) hcfd:EPSDTIndic od_epsdt
 Medicaid Paid ator
Not mapped in
 MA Paid
Claim/ XCCR
 Medicaid Payment
echcf:ServiceLine
 Medicaid Paid Amt Info/
 Medicaid is the payor of last resort hcfd:FamilyPlanni
 Please pay $ --- to the State agency ngIndicatorIndicat
 Medicaid Billed Amount or
 Medicaid Paid
 Medicaid Paid Amt
 Medicaid Owed
 Medicaid Allowed
1. Medicaid Amount
2. Medicaid Payment

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If a ‘Y’, ‘Yes’ or ‘X’, send ‘Y’.
 If blank or anything other than ‘Y’, ‘Yes’ or ‘X’, leave blank.
 If a detail line has been crossed out, it should not be keyed.
 If a detail line has been crossed out, and corrected, the corrected information should be keyed.
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on the following
detail lines, copy down the information from the completed detail lines where applicable.
 Do not output information from this field if the claim is not identified as a Medicaid claim
EDI Requirements
 Only key if present on Medicaid claims—not valid for non-Medicaid claims
 Pass either Y or blank.
 Must send valid ANSI value of Y or blank.

24i -HCFA EMG Cigna Business Requirements 2400 EMERGENCY
(HCFA 1500)  Key if present. SV1 -INDICATOR
 If an X is in this field, key as a Y. SV109=Y or 1073 PIC X(01)
CBH Proclaim  If blank or anything other than Y, leave blank. Blank DETAIL
N/A  If a detail line has been crossed out, and corrected, the corrected information should be keyed. ECHCF:
 If a claim form is received with one detail line completed, and arrows pointing downward, handwritten or typed, on Claim/ ECR field:
CBH Common the following detail lines, copy down the information from the completed detail lines where applicable. echcf:ServiceLine E3-
Claim Field Info/ EMERGENCY
Name: EDI Requirements hcfd:EmergencyI -IND
N/A  Pass either Y or blank. ndicator
XCCR Field: Xnet Field
S00-EMER-IND Name:
EMERG IND
Core WebDE:
Emg
Select
WebDE:
od_emg
24J (CMS) Rendering Cigna Business Requirements (CR-EMR0430515 RENDERING-
Provider ID # -  Key if present from first NPI found in 24J. Effective: PROVIDER-
NPI  If there is no NPI listed in 24J send Blank. 10/22/15) If NPI NATL-ID
(CMS 1500)  If NPI in 24J is missing, incomplete or partially illegible – send blank is present in

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If more than 12 characters present, key in 1st 12 characters Field 24j – Send ECR field:
CBH Proclaim  NPI Numbers should be keyed with no spaces. This applies to all NPI fields on all Medical form types. For example: NPI as: E2-RENDER-
Field Name:  NPI Number listed on the claim as: 89 97865345 PRV-NATL-ID
N/A If Billing and
Rendering Provider 66
 The Luhn formula is applied to validate NPI information submitted. NPI are the same: 67 Xnet Field
CBH Common  If the NPI is missing, incomplete or partially illegible, the NPI number will not be output. Loop 2420A Name:
Claim Field NM101 = 82 RENDER
Name: NM102,03,04 from NATL ID
RENDER NATL Key the Billing and Rendering NPI from the bottom section of the claim. This claim format only. These are system generated from box 33
ID electronic submission processed by CPR. This is a very specific claim form resulting from and EDI drop to paper claim. NM108 = XX Note: No
NM109 = NPI mapping for
Number RENDER
NATL ID at
If Billing and the claim
EDI Requirements Rendering Provider 66 level. The
 NPI qualifier of XX should always be sent when sending NPI. NPI are different 67 Billing Prov
 Remove special characters or Signature on NPI is
 NPI Number should be keyed and output to Cigna with no spaces file is present: mapped to the
 NPI is an alphanumeric field Loop 2420A RENDER-
 NPI must be a minimum of 2 characters in order to be compliant. NM101=’82’ NATL-ID field
 Cannot send more than one NPI number at the line level NM102, 03, 04 in Xnet.
from box 31
NM108 = XX
NM109=NPI
number Select
IF NO NPI is WebDE:
present : then do X12_2420A_N
not send NM108 M1_IDCODE
or NM109 QUAL
ECHCF:
Claim/ XCCR: M05-
echcf:ServiceLineI PARTY-REF-
nfo/ TY-CD
hcfd:ServiceLinePr
oviders/
hcfd:RenderingSer
viceProviderInfo/
ucfd:PrimaryIdentif
ier/ucf:Identifier

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
24J Rendering Cigna Business Requirements N/A N/A N/A

CMS Provider ID # - Not required, do not key.
Taxonomy
Number (CMS
1500)
24J-HCFA COB (HCFA Cigna Business Requirements N/A N/A N/A

1500) Not required, do not key.
24K-HCFA Reserved for Cigna Business Requirements For each item: REMARKS-
Local Use  Key if present. 2300 CLM-DATA
 If a detail line has been crossed out, it should not be keyed. NTE OCCURS 0
CBH Proclaim  If a detail line has been crossed out, and corrected, the corrected information should be keyed. NTE01=ADD 363 TO 10 TIMES
Field Name: NTE02 352 PIC X(80)
N/A EDI Requirements CLAIM LEVEL
 Map to NTE in loop 2300, without overlapping other NTE information ECHCF:
Claim/ ECR Field
CBH Common NOTE: echcf:ClaimDetail E2-
Claim Field For Professional: s/hcfd:ClaimNote/ REMARKS-
Name: All of these are appended together, IF PRESENT, in this order: ucf:Value CLM-DATA(1)
CLAIM LEVEL R
EMARKS FSAAmt XCCR Field: Xnet Field
Remarks (field 10d) M30-NOTE-TXT Name:
RemarksGen_1 (1st 1/3 of claim form) CLAIM LEVEL
RemarksGen_2 (2nd 1/3 of claim form) REMARKS
RemarksGen_3 (3rd 1/3 of claim form)
Remark2 (field 24k)
Narr1, 2, 3, 4, 5
The NTE02 element has a max of 80 characters so we only pass the first 80. There can only be 1 NTE segment.
24K-MM Comments/ Cigna Business Requirements for each item: REMARKS-

Remarks  Key if present. 2300 CLM-DATA
NTE OCCURS 0

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
EDI Requirements NTE01=ADD 363 TO 10 TIMES
CBH Proclaim  Map to NTE in loop 2300, without overlapping other NTE information NTE02 362 PIC X(80)
Field Name: CLAIM LEVEL
PRV-TAX-ID NOTE:
For Professional: ECHCF: ECR Field
All of these are appended together, IF PRESENT, in this order: Claim/ E2-
CBH Common echcf:ClaimDetail REMARKS-
Claim Field FSAAmt s/hcfd:ClaimNote/ CLM-DATA(1)
Name: Remarks (field 10d) ucf:Value
BILLING ID RemarksGen_1 (1st 1/3 of claim form) Xnet Field
RemarksGen_2 (2nd 1/3 of claim form) XCCR Field: Name:
RemarksGen_3 (3rd 1/3 of claim form) M30-NOTE-TXT CLAIM LEVEL
Remark2 (field 24k) REMARKS
Narr1, 2, 3, 4, 5
25 Federal Tax ID X Cigna Business Requirements If NPI is NOT If NPI IS BILLING-

HCFA, Number  Required present in present in PROVIDER-
CMS  Key if present. Field 33a – Send Field 33a ID PIC X(30)
CBH Proclaim  Do not key punctuation or spaces. Tax ID as: – Send CLAIM LEVEL
Field Name:  Cannot contain special characters Tax ID as: RENDERING-
PRV-TAX/SSN  Cannot contain alpha characters. If Billing and PROVIDER-
 If missing or illegible, review the attachments to determine if the information is available prior to rejecting for missing or illegible. Rendering If Billing ID-NUMBER
 If tax ID is less than 9 digits after elimination of special characters, or is blank, reject claim Provider are the and PIC X(20)
CBH Common  If tax ID is greater than 9 digits output only the first 9 digits. same. Rendering CLAIM LEVEL
Claim Field  Key NPI number information from NPI box 33a on the claim, and a minimum of 2 characters exist. Loop 2010AA Provider
Name:  If NPI is more than 12 characters, key in 1st 12 characters See box 33a for are the ECR field:
BILLING EIN NM1 entry same. E2-BILL-PRV-
Vision Claims Requirements: NM101=85 Loop ID
 Applies to Misc Medical claims only. Nm102,03,04 2010AA
 Refer to Appendix H. from box 33 See box Xnet Field
 If the vision claim is assigned and does not have a TAX ID submitted, use default tax id: T16161616. REF01=EI, SY (if 33a for Name:
 If your vision claim is not assigned and does not have a TAX ID submitted, use default tax id:T77777777. These claims will mostly blank, then use NM1 entry BILLING ID
be cash register receipts of some kind – but they must not have an assignment to use this TAX ID. EI) NM101=85
REF02= Tax ID Nm102,03,
Medicaid Specific Claim Processing: 04 from

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If 2 TINs on claim and unable to identify as Medicaid , reject for Multiple Tin Numbers. Loop 2000A box 33 Core WebDE:
 Key the Medicaid provider information from the Attachment if it says “remit to” or “make payment to” on the attachment. PRV01 = BI REF01= EI, BillPin or
PRV02 = PXC SY or 1G ProvTaxI
Medicaid Specific Claim Processing Guidelines for Medicaid Claims Received in the Kennett Mailroom: REF02 = D
If Billing and Tax ID
 When a Medicaid claim is received in the Select PO Boxes or Fax lines and there is wording “remit to” or “make payment to” and the Rendering Number Select
Medicaid agency is noted anywhere on the claim or supporting documentation, the Medicaid provider information should be keyed Provider are Loop WebDE:
in the Billing provider field. different: 2000A X12_2010AA_
Loop 2010AA PRV01 = BI NM1_REF_R
Federal Tax ID Number See box 33a for PRV02 = EFID2
 If 2 TINs on claim and unable to identify as Medicaid , reject for Multiple Tin Numbers. NM1 entry PXC
 Key the Medicaid provider information from the Attachment if it says “remit to” or “make payment to” on the attachment. NM101=85 Not in XCCR
Nm102,03,04
from box 33 If Billing
EDI Requirements REF01=EI and
 If tax ID is less than 9 digits after elimination of special characters, or is blank, reject claim REF02=TAX ID Rendering
 If tax ID is greater than 9 digits output only the first 9 digits. Provider
 No special characters. Loop 2310B are
 No alpha characters. NM101 = 82 different:
 Only one Billing provider allowed per DCN NM102,03,04 Loop
Valid qualifiers for Tax ID sent in the REF01 from box 31 2010AA
 EI = Employer Tax ID Number See box
 NPI qualifier of XX should always be sent when sending NPI. ECHCF: 33a for
 NPI is an alphanumeric field Claim/ NM1 entry
 NPI must be a minimum of 2 characters in order to be compliant. echcf:RelatedPro NM101=85
vidersInfo/ Nm102,03,
5010 change impacting HCFA Field 25 Federal Tax ID (HCFA, CMS, MM) (Loop 2010AA, REF01=SY). Additional output rules to hcfd:BillingProvid 04 from
er/ ucfd:TaxID box 33
identify an invalid SSN when it is sent in the REF01=SY segment:
REF01= EI,
 IF…. SY or 1G
 ‘00’ is in the fourth and fifth position REF02 =
 ‘0000 is in the last four positions of the numbers Tax ID
 9 in the first digit Number
 000 in the first three digits Loop
 666 in the first three digits 2310B
IF NM101 =
….of the SSN in the 2010AA loop, REF01=SY segment, 82
 THEN send default 999999999 in REF01=EI NM102,03,
04 from
EDI Print Out Claims: box 31

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If both the EIN and TIN are present on EDI print out claims submitted to the EMR for processing, output the TIN information on the NM108=
claim in the provider TIN field. XX
 This change will NOT impact the specific requirements for other print out forms (i.e. behavioral claims) NM109 =
 This change only applies to a specific type of EDI print out that payer solutions sends to the EMR. NPI
Number
from box
33a
25 Federal Tax ID X Cigna Business Requirements (Misc. Med) If NPI is NOT If NPI IS BILLING-
--MM Number  Required present in present in PROVIDER-
 Key if present. Field 33a – Send Field 33a ID PIC X(30)
CBH Proclaim  Do not key punctuation or spaces. Tax ID as: – Send CLAIM LEVEL
Field Name:  Cannot contain special characters Tax ID as: RENDERING-
PRV-TAX/SSN  Cannot contain alpha characters. If Billing and PROVIDER-
 If tax ID is less than 9 digits after elimination of special characters, or is blank, default 999999999 Rendering If Billing ID-NUMBER
 If tax ID is greater than 9 digits output only the first 9 digits. Provider are the and PIC X(20)
CBH Common  Key NPI number information from NPI box 33a on the claim, and a minimum of 2 characters exist. same. Rendering CLAIM LEVEL
Claim Field  If NPI is more than 12 characters, key in 1st 12 characters Loop 2010AA Provider
Name: See box 33a for are the ECR field:
BILLING EIN Medicaid Specific Claim Processing: NM1 entry same. E2-BILL-PRV-
 If 2 TINs on claim and unable to identify as Medicaid , reject for Multiple Tin Numbers. NM101=85 Loop ID
 Key the Medicaid provider information from the Attachment if it says “remit to” or “make payment to” on the attachment. Nm102,03,04 2010AA
from box 33 See box Xnet Field
Vision Claims Requirements: REF01=EI, SY (if 33a for Name:
blank, then use NM1 entry BILLING ID
EDI Requirements EI) NM101=85
 If tax ID is less than 9 digits after elimination of special characters, or is blank, default 999999999 REF02= Tax ID Nm102,03,
 If tax ID is greater than 9 digits output only the first 9 digits. 04 from
 No special characters. Loop 2000A box 33 Core WebDE:
 No alpha characters. PRV01 = BI REF01= EI, BillPin or
 Only one Billing provider allowed per DCN PRV02 = PXC SY or 1G ProvTaxI
Valid qualifiers for Tax ID sent in the REF01 REF02 = D
 EI = Employer Tax ID Number If Billing and Tax ID
 NPI qualifier of XX should always be sent when sending NPI. Rendering Number Select
 NPI is an alphanumeric field Provider are Loop WebDE:
 NPI must be a minimum of 2 characters in order to be compliant. different: 2000A X12_2010AA_
Loop 2010AA PRV01 = BI NM1_REF_R
5010 change impacting HCFA Field 25 Federal Tax ID (HCFA, CMS, MM) (Loop 2010AA, REF01=SY). Additional output rules to See box 33a for PRV02 = EFID2
identify an invalid SSN when it is sent in the REF01=SY segment: NM1 entry PXC
NM101=85
 IF….
Nm102,03,04 If Billing
 ‘00’ is in the fourth and fifth position

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 ‘0000 is in the last four positions of the numbers from box 33 and
 9 in the first digit REF01=EI Rendering
REF02=TAX ID Provider
 000 in the first three digits
are
 666 in the first three digits Loop 2310B different:
….of the SSN in the 2010AA loop, REF01=SY segment, NM101 = 82 Loop
 THEN send default 999999999 in REF01=EI NM102,03,04 2010AA
from box 31 See box
EDI Print Out Claims: 33a for
 If both the EIN and TIN are present on EDI print out claims submitted to the EMR for processing, output the TIN information on the ECHCF: NM1 entry
claim in the provider TIN field. Claim/ NM101=85
 This change will NOT impact the specific requirements for other print out forms (i.e. behavioral claims) echcf:RelatedPro Nm102,03,
 This change only applies to a specific type of EDI print out that payer solutions sends to the EMR. vidersInfo/ 04 from
hcfd:BillingProvid box 33
 er/ ucfd:TaxID REF01= EI,
SY or 1G
REF02 =
Tax ID
Number
Loop
2310B
IF NM101 =
82
NM102,03,
04 from
box 31
NM108=
XX
NM109 =
NPI
Number
from box
33a
n/a- MM FSA Rollover Cigna Business Requirements 2100 Not in ACCR

Indicator  Key if present, provided that the claim form has been signed by the insured. SBR
 If the Yes box is checked, key “FSA” in Subscriber Account Name field. SBR04 = FSA 93 ECR:
CBH Proclaim  If the No box is checked, do not key. Loop 2000B E1-FST-
Field Name:  If the Yes box and the No box are checked, key “FSA” in Subscriber Account Name field. SBR04 FLEX-AMT

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
N/A  If neither box is checked, do not key.
ECHCF: Not in XCCR
EDI Requirements Claim/
CBH Common  Remove special characters. echcf:SubscriberI
Claim Field nfo/
Name: hcfd:EnrolllmentI
N/A nfo/
hcf:d:GroupName
n/a- MM FSA Rollover Cigna Business Requirements 2300 Not in ACCR

Amount  Key if present, provided that the claim form has been signed by the insured, and the Yes box is checked. NTE01 = ADD 363
 If dollar amount is present, key “FSA:XXXXXX.XX” in Remarks field with X’s representing dollar amount. NTE02 352 ECR:
CBH Proclaim E1-FST-
Field Name: EDI Requirements ECHCF: FLEX-AMT
N/A  Remove special characters. Claim/
 Map to NTE in loop 2300, without overlapping other NTE information. echcf:ClaimDetail Not in XCCR
s/
CBH Common For Professional: hcfd:ClaimNote/
Claim Field All of these are appended together, IF PRESENT, in this order: ucf:Qualifier
Name:
N/A FSAAmt
Remarks (field 10d) Claim/
RemarksGen_1 (1st 1/3 of claim form) echcf:ClaimDetail
RemarksGen_2 (2nd 1/3 of claim form) s/
RemarksGen_3 (3rd 1/3 of claim form) hcfd:ClaimNote/
Remark2 (field 24k) ucf:Value
Narr1, 2, 3, 4, 5
26 Patient Account X Cigna Business Requirements 2300 PATIENT-

No.  Key if present. CLM01 1028 NUMBER
 Eliminate punctuation and spaces, keying up to the first 25 digits. PIC X(38)
CBH Proclaim  If blank, output a single zero (0). Claim/ CLAIM LEVEL
Field Name:  To help identify the Patient Account Number when not clearly indicated, refer to the below list of terms commonly submitted as the echcf:ClaimIdentif
PRV-PAT-NUM Patient Account Number. icationInfo/ ECR field:
hcfd:ProviderClai E2-PAT-NUM
May be identified by but not limited to: mNumber

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
CBH Common  Patient Control Number
Claim Field  Pat Cntrl No. XCCR: C00- Xnet Field
Name: PATNT-ACCT- Name:
PAT NBR EDI Requirements NUM PAT NBR
 If patient account number is blank, send a single zero.
Core WebDE:
PatNo
Select
WebDE:
od_pat_acct_
no
27 Accept Cigna Business Requirements 2300 MEDICARE-
Assignment  Key if present, from Medicare EOB only. CLM07 1359 ACCEPTS-
(Medicare)  If not present on Medicare EOB, if present on Medicare EOB but not being output, or if Medicare EOB is not present, key from ASSIGNMEN
claim. Claim/ T
CBH Proclaim  If present on claim, but both boxes are marked, output as “Yes/Accepts”. echcf:SubscriberI PIC X(01)
Field Name:  If not present on claim and Medicare EOB is present and Medicare Reason Code 45 is being output, output as “No/Does Not nfo/ CLAIM LEVEL
N/A Accept”. hcfd:InsuranceInf
 If not present on claim and Medicare EOB is present and Medicare Reason Code 45 is not being output, but other Medicare Reason o/ ECR field:
Codes are being output, output as “Yes/Accepts”. hcfd:Assignment E2-
CBH Common  If not present on claim and no Medicare EOB is present, or if not present on claim and Medicare EOB is present, but there are no PlanParticipation MEDICARE-
Claim Field Medicare Reason Codes being output, output as “No/Does Not Accept” Code ACCEPTS-
Name: ASSIGN
MEDI ASSIGN EDI Requirements XCCR field:
 “A” = Yes/Accepts C00-MEDCR-
 “C” = No/Does not accept ASGMNT-CD Xnet Field
Name:
MEDI
ASSIGN
Core WebDE:
AcceptAssign
ment
Select
WebDE:
od_accept_as
g

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
28 Total Charges Cigna Business Requirements 2300 CLAIM-
 Key if present. CLM TOTAL-
CBH Proclaim  Total charges amount should be calculated as the sum of the detail lines. CLM02 782 CHARGES
Field Name:  System should balance the detail lines to the total charges amount. If out of balance, a system generated message should appear PIC 9(13)V99
TOT-CHARGE- informing the user that the detail lines are out of balance and that the total charge should be $xxx.xx while forcing the user to verify CLAIM LEVEL
CHAR the charges. Length of Charge
 If claim is still out of balance, re-total, so that the total charge matches the sun of the detail lines. has increased to ECR field:
Charges with a greater value than $9,999,999.99 18 E2-CLAIM-
CBH Common  Follow the process below when a claim with a value greater than $9,999,999.99 is received. TOTAL-
Claim Field  Example: Claim is received for $11,000,000.00 with dates of service of 01-01-07 through 10-01-07 should be split as: CHARGES
Name:  1st Claim - Date of service = 01-01-07 through 10-1-07, Total charge = $9,999,999.99 Claim/
TOTAL CHARG echcf:ClaimAmou
ES nts/ Xnet Field
 Example: Claim is received for $21,000,000.00 with dates of service of 09-01-07 through 02-01-08 should be split as: hcfd:TotalClaimC Name:
 1st Claim - Date of service = 09-1-07 through 12-31-07, Total charge = $9,999,999.99 harge TOTAL
 2nd Claim - Date of service = 01-01-08 through 02-02-08, Total charge = $9,999,999.99 CHARGES
 3rd Claim - Date of service = 01-01-08 through 02-02-08, Total charge = $1,000,000.02 XCCR field:
 Example: Claim is received for $21,000,000.00 with dates of service of 1-1-07 through 10-1-07 should be split as: C00-TOT- Core WebDE:
SUBMT-CHRG- TotCharge
AMT
 2nd Claim - Date of service = 1-1-07 through 10-1-07, Total charge = $9,999,999.99 Select
 3rd Claim - Date of service = 1-1-07 through 10-1-07, Total charge = $1,000,000.02 WebDE:
od_total_chg
EDI Requirements
 The total charge amount must equal the sum of the detail lines.
29 Amount Paid Cigna Business Requirements 2300 PATIENT-

 Key if present. AMT AMOUNT-
CBH Proclaim Miscellaneous Medical AMT01=F5 522 PAID PIC
Field Name:  To help identify the Amount Paid when not clearly indicated refer to the below list of terms commonly submitted as the Amount Paid. AMT02 782 9(13)V99
N/A May be identified by but not limited to: CLAIM LEVEL
 Amount Paid
 Payment Amount Claim/ ECR field:
CBH Common  Patient Payment echcf:ClaimAmou E2-PAT-
Claim Field  Payment nts/ AMOUNT-
Name: hcfd:PatientPaid PAID
 Credits

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
PATIENT PAID  Debit Amount
 Cash
 Charge XCCR field: Xnet Field
 Check C00-PATNT-PD- Name:
 Credit Card (CC) AMT PATIENT
 Visa PAID
 Master Card
 American Express
Core WebDE:
 Discover AmtPaid
 CC Payment
 CC Pmt Select
 USD (United States Dollars WebDE:
 Money Order od_amount_p
 Payment either preceded or followed by the patients name aid
State of Wyoming Mail – Received in PO Box 188026

 If the assignment of benefits is determined to be “No”, do not key the amount paid if present on the claim.
EDI Requirements
 If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the Cigna on-site
representative for further processing instruction.

30 Balance Due Not required, do not key. N/A N/A N/A
N/A Rendering Cigna Business Requirements For Claim Level RENDERING-

Provider ID # -  Key if present from first NPI found in 24J. If there is no NPI listed in 24J send NPI from field 33. If both 24J and 33 are blank, send Rendering NPI: PROVIDER-
(field not NPI TIN from field 25 NATL-ID
represente (HCFA 1500) -  If more than 12 characters present, key in 1st 12 characters If NPI is present
d on claim Claim Level -  NPI Numbers should be keyed with no spaces. This applies to all NPI fields on all Medical form types. For example: in ECR Field:
form) Rendering NPI  NPI Number listed on the claim as: 89 97865345 Field 24j – Send E2-RENDER-
NPI as: PRV-NATL-ID
CBH Proclaim
Field Name:  The Luhn formula is applied to validate NPI information submitted. If NPI located in 66 Xnet Field

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
N/A  If the NPI is incomplete or partially illegible, the NPI number will not be output. 24J 67 Name:
Loop 2310B RENDER
EDI Requirements NM101 = 82 NATL ID
CBH Common  NPI qualifier of XX should always be sent when sending NPI. NM102,03,04
Claim Field  Remove special characters from box 24J Note: No
Name:  NPI Number should be keyed and output to Cigna with no spaces NM108 = XX mapping for
N/A  NPI is an alphanumeric field NM109 = NPI RENDER
 NPI must be a minimum of 2 characters in order to be compliant. Number NATL ID at
 Cannot send more than one NPI number at the line level the claim
If NPI not level. The
 located in 24J 66 Billing Prov
Loop 2310B 67 NPI is
NM101 = 82 mapped to the
NM102,03,04 XCCR: RENDER-
from box 33 M05- NATL-ID field
NM108 = XX PARTY- in Xnet.
NM109 = NPI REF-TY-
CD
If NPI not Core WebDE:
located in 24J or GetFirstRend
33 NPI()
Loop 2310B
NM101 = 82 Select
NM102,03,04 WebDE:
from box 25 X12_2310B_N
NM108 = XX M1_IDCODE
NM109 = NPI
Claim/
echcf:RelatedPro
vidersInfo/
hcfd:RenderingS
erviceProviderInf
o/
ucfd:PrimaryIdent
31 Signature of Cigna Business Requirements Loop 2310B RENDERING-

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Physician Last  Information will be populated from the provider table if a match was made based on tin # and address. If not, key as shown on NM1 PROVIDER-
Name or claim. NM101=82 98 LAST-NAME
Supplier  Key physician or supplier last name if available and legible. NM102=1 1065 PIC X(35)
including  Do not use punctuation. Do not use name prefixes (Dr., Mr., Mrs., etc). NM103 1035 CLAIM LEVEL
degrees or  Titles may be presented before or after the name.
credentials  If the last name is combined, key both (Adler Lee, Mc Smith, Van Damme) - do not key special characters. Claim/ ECR field:
 If a title is present and can be identified as a title, do not key. echcf:RelatedPro E2-
CBH Proclaim vidersInfo/ RENDERING-
 If unable to determine the first name, last name and credentials, refer to the Name Format Examples document for making the
Field Name: hcfd:RenderingS PRV-LAST-
determination of how to key.
PRV-NAME erviceProviderInf NAME.
 If unable to determine title, first and last name, key all in the last name field.
o/ucfd:LastName
CBH Common  If generational suffix is present, key (Jr., Sr., I., II., III., IV., V.)
Claim Field  Key last name, include generational suffix, space, include professional designation(s) and/or provider’s credentials (if legible) as XCCR: M00- Xnet Field
Name: part of the last name preceded by a space. Do not output “signature illegible” if providers last name is legible but credentials are LAST-NM-ORG- Name:
RENDER not. Output providers last name. NM RENDER
LNAME  If individual name is not present, but group or facility name is present, output group or facility name in last name field. LNAME
 If individual name and group or facility name are both present, output individual name.
 If individual name is separated and presented as two lines of information, consider both lines in name parsing determination, and
capture all information present.
 If “Signature On File”, “Sign. On File”, “Doctor’s Signature On File”, or “Signature Waived” is present, do not output. If a legible Core WebDE:
provider name is also present, it should be output. SigPresent,
 If signature is illegible, but typed name is present, output typed name. Do not output “Signature Illegible”. RendLast+Re
 If field 31 is illegible, evaluate Field 33 to see if an individual provider name is present and can be clearly matched to the provider in ndSpec,
Field 31 (for use to support or reference when Field 31 is not completely legible) RendFirst,
 If an individual name is not available in Field 33, evaluate Field 32 to see if an individual provider name is present and can be
clearly matched to the provider in Field 31 (for use to support or reference when Field 31 is not completely legible). Select
 If names are not available in Fields 33 or 32 to use as comparison to data in Field 31, send Signature Illegible. WebDE:
 Credentials should not be included in the illegible/legible determination for field 31. If first and last name are legible, output first and od_attend_sig
last name as listed on the claim. If first and last name cannot be parsed, key all in the last name field. Do not output “signature ,
illegible” due to credentials, should only be sent if last name is illegible. od_attend_na
 If illegible data is present, follow the guidelines above. Legible Data Document guidelines do not apply to this field. me_l,
 If “DBA” is present, do not output “DBA”. Provider name should still be output. od_attend_na
 If after removing “DBA”, two names of the same type are present (i.e.: two individuals, two groups, or two facilities), key the me_f,
name after “DBA” od_attend_na
 If after removing “DBA”, two names of different types are present, apply the hierarchy for this field me_m
Example:
 If individual name is not present, but group or facility name is present, output group or facility name in last name field.
 If individual name and group or facility name are both present, output individual name.
 If multiple provider names are present on a claim form, and one individual provider is not identified as the rendering provider, key
the Organization (group or facility) as the rendering provider.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Individual vs. Organization Determination

 If any of the following terms are listed after the provider name in field 17, 31, and/or 33 on a HCFA or Miscellaneous Medical form,
key as an organization and not as an individual provider.
Organization Abbreviations
 APC
 ASC
 CORP
 Corporation
 INC
 LC
 LLC
 LTD
 MAGD
 PA (Note: See PA Exception Handling Guidelines and examples below)
 PC
 PLD
 PLLC
 PSC
 SC
 Above is a list of Organizations, if any of the above Organization abbreviations are presented at the END of an individual Provider
name, key as an Organization. (Key all in the last name field, where applicable)
 ONLY key as Organization when these Organization abbreviations are the last thing presented after the name, with the exception of



EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Veteran Affairs Exception Handling Guidelines

 All claims received in the dedicated Veterans Affairs PO Box (PO Box 188017, Chattanooga, TN 37422) will have the special
processing rule listed below applied to all HCFA claims:
 Field 31 – Rendering Physician Name will be replaced with Field 33 – Billing Provider name
EDI Requirements
 If provider’s credentials appear on claim, map to rendering provider last name with space in between name and credentials.
 Default is not required when rendering provider is not present in field 31
 When the rendering provider information is blank (EDI and paper claims) it is assumed that the Billing provider is the same as the
rendering provider and no rendering provider loop is created
 During the mapping process to the internal proprietary formats, the billing information is copied to the rendering provider fields,
when the rendering provider loop was not created.
Auditing Guide:
 If Field 31 is blank or if Signature on File is present, the Billing Name from field 33 is mapped to the Rendering Provider Name in
Xnet.
 In Xnet, information present in the RENDER ADDR: field is populated systematically from Field 32. The Rendering Address is not
a field keyed by the vendors.
 Single character credentials should not be captured. (Example: Paul T Cook M)
 If numbers are presented after the Provider’s name and there is no space between the name and numbers, send all in the last
name field. (Example: Paul T Cook MD123 – Send all in the last name field: Paul T Cook MD123)
 If numbers are presented after the Provider’s name and there is a space between the characters and the numbers, do not key the
numbers and send the name in the first and last name fields. (Example: Paul T Cook MD 123 – Send Paul (first name) Cook (last
name) MD (credentials).
 If Select Superbill, performing provider is keyed in box 17
EMR Keying Instructions:

See below
31 Signature of Cigna Business Requirements 2310B RENDERING-
Physician First  Information will be populated from the provider table if a match was made based on tin # and address. If not, key as shown on NM1 PROVIDER-
Name or claim. NM104 1036 FIRST-NAME
Supplier  Key physician or supplier last name if available and legible. PIC X(25)

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Do not use punctuation. Do not use name prefixes (Dr., Mr., Mrs., etc). Claim/ CLAIM LEVEL
CBH Proclaim  Titles may be presented before or after the name. echcf:RelatedPro
Field Name:  If the last name is combined, key both (Adler Lee, Mc Smith, Van Damme) - do not key special characters. vidersInfo/
PRV-NAME  If a title is present and can be identified as a title, do not key. hcfd:RenderingS ECR field:
 If unable to determine the first name, last name and credentials, refer to the Name Format Examples document for making the erviceProviderInf E2-
CBH Common determination of how to key. o/ucfd:FirstName RENDERING-
Claim Field  If unable to determine title, first and last name, key all in the last name field. PRV-FIRST-
Name:  If individual name is not present, but group or facility name is present, output group or facility name. XCCR: M00- NAME
RENDER  If individual name and group or facility name are both present, output individual name in last name field. FRST-NM
FNAME  If individual name is separated and presented as two lines of information, consider both lines in name parsing determination, and Xnet Field
capture all information present. Name:
 If “Signature On File”, “Sign. On File”, “Doctor’s Signature On File”, or “Signature Waived” is present, do not output. If a legible RENDER
provider name is also present, it should be output. FNAME
 If signature is illegible, but typed name is present, output typed name. Do not output “Signature Illegible”.
 If field 31 is illegible, evaluate Field 33 to see if an individual provider name is present and can be clearly matched to the provider in
Field 31 (for use to support or reference when Field 31 is not completely legible).
 If an individual name is not available in Field 33, evaluate Field 32 to see if an individual provider name is present and can be
clearly matched to the provider in Field 31 (for use to support or reference when Field 31 is not completely legible).
 If names are not available in Fields 33 or 32 to use as comparison to data in Field 31, send Signature Illegible.
 Credentials should not be included in the illegible/legible determination for field 31. If first and last name are legible, output first and
last name as listed on the claim. If first and last name cannot be parsed, key all in the last name field. Do not output “signature
illegible” due to credentials, should only be sent if last name is illegible.
 If illegible data is present, follow the guidelines above. Legible Data Document guidelines do not apply to this field.
 If “DBA” is present, do not output “DBA”. Provider name should still be output.
Miscellaneous Medical Only:
 If multiple provider names are present on a claim form, and one individual provider is not identified as the rendering provider, key
the Organization (group or facility) as the rendering provider.

 APC
 ASC
 CORP
 Corporation
 INC
 LC
 LLC
 LTD

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 MAGD
 PC
 PLD
 PLLC
 PSC
 SC


EDI Requirements
 Default is not required when rendering provider is not present in field 31
 When the rendering provider information is blank (EDI and paper claims) it is assumed that the Billing provider is the same as the
rendering provider and no rendering provider loop is created
 During the mapping process to the internal proprietary formats, the billing information is copied to the rendering provider fields,
when the rendering provider loop was not created.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Auditing Guide:
 If Field 31 is blank or if Signature on File is present, the Billing Name from field 33 is mapped to the Rendering Provider name in
Xnet.
 In Xnet, information present in the RENDER ADDR: field is populated systematically from Field 32. The Rendering Address is not
a field keyed by the vendors.
 Single character credentials should not be captured. (Example: Paul T Cook M)
 If numbers are presented after the Provider’s name and there is no space between the name and numbers, send all in the last
name field. (Example: Paul T Cook MD123 – Send all in the last name field: Paul T Cook MD123)
 If numbers are presented after the Provider’s name and there is a space between the characters and the numbers, do not key the
numbers and send the name in the first and last name fields. (Example: Paul T Cook MD 123 – Send Paul (first name) Cook (last
name) MD (credentials).
 If Select Superbill, performing provider is keyed in box 17
31 Signature of Cigna Business Requirements 2300 PROVIDER-

Physician or  If name is unreadable, then send signature indicator equal to a Y, and map the words “Signature Illegible” to RENDERING- CLM SIGNATURE
Supplier PROVIDER-LAST-NAME and RENDERING-PROVIDER-FIRST-NAME fields. CLM06=Y or N PIC X(01)
Indicator  If name is readable, then send signature indicator equal to a Y, and map the name to RENDERING-PROVIDER-LAST-NAME and CLAIM LEVEL
RENDERING-PROVIDER-FIRST-NAME fields. ECHCF:
CBH Proclaim  If no name is present on the claim, then send signature indicator equal to an N. Claim/ ECR field:
Field Name: echcf:RelatedPro E2-PRV-
N/A EDI Requirements vidersInfo/ SIGNATURE
 Send “Y” or “N” hcfd:BillingProvid
CBH Common er/
Claim Field Auditing Guide: hcfd:ProviderSign
Name:  If Field 31 is blank or if Signature on File is present, the Billing Name from field 33 is output as the Rendering Provider in Xnet. atureOnFile
N/A
XCCR field:
C00-PROV-SIG-
IND
31 Date of Cigna Business Requirements N/A N/A N/A
Physician Not required, do not key.
Signature
32 Name of Facility Cigna Business Requirements Loop 2310C RENDERING-

where services  Key if present. NM1 FACILITY-
were rendered  If field contains a facility name, a group name, and an individual name, key the facility name. NM101 = 77 98 NAME PIC
 If field contains a facility name and a group name, key the facility name. NM102 = 2 1065 X(35)
CBH Proclaim  If field contains a facility name and an individual name, key the facility name. (NON-PERSON) 1035 CLAIM LEVEL

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Field Name:  If field contains a group name and an individual name, key the group name. NM103 =
N/A  If field contains only an individual name, key the individual name. RENDERING ECR field:
 If generational suffix is present, key (Jr., Sr., I., II., III., IV., V.) FACILITY NAME E2-
 Key last name, include generational suffix, space, include professional designation(s), and/or provider’s credentials as part of RENDERING-
CBH Common the last name preceded by a space. FAC-NAME
Claim Field  Logic for determining group vs. facility is reflected in Appendix K. ECHCF:
Name:  If two lines are present, only key the first line. Claim/
RENDER FAC  If “Same” is present, key name from field 33/Billing Name, as long as it is a group or facility. echcf:RelatedPro Xnet Field
NAME  If “DBA” is present, do not output “DBA”. Provider name should still be output. If there are two names present, follow the logic vidersInfo/ Name:
for determining facility, group and individual, and remove the DBA prior to output. Keying requirements state, the facility or hcfd:ServiceFacili RENDER FAC
group name should be captured and not the individual. Example: "James D Weiss MD DBA Total Rehab". Facility or Group tyInfo/ NAME
. should be output, per logic. "DBA" should not be output as part of the name, only output "Total Rehab". ucfd:AddressInfo/
If name of facility where services were rendered is blank or illegible and an address is present, output as XXX ucfd:Name Select
WebDE:
 Address of facility where services were rendered cannot be sent if name is missing XCCR: M00- od_render_na
 City of facility where services were rendered cannot be sent if name is missing LAST-NM-ORG- me
NM
 State of facility where services were rendered cannot be sent if name, address or city are missing
 Zip code of facility where services were rendered cannot be sent if name, address, city or state are missing
 If an ambulance route is present: Key the “to” location as the Facility Name
 For Miscellaneous Medical claim forms, the following terms can be used to identify the name of the Facility where services
were rendered:
 Performed At
 Location
EDI Requirements
 Remove punctuation and spaces
 If blank, leave blank
 Do not send rendering facility segments when place of service is 12.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
32 Address of Cigna Business Requirements Loop 2310C RENDERING-
Facility where  Key if present. N3 FACILITY-
Services were  If present, include both lines of the address. N301 = Addr1 166 ADDRESS-1
rendered.  If data is present in address 2, then address 1 cannot be blank. If address 2 is present and address 1 is not, move address 2 up to N302 = Addr2 166 PIC X(35)
address 1. CLAIM LEVEL
CBH Proclaim  If “Same” is present, key address from field 33/Billing Physicians address, as long as it is a group or facility. RENDERING-
Field Name:  Do not use punctuation or spaces. ECHCF: FACILITY-
N/A  Address of facility where services were rendered cannot be sent if name is missing. Claim/ ADDRESS-2
 If a name is present and the address of facility where services were rendered is blank or illegible, send “XXX” as the default. echcf:RelatedPro PIC X(35)
CBH Common vidersInfo/ CLAIM LEVEL
Claim Field EDI Requirements hcfd:ServiceFacili
Name:  Address 1 cannot be blank if address 2 is present. tyInfo/ ECR field:
RENDER FAC  Remove special characters. ucfd:AddressInfo/ E2-
ADDR  Default XXX ucfd:AddressLine RENDERING-
 Do not send rendering facility segments when place of service is 12. 1 FAC-ADDR-1
E2-
Auditing Guide: Claim/ RENDERING-
 Do not count errors for standard Postal abbreviations being keyed for Street, Lane, Drive, Boulevard, Avenue etc… as long as echcf:RelatedPro FAC-ADDR-2
the abbreviation is keyed correctly. vidersInfo/
hcfd:ServiceFacili
tyInfo/ Xnet Field
ucfd:AddressInfo/ Name:
ucfd:AddressLine RENDER FAC
2 ADDR
XCCR Field: Select

M00-ADDR-LN1 WebDE:
M00-ADDR-LN2 od_render_ad
dr

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
32 City of Facility Cigna Business Requirements Loop 2310C RENDERING-
where services  Key if present. N4 FACILITY-
were rendered.  Do not use punctuation or spaces. N401 19 CITY PIC
 Must be a minimum of two characters. If less than two characters, do not output. X(30)
CBH Proclaim  If “Same” is present, key city from field 33. ECHCF: CLAIM LEVEL
Field Name:  City of facility where services were rendered cannot be sent if name is missing. Claim/
N/A  Address of facility where services were rendered cannot be sent if name is missing. echcf:RelatedPro ECR field:
 If a name is present and the address of facility where services were rendered is blank or illegible, send “XXX” as the default. vidersInfo/ E2-
CBH Common  If less than 2 characters, send XXX hcfd:ServiceFacili RENDERING-
Claim Field tyInfo/ FAC-CITY
Name: EDI Requirements ucfd:AddressInfo/
RENDER FAC  Remove special characters ucfd:City
CITY  Default XXX Xnet Field
 Do not send rendering facility segments when place of service is 12. XCCR Field: Name:
M00-CITY-NM RENDER FAC
CITY
Select
WebDE:
od_render_cit
y
32 State of Facility Cigna Business Requirements Loop 2310C RENDERING-
where services  Key if present. N4 FACILITY-
were rendered.  If “Same” is present, key state from field 33. N402 156 STATE PIC
 Address of facility where services were rendered cannot be sent if name is missing X(02)
CBH Proclaim  State of facility where services were rendered cannot be sent if name, address or city are missing. ECHCF: CLAIM LEVEL
Field Name:  If name is present and state of facility where services were rendered is blank, illegible or length of 2 is not met, send “XX” as the Claim/
N/A default. echcf:RelatedPro ECR field:
vidersInfo/ E2-
CBH Common EDI Requirements hcfd:ServiceFacili RENDERING-
Claim Field  Remove special characters. tyInfo/ FAC-STATE
Name:  Default “XX” ucfd:AddressInfo/
RENDER FAC  State must be a valid postal abbreviation. ucfd:State Xnet Field
STATE  Do not send rendering facility segments when place of service is 12 Name:
XCCR field: RENDER FAC
M00-STE-PROV- STATE
CD
Select
WebDE:
od_render_sta

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
te
32 Zip Code of Cigna Business Requirements Loop 2310C RENDERING-
Facility where  Key if present. N4 FACILITY-ZIP
services were  If “Same” is present, key zip code from field 33. N403 116 PIC X(11)
rendered.  Zip code of facility where services were rendered cannot be sent if name, address, city or state are missing. CLAIM LEVEL
 Key zip code if present, up to nine digits.
CBH Proclaim  Zip code must be equal to 5 or 9 numerics, no spaces. ECHCF: ECR field:
Field Name:  If blank, default 99999 Claim/ E2-
N/A  Zip code must be equal to 5 or 9---If greater than or less than 5 or 9, default 99999 echcf:RelatedPro RENDERING-
 If name is present and zip code of facility where services were rendered is blank or illegible, send “99999” as the default. vidersInfo/ FAC-ZIP
 If box 32 is blank (name, address, city, state, zip), output default fields as indicated. hcfd:ServiceFacili
CBH Common tyInfo/ Xnet Field
Claim Field EDI Requirements ucfd:AddressInfo/ Name:
Name:  Remove special characters. ucfd:PostalCode RENDER FAC
RENDER FAC Z  Do not send rendering facility segments when place of service is 12. ZIP
IP  If blank, default 99999 XCCR field:
 If greater than or less than 5 or 9, default 99999 M00-POSTL-CD
Select
WebDE:
od_render_zip
32a – Service Facility Cigna Business Requirements Loop 2310C 66 RENDERING-
(CMS) Location - NPI  Key NPI number information from NPI box on form, and a minimum of 2 characters exist. NM101=77 67 FACILITY-
(CMS and HCFA  Key NPI if present even if more than 10 characters are listed, do not limit to only 10 characters. NM02, 03, 14 NATL-ID
1500)  NPI Numbers should be keyed with no spaces. This applies to all NPI fields on all Medical form types. For example: from box 32
 NPI Number listed on the claim as: 89 97865345 NM108 = XX ECR field:
NM109= NPI E2-RENDER-
FAC-NATL-ID
 The Luhn formula is applied to validate NPI information submitted.
 If the NPI is incomplete or partially illegible, the NPI number will not be output. ECHCF: Xnet Field
Claim/ Name:
EDI Requirements echcf:RelatedPro RENDER FAC
 NPI qualifier of XX should always be sent when sending NPI. vidersInfo/ NATL ID
 Remove special characters hcfd:ServiceFacili
 NPI Number should be keyed and output to Cigna with no spaces tyInfo/
 NPI is an alphanumeric field ucfd:PrimaryIdent
 NPI must be a minimum of 2 characters in order to be compliant. ifier/ucf:Identifier
Select
XCCR FIELD: WebDE:
M05-PARTY- X12_2310D_
REF-TY-CD NM1_IDCOD

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
E
32B / 24J Rendering Not required, do not key.
Provider ID # -
Taxonomy
Number (HCFA
1500)
Could be located
in field 24J, If
taxonomy in
both fields take
from 32B
33 Physician’s or X Cigna Business Requirements Loop 2010AA BILLING-
Supplier’s Billing 1) NPI not present NM101 = 85 98 PROVIDER-
Name Modification on the current provider lookup. Perform a lookup on 9 digit Provider Tax ID, 1st 10 digits of the billing individual NM102 = 1 or 2 1065 LAST-NAME
name billing organization (examples would be Duke Unive or John Smith) and 1st 3 numeric values of the billing address. NM103 = LN of 1035 PIC X(35)
CBH Proclaim Expectation is for the results to return a 1:1 match on the lookup fields returning the NPI, provider tax ID, billing name, address, Fac. 1036 CLAIM LEVEL
Field Name: city, state and zip code. NM104 = FN if BILLING-
PRV-BILL-  What happens if no results are found? Copy down the tax ID from the lookup field to the actual field and key the billing NM102 = 1 PROVIDER-
NAME name, address, city, state and zip from claim. FIRST-NAME
 What happens if the billing NPI populates? Accept what populated from the Cigna provider table. ECHCF: PIC X(25)
CBH Common  What happens if billing name is different from claim? Accept what populated from the Cigna provider table. Claim/ CLAIM LEVEL
Claim Field  What happens if billing address is different from claim? Accept what populated from the Cigna provider table. echcf:RelatedPro
Name: 2) NPI is present vidersInfo/ ECR field:
BILLING Perform lookup on Billing NPI, tax ID, 1st 3 digits of the numeric values of billing street address and add logic to remove exact hcfd:BillingProvid E2-BILL-PRV-
FNAME match duplicates. Expectation is for the results to return a 1:1 match on the lookup fields returning the NPI, provider tax ID, er/ LAST-NAME
billing name, address, city, state and zip code. ucfd:AddressInfo/ E2-BILL-PRV-
 What happens if no results are found? Copy down the Billing NPI from the lookup field to the actual field and key the tax ucfd:Name (if FIRST-NAME
ID, billing name, address, city, state and zip from claim. person indicator
 What happens if tax ID is different from claim? Accept what populated from the Cigna provider table. is 2). Xnet Field
Name:
 What happens if billing name is different from claim? Accept what populated from the Cigna provider table.
Claim/ BILLING
 What happens if billing address is different from claim? Accept what populated from the Cigna provider table.
echcf:RelatedPro LNAME
vidersInfo/ BILLING
 Information will be populated from the provider table if a match was made based on tin # and address hcfd:BillingProvid FNAME
 If not populated, key as shown on claim if present. er/
 If field contains a group name, a facility name, and an individual name, key the group name. ucfd:AddressInfo/
 If field contains a group name and a facility name, key the group name. ucfd:LastName (if
 If field contains a facility name and an individual name, key the facility name. person indicator Core WebDE:
 If field contains a group name and an individual name, key the group name. is 1). BillLast+"

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 If field contains only an individual name, key the individual name. Key the last name, a space, include generational suffix, "+BillSpec or
space, include professional designation(s), and/or provider’s credentials as part of the last name preceded by a space. Then Claim/ BillOrg,
key first name. echcf:RelatedPro BillFirst
 If generational suffix is present, key (Jr., Sr., I., II., III., IV., V.) vidersInfo/
 Logic for determining group vs. facility is reflected in Attachment K. hcfd:BillingProvid
 If two lines are present, only key the first line. er/ Select
 If “DBA” is present, do not output “DBA”. Provider name should still be output. ucfd:AddressInfo/ WebDE:
 If after removing “DBA”, two names of the same type are present (i.e.: two groups, two facilities, or two individuals), key the ucfd:FirstName (if X12_2010AA_
name after “DBA” person indicator NM1_PROVN
 If after removing “DBA”, two names of different types are present, apply the hierarchy for this field is 1). AME,
Example: od_prov_nam
 If field contains a group name, a facility name, and an individual name, key the group name. XCCR : e_f,
 If field contains a group name and a facility name, key the group name. M00-LAST-NM- od_prov_nam
 If field contains a facility name and an individual name, key the facility name. ORG-NM e_m
 If field contains a group name and an individual name, key the group name. M00-FRST-NM
 If blank, illegible or invalid, reject claim
 If missing or illegible, review the attachments to determine if the information is available, prior to rejecting form missing or
illegible information. (Effective: 06/27/13 CR-EMR0060213.1)

 APC
 ASC
 CORP
 Corporation
 INC
 LC
 LLC
 LTD
 MAGD
 PC
 PLD
 PLLC
 PSC
 SC

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level



Medicaid Specific Claim Processing Guidelines for Medicaid Claims Received in the Kennett Mailroom: (Effective 01/08/15 CCF
14-039)
 When a Medicaid claim is received in the Select PO Boxes or Fax lines and there is wording “remit to” or “make payment to” and the
Medicaid agency is noted anywhere on the claim or supporting documentation, the Medicaid provider information should be keyed
in the Billing provider field.
Billing Provider Name and Address:

 Key the Medicaid provider information as the billing provider from the claim/attachment if the term “remit to” or “make payment to” is
provided on the claim/attachment.
EDI Requirements
 If blank, illegible or invalid, reject claim

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
33 Physician’s or Cigna Business Requirements 2010AA BILLING-

Supplier’s  Information will be populated from the provider table if a match was made based on tin # and address N3 PROVIDER-
Address  If not populated, key as shown on claim if present. N301 = Addr1 166 ADDRESS-1
 If present, include both lines of the address. N302 = Addr2 166 PIC X(35)
CBH Proclaim  Physician address cannot be sent if physician name is missing. CLAIM LEVEL
Field Name:  If data is present in address 2, then address 1 cannot be blank. If address 2 is present and address 1 is not, move address 2 up to ECHCF: BILLING-
PRV-BILL- address 1. Claim/ PROVIDER-
ADDR  If field 33 is not legible, compare to field 32, if enough information is legible to compare the 2 fields and they match, use the address echcf:RelatedPro ADDRESS-2
PRV-BILL- information in field 32 as the address information for field 33. (ex: 14353303290962) vidersInfo/ PIC X(35)
ADDR-2  If field 33 only has a provider name but no address, but an address is located in field 32, use the address in field 32 as the address hcfd:BillingProvid CLAIM LEVEL
for field 33. (ex: 14342307894642) er/
CBH Common  On superbill, if only one address for “rendering facility” “place of services” etc (equates to field 32) then use this as address for field ucfd:AddressInfo/ ECR field:
Claim Field 33. (ex: 14342401751122) ucfd:AddressLine E2-BILL-PRV-
Name:  Matching Criteria: 1 ADDR-1
BILLING ADDR  Numeric of street address E2-BILL-PRV-
 Street name of address Claim/ ADDR-2
 City echcf:RelatedPro
 State vidersInfo/ Xnet Field
 Zip Code hcfd:BillingProvid Name:
 If missing or illegible, review the attachments to determine if the information is available. (Effective: 06/27/13 CR-EMR0060213.1) er/ BILLING
 If any of the address fields are blank, incomplete or illegible, do not follow the “key as much legible information as possible rule”, ucfd:AddressInfo/ ADDR
send the defaults as outlined below: ucfd:AddressLine
 Address = “XX” 2
 City = “XXX” Select
 State = “XX” XCCR : WebDE:
 Zip = “999999999” M00-ADDR-LN1 od_prov_addr
M00-ADDR-LN2 _1,
Medicaid Specific Claim Processing Guidelines for Medicaid Claims Received in the Kennett Mailroom: od_prov_addr
 When a Medicaid claim is received in the Select PO Boxes or Fax lines and there is wording “remit to” or “make payment to” and the _2

EDI Requirements
 Address 1 cannot be blank if address 2 is present.

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Default XX if blank, illegible or less than 2 characters
Auditing Guide:
 Do not count errors for standard Postal abbreviations being keyed for Street, Lane, Drive, Boulevard, Avenue etc… as long as
the abbreviation is keyed correctly.
NOTE: To be HIPAA-compliant, PO Box or Lockbox information may not be sent in Loop 2010AA Billing Provider. This information must
be sent in Loop 2010AB Pay-to Provider. Should Cigna relax the edit for paper claims and allow PO / Lockbox information be sent in
Loop 2010AA if it is the only address available for the provider or should the claim be rejected for Missing Provider Address?

33 Physician’s or Loop 2010AA BILLING-
Supplier’s City Cigna Business Requirements N4 PROVIDER-
 Information will be populated from the provider table if a match was made based on tin # and address N401 19 CITY PIC
CBH Proclaim  If not populated, key as shown on claim if present. X(30)
Field Name:  If field 33 is not legible, compare to field 32, if enough information is legible to compare the 2 fields and they match, use the address CLAIM LEVEL
PRV-BILL-CITY information in field 32 as the address information for field 33. (ex: 14353303290962) ECHCF:
 If field 33 only has a provider name but no address, but an address is located in field 32, use the address in field 32 as the address Claim/
for field 33. (ex: 14342307894642) echcf:RelatedPro ECR field:
CBH Common  On superbill, if only one address for “rendering facility” “place of services” etc (equates to field 32) then use this as address for field vidersInfo/ E2-BILL-PRV-
Claim Field 33. (ex: 14342401751122) hcfd:BillingProvid CITY
Name:  Matching Criteria: er/
BILLING CITY  Numeric of street address ucfd:AddressInfo/ Xnet Field
 Street name of address ucfd:City Name:
 City BILLING CITY
 State XCCR :
 Zip Code M00-CITY-NM
 Must be a minimum of two characters. If less than two characters, send as “XXX”. Select
 If missing or illegible, review the attachments to determine if the information is available. (Effective: 06/27/13 CR-EMR0060213.1) WebDE:
od_prov_city
Medicaid Specific Claim Processing Guidelines for Medicaid Claims Received in the Kennett Mailroom:


EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
EDI Requirements
Remove special characters

33 Physician’s or Cigna Business Requirements Loop 2010AA BILLING-
Supplier’s State  Key if present. Information will be populated from the provider table if a match was made based on tin # and address N4 PROVIDER-
 If not populated, key as shown on claim if present. N402 156 STATE PIC
CBH Proclaim  Physician state cannot be sent if physician name, physician address or physician city are missing. X(02)
Field Name:  If field 33 is not legible, compare to field 32, if enough information is legible to compare the 2 fields and they match, use the address ECHCF: CLAIM LEVEL
PRV-BILL-ST information in field 32 as the address information for field 33. (ex: 14353303290962) Claim/
 If field 33 only has a provider name but no address, but an address is located in field 32, use the address in field 32 as the address echcf:RelatedPro
for field 33. (ex: 14342307894642) On superbill, if only one address for “rendering facility” “place of services” etc (equates to field vidersInfo/ ECR field:
CBH Common 32) then use this as address for field 33. (ex: 14342401751122) hcfd:BillingProvid E2-BILL-PRV-
Claim Field er/ STATE
Name:  Matching Criteria: ucfd:AddressInfo/
BILLING STATE  Numeric of street address ucfd:State Xnet Field
 Street name of address Name:
 City XCCR : BILLING
 State M00-STE-PROV- STATE
 Zip Code CD
 If missing, invalid or illegible default “XX” Select
WebDE:
Medicaid Specific Claim Processing Guidelines for Medicaid Claims Received in the Kennett Mailroom: od_prov_state

EDI Requirements
State must be a valid postal abbreviation.
Remove special characters

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
33 Physician’s or Cigna Business Requirements Loop 2010AA BILLING-
Supplier’s Zip  Information will be populated from the provider table if a match was made based on tin # and address N403 PROVIDER-
Code  If not populated, key as shown on claim if present. 116 ZIP PIC
 Physician zip code cannot be sent if physician name, physician address, physician city or physician state are missing. X(11)
CBH Proclaim  Zip code must be equal to 5 or 9 numerics, no spaces. CLAIM LEVEL
Field Name:  If field 33 is not legible, compare to field 32, if enough information is legible to compare the 2 fields and they match, use the address ECHCF:
PRV-BILL-ZIP information in field 32 as the address information for field 33. (ex: 14353303290962) Claim/
 If field 33 only has a provider name but no address, but an address is located in field 32, use the address in field 32 as the address echcf:RelatedPro ECR field:
for field 33. (ex: 14342307894642) vidersInfo/ E2-BILL-PRV-
CBH Common  On superbill, if only one address for “rendering facility” “place of services” etc (equates to field 32) then use this as address for field hcfd:BillingProvid ZIP
Claim Field 33. (ex: 14342401751122) er/
Name:  Matching Criteria: ucfd:AddressInfo/ Xnet Field
BILLING ZIP  Numeric of street address ucfd:PostalCode Name:
 Street name of address BILLING ZIP
 City XCCR :
 State M00-POSTL-CD Select
 Zip Code WebDE:
 If missing or illegible, review the attachments to determine if the information is available od_prov_zip
EDI Requirements

33 Physician’s, Cigna Business Requirements: N/A N/A N/A
Supplier’s  Information will be populated
Phone Number  If not, key as shown on claim
 Exclude 000-000-0000 if present
Medicaid Specific Claim Processing:

 Key the Medicaid provider information from the Attachment if it says “remit to” or “make payment to” on the attachment.
EDI Requirements
ANSI Segment:
PER01 = "IC"

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
PER02 = "" (blank)
PER03 = "TE" (for telephone)
PER04 = "[phone number]"
33-HCFA GRP# Cigna Business Requirements Not applicable Not Not applicable
Not Required, do not key applicable
33-HCFA PIN # Cigna Business Requirements Loop VENDOR-ID-

 Key if present. 2010AA CHAT
CBH Proclaim  If greater than or less than 7 characters, output the field as blank. REF 128
Field Name:  Do not key punctuation or spaces. NM101= 85 127 ECR Field:
N/A  Cannot contain special characters 2010BB E2-VENDOR-
 Cannot contain alpha characters. NM101=PR ID-CHAT
CBH Common  For Old HCFA only. REF01 = G2
Claim Field REF02 = XCCR Field
Name: EDI Requirements VENDOR ID not present
N/A Remove special characters. CHAT
(Added: 6/18/13):
ECHCF:
Claim/
echcf:RelatedPro
vidersInfo/
hcfd:BillingProvid
er/
hcfd:PayerProvid
erNumber
33a Billing Provider Cigna Business Requirements Loop 2010AA 66 BILLING-

(CMS) Information -  Key NPI number information from NPI box on form, and a minimum of 2 characters exist. NM101=85 67 PROVIDER-
NPI (CMS 1500)  Key NPI if present even if more than 10 characters are listed, do not limit to only 10 characters. NM102, 03, 04 NATL-ID
 NPI Numbers should be keyed with no spaces. This applies to all NPI fields on all Medical form types. For example: from box 33
CBH Proclaim NM108 = XX Xnet Field
 NPI Number listed on the claim as: 89 97865345
Field Name: NM109 NPI Name:
N/A  NPI Number should be keyed and output to Cigna as 8997865345 BILLING
 The Luhn formula is applied to validate NPI information submitted. ECHCF: NATID
 If the NPI is incomplete or partially illegible, the NPI number will not be output. Claim/

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
CBH Common echcf:RelatedPro ECR field:
Claim Field Key the Billing and Rendering NPI from the bottom section of the claim. This claim format only. These are system generated from vidersInfo/ E2-BILL-PRV-
Name: hcfd:BillingProvid NATL-ID
electronic submission processed by CPR. This is a very specific claim forms.
BILLING NATL er/
ID ucfd:PrimaryIdent
ifier/ucf:Identifier Core WebDE:
EDI Requirements BillNPI
 NPI qualifier of XX should always be sent when sending NPI. XCCR Field:
 Remove special characters M05-PARTY- Select
 NPI Number should be keyed and output to Cigna with no spaces REF-TY-CD WebDE:
 NPI is an alphanumeric field X12_2010AA_
 NPI must be a minimum of 2 characters in order to be compliant. NM1_IDCOD
 Remove NPI data if the NPI first digit value on the claim is 0, 5, 6, 7, 8, 9 after the NPI goes through the Luhn formula (scrub it out E
and send nothing)
33b Cigna Business Requirements

Not Required.
n/a - MM Other Insurance Cigna Business Requirements 2320 OI-PAID-

Paid Amount  Key if present, if no EOB present. AMT AMOUNT
(Claim Level) AMT01=D 522 PIC X(02)
EDI Requirements AMT02 782 PIC 9(08)V99
CBH Proclaim  Must be numeric. CLAIM LEVEL
Field Name:  If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the Cigna on-site ECHCF:
N/A representative for further processing instruction. Claim/ ECR field:
echcf:ClaimCOBI E2-OI-PAID-
nfo/ AMT(1)
CBH Common hcfd:OtherPayerA
Claim Field djudicationInfo/ Xnet Field
Name: hcfd:OtherPayerP Name:
N/A aidAmount OI PAID
XCCR :
C25-COB-AMT
Attachment Cigna Business Requirements: 2300 DOCUMENT-

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
Codes  Key if present. PWK 755 TYPE
 Only valid ANSI values can be sent to identify the attachment type. PWK01 = 756 PIC X(02)
 When an attachment exists that does not match any of the attachment types, pass ANSI value of OZ (Attachment). Attachment Code CLAIM LEVEL
 When two different types of attachments exist, pass each ANSI value. If one of the attachments is an Explanation of Benefits, pass PWK02 = AA DOCUMENT-
EB as the first attachment indicator and the other attachment value as the second attachment indicator. TYPE2
 When more than two different types of attachments exist and one of the attachments is an x-ray attachment, pass RB as the primary When PIC X(02)
indicator. PWK02=BM, CLAIM LEVEL
 When two attachments exist and one is a x-ray attachment and the other is an Explanation of Benefits, pass RB as the primary PWK05= AC
indicator (Attachment REPORT-
 When more than two different types of attachments exist (not including x-ray) and one of the attachments is an Explanation of control #) TRANSMISSI
Benefits, pass EB as the first attachment indicator, and pass OZ for the additional attachments. PWK06=Control ON-CODE
 When more than two different types of attachments exist and none are an Explanation of Benefits or x-rays, pass OZ as the first # assigned to 1032 PIC X(02)
attachment indicator. document CLAIM LEVEL
INSURANCE-
Select Attachment Codes for COB INDICATOR
2320
 The alpha attachment code will be transmitted per existing guidelines in the NTE Segment [No change to current] SBR09 = MB or ECR FIELD:
 Only valid ANSI values can be sent to identify the attachment type in 2300 PWK segment CI 15 E2-
 All other attachment codes and processing rules remain intact REPORT-
TRANMISSIO
ECHCF: N-CODE
EDI Requirements: Claim/
 No Special Characters echcf:ClaimDetail
 More than one attachment code may be present s/ Xnet Field
hcfd:ClaimAttach Name:
 Valid ANSI attachment type values to be passed in PWK01 are: mentInfo/ ATTACHMEN
hcfd:ReportType T DOC TYPE:
AS = Admission Summary (TYPE 2):
Claim/ ATTACHMEN
B2 = Durable Medical Equipment Prescription echcf:ClaimDetail T DCN:
s/
CT = hcfd:ClaimAttach XCCR:
 Itemized Bill mentInfo/ C00-CLM-
 Letter hcfd:AttachmentT TRANS-TY
 Medical records ransmissionCode
 Oxygen Therapy Certification
 Possible Fraud Claim/
echcf:ClaimDetail
 Repricing Charges
s/
 Eligibility

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
hcfd:ClaimAttach
DA = mentInfo/
 Periodontal Charting hcfd:AttachmentC
 Dental Models ontrolNumber
DG = Diagnostic Report
DS = Discharge Summary
EB = Explanation of Benefits
 If Medicare EOB, output Insurance Indicator as MB.
 If Commercial OI EOB (including Cigna EOB), output Insurance Indicator as CI.
 If Medicare EOB and Commercial OI EOB, output Insurance Indicator as MB.
MT = Models
NN = Nursing Notes
OB = Operative Notes or Reports
OZ =
 Medicaid
 Attachment
 Support Data for Claim
PN =
 Physical Therapy Notes
 Chiropractic Justification
PO = Prosthetics or Orthotic Certification

PZ = Physical Therapy Certification
RB =
 X-Ray Received
 Radiology Films
 Photographs
RR = Radiology Reports
RT =

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
 Ambulance Certification
 Emergency Room Report
 Laboratory Results
 Physician’s Report
 Report of Tests and Analysis Report
 Parenteral or Enteral Certification
 Valid ANSI attachment type values to be passed in PWK02 are:
AA= Available on Request at Provider Site

BM= By Mail
N/A Corrected Claim Cigna Business Requirements Loop 2300 Select

Indicator  If stamp or note indicating corrected claim, key 1 for Yes, 2 for No. CLM WebDE:
CLM05-3 = ‘7’ 1325 CorrectedClai
The following terms found handwritten, stamped, or typed on any page of the documentation, should be considered as the term m
“Corrected”: Corrected Claim
o Corrected claim values: Not mapped in
o Corrected coding Prof = ‘7’ XCCR
o Corrected Inst = ‘7’
o Corrected – any reference to boxes or fields listed on the claim form. Dent = ‘7’
o Corrected billing
o Corrected bill
o Claim corrected
o Corrective Claim
o Claim Correction
 If claim has the word REPLACEMENT also consider as corrected = Yes.
 If field 22 (Resubmission code) contains a ‘7’ or reference of ‘corrected claim’ it can be considered a corrected claim—i.e. output a 7
in loop 2300, CLM05-3
EDI Requirements
 If corrected claim, then map ‘7’ to CLM05-3.
Auditing Note:

EDI
Gateway’s
Required
ANSI Common
to ANSI
Submit Element
to EDI Number
Gateway
or Detail
Level
If the claim is considered to be a corrected claim, the ‘TYPE BILL 3:’ field in Xnet will be ‘7’ See example below:
 Submitted on claim form (Image Number 14015300022602)
o ‘Corrected Claim’ stamped on claim
 Output to Xnet ‘Hospital Only Data’ section of report:
o TYPE BILL 1: 81 TYPE BILL 2: B TYPE BILL 3: 7

ANESTHESIA
SERVICES
NOTE: Only keying difference between Anesthesia claims is Field 24G Days or Units and Anesthesia Minutes. All other fields follow standard HCFA guidelines.
ANSI
HCFA Claim Required to Loop ANSI EDI Gateway’s Common Claim
HCFA
Form Field Submit to EDI Current Requirements Segment Element Record Field Name, Size, Claim or
Field #
Name GW. Data Number Detail Level
Element
Anesthesia charges can be identified as follows:
 0xxxx (Procedure Codes that begin with 0[zero]).
 CPT4 Modifier values of: 23, P1, P2, P3, P4, P5, P6.-HCPCS Modifier values of: AA, AB,
AC, AD, AE, AF, AG, QK, QS, QX, QZ-Minutes or Time, if present
 Hours / minutes of surgical anesthesia time are noted
 Time units are provided
 To & Form time is provided
NOTE: Provider Specialty Code is also another indicator. However, at this time there is no
standard place on the HCFA-1500 form to capture this information.
NOTE: If the CPT4 Code/Modifier, HCPC Code/Modifier does not indicate Anesthesia, but the
claim is clearly a bill for Anesthesia (i.e.: by the presence of time spans), pass as an Anesthesia
record and include the Anesthesia segment.
NOTE: Exception – CPT codes 99100, 99116, 99135, and 99140 billed with TOS 7 should be
sent in an SV1 Segment.
24G Days or Units Do not key for units/days for anesthesia claims N/A N/A N/A
24G Anesthesia Minutes Business Requirements Loop 2400 ANES-MINUTES PIC9(13)V99
 Key as shown on claim (including decimals). SV1 DETAIL LEVEL
 If minutes are not available on claim, then enter start and end time. The system will SV103 = MJ 380
calculate the number of anesthesia minutes. SV104 REMARKS-DET DATA
 If only units are present, minutes must be calculated by multiplying units by 15. For each OCCURS 0 TO 10 TIMES PIC X(80)
 If units and minutes are both present, only key minutes. item:
 If a detail line has been crossed out, it should not be keyed. 2400
 If a detail line has been crossed out, and corrected, the corrected information should be NTE 363 Xnet Field Name:
keyed. NTE01=ADD 352 ANES MIN

NTE02
EDI Requirements
 Numeric only
Key as Durable Medical Equipment (DME) if the provider is a medical supply provider such as Caremark Associates.
DME charges can be identified by the following indicators:
- Procedure code is a HCPC beginning with E, K, or L.
- A list of items considered Durable Medical Equipment is attached as Attachment “B”
DURABLE MEDICAL
EQUIPMENT
NOTE: Only keying difference between requirements for Durable Medical Equipment are found in Fields 24F and 24G. All other fields follow standard HCFA guidelines.
EDI Gateway’s
Req’d
ANSI Common Claim
HCFA to ANSI
HCFA Claim Form Current Requirements Loop Record Field
Field Submi Element
Field Name Segment Name, Size,
# t to Number
Data Element Claim or Detail
EDI G.
Level
 Key as Durable Medical Equipment (DME) if the provider is a medical supply provider such as Caremark 
Associates.
 DME charges can be identified by the following indicators:
- Procedure code is a HCPC beginning with E, K, or L.
 A list of items considered Durable Medical Equipment is attached as Attachment “B”
24F $ Charges X Business Requirements DME-CHARGE-

 Key if present. 2400 AMOUNT PIC
 If charge amount is blank, or zeroes, key a single zero (0). SV1 522 9(13)V99 DETAIL
 If DME charge field is blank and rental price is present, copy rental price into charges field and send both fields SV102 782 LEVEL
electronically.
 If DME charge field is blank and purchase price is present, copy the purchase price into charges field and send both Xnet Field Name:
electronically. DME CHARGE
 If DME charge field is blank and purchase price and rental price are present, copy rental price into charges field and
send all three fields electronically.
 If a detail line has been crossed out, and corrected, the corrected information should be keyed.
EDI Requirements
 If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the Cigna

on-site representative for further processing instruction.
24F $ Charges-Rental Price Business Requirements 2400 DME-RENTAL-

 Key if present SV5 PRICE PIC9(13)V99
 If there is no indication of the rental or purchase price, then send the line item charge for the DME service in the SV504 782 DETAIL LEVEL
purchase price and a single zero (0) in the rental price.
 If a detail line has been crossed out, it should not be keyed. Xnet Field Name:
 If a detail line has been crossed out, and corrected, the corrected information should be keyed. RENTAL AMT
EDI Requirements
 If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the
Cigna on-site representative for further processing instruction.
24F $ Charge-Purchase Price Business Requirements 2400 DME-PURCHASE-

 Key if present SV5 PRICE PIC9(13)V99
 If there is no indication of the rental or purchase price, then send the line item charge for the DME service in the SV505 782 DETAIL LEVEL
purchase price and a single zero (0) in the rental price.
 If a detail line has been crossed out, it should not be keyed. Xnet Field Name:
 If a detail line has been crossed out, and corrected, the corrected information should be keyed. PURCHASE AMT
EDI Requirements
24G DME Time Qualifier Business Requirements 2400 DME-TIME-

 Key if present. SV5 QUALIFIER
 If a detail line has been crossed out, it should not be keyed. SV502=DA=DAY 355 PICX(02) DETAIL
 If a detail line has been crossed out, and corrected, the corrected information should be keyed. S LEVEL
EDI Requirements
 If time qualifier is blank, default to DA
Medicaid Claim These requirements are specifically for the Medicaid claims in Chattanooga Mailroom that come through their specialized PO Box.
Processing
NOTE: Specific keying difference between requirements for Medicaid are found below. Some of the special keying rules can be seen in the actual HCFA requirement guidelines. All other fields follow standard HCFA
guidelines.
HCFA HCFA Claim Req’d Current Requirements ANSI ANSI EDI Gateway’s

Common Claim
to
Loop Record Field
Field Form Field Submit Element
Segment Name, Size,
# Name to EDI Number
G.
Level
24H EPSDT Family Business Requirements 2400 Not mapped in

Plan  Only key if present and the claim is a Medicaid claim SV1 ACCR
 A Medicaid claim can be identified through the following process: SV1 11
 Use box 17, 24, 31, 32, 33 and attachments looking for common SV1 12 Not mapped in
verbiage below. ECR
 Medicaid agency identified in field 31 or 33 of a HCFA claim form. ECHCF:
 Medicaid agency identified in field 1 of a UB92 claim form Claim/echcf:ServiceLineInfo/hcfd:EPSDTIndicator
 Medicaid agency identified in field 2 of a UB04 claim form Select
Common Verbiage used to Identify Medicaid claims for standard Claim/echcf:ServiceLineInfo/
WebDE:
claim forms: hcfd:FamilyPlanningIndicatorIndicator
od_epsdt
 HCFA/UB form accompanied by a cover letter indicating claim was
submitted for payment by a Medicaid agency
 Medicaid Reclamation Claim (watermark on claims)
Not mapped in
 Medicaid Paid XCCR
 MA Paid
 Medicaid Payment
 Medicaid is the payor of last resort
 Please pay $ --- to the State agency
 Medicaid Billed Amount
 Medicaid Paid
 Medicaid Owed
 Medicaid Allowed
3. Medicaid Amount
4. Medicaid Payment
 If a ‘Y’, ‘Yes’ or ‘X’, send ‘Y’.
 If blank or anything other than ‘Y’, ‘Yes’ or ‘X’, leave blank.
 If a detail line has been crossed out, and corrected, the corrected information
should be keyed.
 If a claim form is received with one detail line completed, and arrows pointing
downward, handwritten or typed, on the following detail lines, copy down the
information from the completed detail lines where applicable.
 Do not output information from this field if the claim is not identified as a
Medicaid claim
EDI Requirements
 Only key if present on Medicaid claims—not valid for non-Medicaid claims
 Pass either Y or blank.

N/A Medicaid Paid Business Requirements Loop 2430 ADJ-AMT-PAID-
Amount – Detail  Key if present. SVD01 = 000000000 67 BY-OTHER-
Level  If "0" or "0.00" is present, output "0" or "0.00". SVD02 = AMT 782 CARRIER
 If this field is blank, output “.00”. SVD03 = HC 235 PIC 9(08)V99
Proc Code 234 DETAIL LEVEL
EDI Requirements SVD05 = Units 380
 Must be numeric. DTP01 = 573 374 ADJ-OI-DTE-
 Remove special characters. DTP02 = D8 1250 SERV-FROM PIC
 If the SVD is output, must also output the claim Date of Service (From) in the DTP03 = Adjustment date (date service line was adjudicated) 1251 X(08)
DTP03. DETAIL LEVEL
 Date must be valid and in CCYYMMDD format.
 If a value greater than $9,999,999.99 is presented, the claim will be removed
from batch and forwarded to the Cigna on-site representative for further
processing instruction.
N/A Hierarchical Level EDI Requirements 2000B

Information Must be sent on all Medicaid claims as S SBR01=S
N/A Medicaid Primacy EDI Requirements 2320

Info Must be sent on all Medicaid claims as P SBR01=P
N/A Medicaid Claim EDI Requirements 2320

Filing Code Must be sent on all Medicaid claims as MC SBR09=MC
N/A CBH Medicaid  CBH Medicaid Claims are routed through the same submitter id for all CBH, no
Claims Medicaid amounts are keyed. The same procedures, in place today, will be used
to identify these claims.
 “Medicaid” is to be output in the claim level remark field.
NA Select Mailroom Medicaid claims received in the Select mailroom will be keyed with an attachment
Medicaid Claims code of OZ and specific requirements listed in the field requirements above)
Attachment Medicaid Specific Claim Processing Guidelines for Medicaid Claims Received in
Indicator the Select Mailroom:
 When a Medicaid claim is received in the Select PO Boxes or Fax lines and there
Federal Tax ID is wording “remit to” or “make payment to” and the Medicaid agency is noted
Number anywhere on the claim or supporting documentation, the Medicaid provider
information should be keyed in the Billing provider field.
Billing Provider
Name and Federal Tax ID Number
Address  If 2 TINs on claim and unable to identify as Medicaid , reject for Multiple Tin
Numbers.
 Key the Medicaid provider information from the Attachment if it says “remit to” or

“make payment to” on the attachment.

 Key the Medicaid provider information as the billing provider from the
claim/attachment if the term “remit to” or “make payment to” is provided on the
claim/attachment.
Medicaid Payment Verbiage

Agency Paid
Agency Paid Amount
Agency Paid Amt
Amount Paid by TDAS

HFS Paid
HFS Payment
HMS Payment (Effective: 09/26/13 CR-EMR06020913)
IDPA Paid
IDPA Payment
MA Paid
Medicaid Allowed Amount
Medicaid Amount
Medicaid Billed Amount
Medicaid Owed
Medicaid Paid
Medicaid Paid Amt
Medicaid Payment
Medi-Cal Paid
State Paid

Pre-Price Claim
Processing
EDI Gateway’s
Req’d
ANSI Common Claim
HCFA to ANSI
HCFA Claim Form Loop Record Field
Field Submit Current Requirements Element
# to EDI Number
G.
Level
N/A Pre-Pricing – Detail Level Business Requirements 2400 TPO-ALLOWED-
 Key if present. HCP01 = 10 782 AMOUNT PIC
 If Healthlink repricing sheet has Participating Status = N & an allowed amount is provided - - key the allowed amount HCP02 = Allowed 9(13)V99 DETAIL
even if the participating status is N or says non participating) Amt LEVEL
EDI Requirements
 Must be numeric
Common Verbiage
 Adjusted Rate
 Allowed
 Allowed Amount
 Contracted Amount
 Gross Allowed (On “Quick Claims”)
 Healthlink Contracted
 Negotiated Amount
 Negotiated Fee
 Pre-price Amount
 Prepriced Adjusted
 Pre-priced Amount
 Re-price Amount
 Re-priced Amount
 Total Allowed
N/A Pre-Pricing – Claim Level Business Requirements 2300 TOTAL-TPO-

 Key if present. HCP01=10 782 ALLOWED-
 If Healthlink repricing sheet has Participating Status = N & an allowed amount is provided - - key the allowed amount HCP02 = Allowed AMOUNT PIC
even if the participating status is N or says non participating) Amt 9(13)V99 CLAIM
LEVEL
EDI Requirements
 Common Verbiage: Adjusted Rate

 Allowed

 Allowed Amount
 Contracted Amount
 Gross Allowed (On “Quick Claims”)
 Healthlink Contracted
 Negotiated Amount
 Negotiated Fee
 Pre-price Amount
 Prepriced Adjusted
 Pre-priced Amount
 Re-price Amount
 Re-priced Amount
 Total Allowed
N/A Pre-Pricing Vendor ID Business Requirements 2300 CLAIM-TPO-ID-

Number  Key if present. HCP NUMBER PIC
 Refer to Pre-Pricing Vendor ID Translation Table for valid values and translations HCP01= 10 127 X(30) CLAIM LEVEL
 If Vendor ID Number cannot be determined, output “??”. HCP04 = Prepricing
Vendor ID up
EDI Requirements to 9 digits (Effective
 Must be two digits. 6/7/15 CR-
EMR0040216.1)
:
N/A Healthlink Participating Business Requirements 2400

Status  Key Participating Status Letter if available on Healthlink repriced claims only NTE01=’TPO’
– P = PPO (network 050 or network N89) 2400
– H = HMO (network 238) NTE-02=
HealthLinkIndicator
– N = Non-network (network 000)
EDI Requirements
 Valid Values: P, H or N
 Do not key special characters
Pre-Pricing Vendor ID Table

Vendor Select Crosswalk Values:
Vendor Name Code
ADMAR 32
AFFORDABLE 30
AHPO (AHP-ACCOUNTABLE HEALTH 752540180
PLANS) 03
ALLIANCE 04 522129786
ALLIANCE HEALTH PLAN 82
ALLEGIANCE C0
ALPHA/INTERGROUP PREFERRED 53
AMER LIFECARE REPRICED CLM 721446087
ANTHEM AMERICAN HEALTH 61
ARAZ GREAT PLAINS REPRICED CLM 411797800
ARAZ GREAT PLAINS REPRICED CLM 411797800
ARKANSAS FIRST SOURCE 44
ARKANSAS PPO (APPO) 39
ASSOCIATES FOR HEALTH CARE 42
BLUE RIDGE NETWORK 93
BPS 24
BUYERS HEALTH 06
CAL MED 46
CAMPBELL SOUP VISALIA CA 05
CARILION-PHY 29
CCN (COMMUNITY CARE NETWORK) 07
CCN TEXAS 99
CENTER CARE REPRICED CLAIM 611072089
CENTER CARE REPRICED CLAIM 611072089
CGN - (Cigna - CGN) 10
CHA (002-59001) 01
CHA (002-59002) 02
Cigna BEHAVIORAL CARE 89
COASTAL HEALTHCARE REPRICE CLM 770311413
COASTAL HEALTHCARE REPRICE CLM 770311413
CNA REFERRALS 98
COMMUNITY BASED HEALTH PLANS A6
COMPMED OKLAHOMA CITY 26
COMPMED TULSA 25

CORESOURCE 31
CUNA B3
ELKHART MED ORG REPRICED CLAIM 350877574
EMERALD HEALTH 28
ENCOMPASS 08
ETHIX 27
FAMILY DR ORDERED SVCS 92
FIRST CHOICE HEALTH-WA A7
FrontPath B6
HAP B2
HEALTH CHOICE ALABAMA 65
HEALTH FIRST 09
HEALTH LINK 10
HEALTH NETWORK 68
HEALTH ONE ALLIANCE A4
Health Partners Integration - HPI B5
HEALTH PARTNERS-KS REPRICE CLM 481251439
HEALTH SOUTH ALLIANCE 38
HEALTH STAR 11
HEALTHCARE ADVANTAGE INC 57
HEALTHLINK MS 83
HEALTHNET KANSAS CITY 58
HEALTHSMART 79
HEALTHSTAR OF GEORGIA 64
HHPO-FAC 12
HRM CAREPASS 70
HSTN MISSISSIPPI 67
HEALTHCARE PREF REPRICED CLAIM 431687358
HEALTHEOS (WPPN) REPRICED CLM 391634080
HEALTHEOS (WPPN) REPRICED CLM 391634080
IDAHO PHYS NTWK REPRICED CLAIM 820462950
INTERWEST HEALTH REPRICED CLM 841375849
INTERMOUNTAIN HEALTH CARE 48
IPN (formerly PRIMARY HEALTH NETWORK) 95
MAGELLAN A9
MAGNA CARE 13
MANAGED HLTH CARE NW 49
MARICOPA 14

MCI 15
MEDCOST 16 561629757
MEDICAL CONTROL 60
MENNINGER HEALTH SYSTEMS/PBHC 96
MERIT BEHAVIORIAL 72
MIDLAND 47 470804331
MIDLANDS CHOICE 75
MIDLANDS CHOICE-MW (MIDWEST
SELECT) 87
MISSISSIPPI HLTH PARTNERS 73
Mohawk Valley Physicians - MVP B7
MOUNTAIN HEALTHCARE 86
MULTIPLAN REPRICED CLAIM 133068979
MULTIPLAN REPRICED CLAIM 133068979
MVP - Mohawk Valley Physicians B7
NAMCI 51
NATIONAL CAPITAL PPO 17
NORFOLK SOUTHERN A5
NORTH TEXAS HEALTH CARE 62
NORTHERN ILLINOIS HEALTH PLAN (NIHP) B9
NTWK HEALTH PLAN REPRICED CLM 391442058
OPTION ONE 40
PCN 59
PIONEER MANAGEMENT 37
PMN 88
PPO OF MICHIGAN (PPOM) 43
PPO OKLAHOMA 94
PPOM REPRICED BUNDLEDCLM 383357687
PPOM REPRICED CLM 383357687
PREFERRED PLAN OF INDIANA 133068979
PREFERREDONE REPRICED CLAIM 411864481
PRONET REPRICED CLAIM 510321584
PREFERRED COMM CHOICE 55
PREFERRED HEALTH CARE INC 41
PREMIER CARE A2
PRIMESOURCE HEALTH PLANS A8
PRINCIPAL HEALTH CARE 56
PROAMERICA 18

QUALITY HEALTHCARE PARTNERS 69
SAGAMORE 76
SAGAMORE HEALTH NETWORK B8 351641636
SANUS PASSPORT 78
SELECT CARE 20
SELECTNET PLUS REPRICED CLAIM 550666324
SHARP INC 21
SIGNATURE ALLIANCE 81
SIGNATURE CARE/MANAGED CARE SVCS 74
SLOAN LAKE B0 840969104
SOUND HEALTH 22
SOUTH GA HEALTH PARTNERS 80
SOUTHCARE 77
SOUTHEAST MED. ALLIANCE 19
SUPERIOR CALIF REPRICED CLAIM 942996631
TEXAS TRUE CHOICE 97
THE ALLIANCE 71
TRUE CHOICE B4
UNITED BEHAVIORAL HEALTH 90
UNKNOWN ??
US HEALTH/OHIO HEALTH 52
USA HEALTH NET 23
VANTAGE/ALLIANCE HEALTH PPO 50
VIRGINIA HEALTH NETWORK 66
WESTERN CAROLINA HEALTH DELIVERY A3
WESTERN PROVIDERS-CONSECO B1
WLEC/WEST LAKE ERIE COAL 85
WPPA 63
WPPN 54
1ST MED NETWORK REPRICED CLAIM 20632772
Texas Members with These requirements apply to any HCFA/Misc Med claim submitted with an Autism / Pervasive Development Disorder / Aspergers Syndrome diagnosis for nutritional supplements and the member is
Autism Diagnosis determined to be a Texas resident (Use the Eligibility lookup to determine Texas residency).

For HCFAs or Miscellaneous Medical claims (paper receipts) received for nutritional supplements, where the written narrative or numeric diagnosis indicates the claim is for Autism / Pervasive Development
Disorder / Aspergers Syndrome:
EDI Gateway’s
Req’d
ANSI Common Claim
HCFA to ANSI
HCFA Claim Form Loop Record Field
Field Submit Current Requirements Element
# to EDI Number
G.
Level
N/A N/A Guidelines for Nutritional Supplements - could be identified by, but not limited to, the following list. Key any nutritional
supplement narrative as presented on the claim.
o Nutrition
o Nutritional
o Nutritional supplement
o Supplement
o Vitamin (s)
o Amino acid
o Enzyme therapy
o Food supplement
o Ensure
o Boost
Diagnosis Codes
Valid diagnosis codes are 299 (could begin with 299) or 780.
Procedure Codes
Valid procedure codes are A9152 and A9153.
21 Diagnosis or Nature of Business Requirements

Illness or Injury (01-12)  Valid diagnosis codes are 299 (could begin with 299) or 780.
 If claim/receipt has an actual dx code of 299 (or beginning with 299) or 780, enter what appears on the claim. If any
other dx code is present, do not key.
 If no dx code is present, but the narrative of Autism, or Pervasive Development Disorder, or Aspergers Syndrome
are present, enter 299 as the dx code.
 If no dx code is present on the receipt but member is TX member and is submitting a claim or receipt for nutritional
supplement(s), enter 299 in the dx field.
EDI Requirements:
Gateway Requirements:

 No specific change
24D Procedures, Services or Business Requirements

Supplies (CPT/HCPCS)  Valid procedure codes are A9152 and A9153.
 If the claim does not have a procedure code, but nutritional supplements are listed, key as follows:
 If the claim/receipt specifically indicates a single vitamin or supplement (such as vitamin B-12, magnesium,
chromium etc. as opposed to a multiple vitamin), enter code A9152 with the appropriate quantity. For example, if a
receipt itemizes 3 different vitamins, enter a quantity of 3 and a procedure code of A9153. If single or multi-vitamin
cannot be determined, use A9152.
 If the claim/receipt indicates a supplement that is made up of several ingredients (such as Ensure), enter the code
of A9153 with a quantity of 1.
EDI Requirements:


Appendix Charts:
Additional Keying Information
Appendix “A”: Assignment Field Verbiage
Appendix “B”: Durable Medical Equipment (DME) Listing
Appendix “C”: Information to be captured in claim level remarks
Appendix “C.1”: CBH Information to be captured in claim level remarks
Appendix “D”: Relationship Code Mapping
Appendix “E”: Place of Service Translation Table
Appendix “G”: Cigna Verbiage
Appendix “H”: Diagnosis Code Chart—Vision Claims
Appendix “I”: Diagnosis Code vs. Verbiage Logic
Appendix “J”: Century Logic
Appendix “K”: Group vs Facility Logic
Appendix “L”: Other Insured Insurance Plan Name or Program Name
Appendix “M”: Cigna Attachment Code List
Appendix “N”: EOB Determination Guidelines
Appendix “O”: COB Field Name Variation List
Appendix “P”: CBH Common Claim and Proclaim Print COB Match Criteria
Appendix “Q”: Medicare vs. Commercial EOB Criteria
Appendix “R”: COB Sorting/Matching Criteria
Appendix “S”: Claim Sorting Criteria
Appendix “T”: Claim Splitting Criteria
Appendix “U”: Renaissance Claims Keying Requirements
Appendix “V”: Example of Provider Name Formats

ADDITIONAL KEYING INFORMATION
CLAIM TYPE AND SERVICE LINE TYPE DERIVATION RULES
IF PROCEDURE CODE THEN CLAIM TYPE IS: AND SERVICE LINE TYPE IS:
IS:
00100 - 01999 A (ANESTHESIA) ANESTHESIA

10000 - 69999 S (SURGERY) MEDICAL
70000 - 79999 MD (PHYSICIAN/MEDICAL) MEDICAL
80002 - 89399 IL (LABORATORY) MEDICAL
90000 - 99999 MD (PHYSICIAN/MEDICAL) MEDICAL
A0021 – A0999 AM (AMBULANCE) MEDICAL
A4206 – A7017 DM (DURABLE MEDICAL) DME
B4034 – B9999 PE (PARENTERAL/ENTERAL) DME
D0120 – D9999 MD DENTAL
E0100 - E1900 DM DME
G0001 – G0172 MD MEDICAL
J0120 – J9999 MD MEDICAL
K0001 - K0534 DM DME
L0100 - L9999 DM DME
P2028 - P9615 IL MEDICAL
T CODES S MEDICAL
V2020 – V2799 MD MEDICAL
V5008 – V5364 MD MEDICAL
SV2 HS HOSPITAL/UB92
SV5 DM DME
SV6 A ANESTHESIA
Revenue Code HS (HOSPITAL/UB92) HOSPITAL
NDC Code or RX (PHARMACY) DRUG
Prescription
Number
IF CPT MODIFIER IS: THEN CLAIM TYPE IS: AND SERVICE LINE TYPE IS:
23, P1, P2, P3, P4, P5, or A (ANESTHESIA) ANESTHESIA
P6
IF HCPCS MODIFIER IS: THEN CLAIM TYPE IS: AND SERVICE LINE TYPE IS:
AA, AB, AC, AD, AE, AF, A ANESTHESIA
AG, QX, or QZ
IF TYPE OF SERVICE IS: THEN CLAIM TYPE IS: AND SERVICE LINE TYPE IS:
7 A ANESTHESIA
(not available on HCFA
1500)
IF MINUTES OR TIME IS A ANESTHESIA
PRESENT
IF MULTIPLE CLAIM MS (HOWEVER, IF ANY OF THE DETAIL LINES ARE AND THERE WILL BE MORE THAN ONE
TYPES EXIST ON A CLAIM ANESTHESIA THEN “A” SHOULD BE OUTPUT) SERVICE LINE TYPE ON THE CLAIM
IF CLAIM SITUATION IS MD MEDICAL
NOT DEFINED ABOVE

117

APPENDIX “A”
ASSIGNMENT FIELD VERBIAGE
Business Requirements
 Key if present.
 Refer to Attachment A for field verbiage.
 If block 13 is blank, then send “N”.
 If invalid (does not match list of valid verbiage), send “Y”.
 If a typed name is present, send “Y”.
Note: The description of “provider” is equal but not limited to the following terms: provider, doctor, physician, dentist, facility, health care
professional.
ASSIGNMENT = Y ASSIGNMENT = Y ASSIGNMENT = N

ASSIGNED BENEFITS TO PHYSICIAN -------------- (dashes in the signature field)
ASSIGNMENT ON FILE AUTHORIZED SIGNATURE ON FILE IN ALREADY PAID

PROVIDERS RECORDS
ALREADY PAID PROVIDER – PLEASE
SEND CHECK TO ME
(example: 13207700203082)
(Effective: 01/16/14 CR-EMR0010114)
ASSIGNMENT ON FILE AT XXX* PATIENT NOT PRESENT CLAIM PAID
AUTH SIGN ON FILE PATIENT NOT PRES SERV DO NOT PAY PROVIDER
AUTHORIZATION ON FILE PATIENT NOT PHYSICALLY PRESENT DO NOT PAY THE PROVIDER
W/PROVIDER
AUTHORIZATION ON FILE WITH PATIENT NOT PHYSICAL PRESENT NO
PROVIDER
AUTHORIZATION ON FILE PATIENT NOT PRESENT FOR SERVICES NOF
BENEFITS ASSIGNED NO SIGNATURE
NO WE HAVE ALREADY PAID
HOSPITAL BASED PHYSICIAN SIG NOT ON FILE
ON FILE
NO SIGNATURE ON FILE
HOSPITAL BASED PHYSICIAN SOF PAID BY CHECK
INSURANCE BENEFITS ARE PATIENT PAID
ASSIGNED TO XXX*
ON FILE PLEASE PAY PROVIDER PAY INSURED
ON FILE PAYMENT TO ME
PATIENTS PAYMENT PAY PATIENT

AUTHORIZATION ON FILE
PAT REQ FOR PMT ON FILE PAY EMPLOYEE
PAY TO PROVIDER PAY TO CLAIMANT
PAY PROVIDER PAY SUBSCRIBER
PLEASE PAY PROVIDER DISPUTED PAY TO INSURED
AMOUNTS REFUNDED
SIG ON FILE PAY TO PATIENT
SIGNATURE ON FILE W/PROVIDER PAY TO PATIENT/INSURED
SIGNATURE ON FILE WITH PAY TO INSURED/PATIENT
PROVIDER
SIGNATURE ATTACHED PAY TO SUBSCRIBER
SIGNATURE ON FILE IN HOSPITAL PAY TO SUB
PLEASE SEND PAYMENT TO PATIENT
(example: 13168301684942)
PLEASE PAY PATIENT DIRECTLY
(example: 13042500497592)
SIGNATURE ON FILE REIMBURSE MEMBER
SIGN ON FILE SIGN NOT ON FILE
SIOF NONE
SOF PRESENT FOR SERVICES
XXX* AUTHORIZATION ON FILE NOT ASSIGNED
XXX* SIGNATURE ON FILE NA
PT REQ PMT ON FILE N/A
ASSIGNED ON CLINIC RECORD NOT APPLICABLE
ASSIGNMENT ACCEPTED NSOF
BENEFIT ASSIGNED MEMBER PAID
BENEFITS ARE ASSIGNED INSURED PAID
INFORMATION ON FILE SEE ATTACHED
INSURED’S SIGNATURE ON FILE SUBSCRIBER PAID
INSURED SIGNATURE ON FILE SUB PAID
PATIENT SIGNATURE ON FILE POLICYHOLDER PAID
PATIENT’S REQUEST FOR PAY MEMBER
PAYMENT ON FILE
PATIENT’S SIGNATURE ON FILE PAY TO MEMBER
SIGN ON FILE IN HOSPITAL PAY POLICYHOLDER

118

APPENDIX “A”
ASSIGNMENT FIELD VERBIAGE
Business Requirements
 Key if present.
 Refer to Attachment A for field verbiage.
 If block 13 is blank, then send “N”.
 If invalid (does not match list of valid verbiage), send “Y”.
 If a typed name is present, send “Y”.
Note: The description of “provider” is equal but not limited to the following terms: provider, doctor, physician, dentist, facility, health care
professional.
ASSIGNMENT = Y ASSIGNMENT = Y ASSIGNMENT = N

SIGNATURE IN DOCTOR’S PAY TO POLICYHOLDER
RECORDS
SIGNATURE CARD ON FILE PAY XXX**
SIGNATURE IS ON FILE PAY TO XXX**
SIGNATURE ON FILE OR ATTACHED Please submit payment to Employee

SIGNED AUTHORIZATION OF FILE Please reimburse the patient
AUTHORIZED SIGNATURE ON FILE Please do not pay provider
IN PROVIDER RECORD REIMBURSE PATIENT
SIGNATURE IN PROVIDER REIMBURSE INSURED
RECORDS
ASSIGNMENT ATTACHED ON FILE REIMBURSE SUBSCRIBER
PUBLIC LAW 99-272 REIMBURSE SUB
PUBLIC LAW 99-272/SECTION REIMBURSE POLICYHOLDER
1729/TITLE 38
PATIENT ASSIGNS BENEFITS TO REIMBURSE XXX**
PHYSICIAN
SIGNATURE CONTAINED IN THE PATIENT TO BE PAID
PROVIDER RECORDS
MEMBER TO BE PAID
INSURED TO BE PAID
Send payment to Insured
SUBSCRIBER TO BE PAID
SUB TO BE PAID
POLICYHOLDER TO BE PAID
XXX** TO BE PAID
PAID
SERVICES PAID IN FULL
PAY ME
NO
PAY SUB
PAID IN FULL
X
*XXX = Provider/Facility Name

**XXX = Actual Patient, Member, Insured, Subscriber, or Policyholder’s Name

119

APPENDIX “B”
DURABLE MEDICAL EQUIPMENT (DME) LISTING
Air Fluidized Bed Flow Meter Oxygen Unit
Alternating Pressure Pads and Mattresses Fluid Temperature Pad Oxygen Walker System
Apnea Monitor Fluidic Breathing Assistor Pacemaker Monitor
Aquamatick K-Thermia Fomentation Device Paraffin Bath Units
Aquawhirl Functional Neuromuscular Stimulators Parallel Bars
Ateriosonde Gel Flotation Pads and Mattresses Percussor
Automatic Blood Pressure Heat Lamps Portable Oxygen Unit
Autosfig Heating Pads Positive Pressure Ventilator Machines
(CPAP/BIPAP)
Back Brace Hospital Bed, Full Electronic Postural Draining Board
Bead Bed Hospital Bed, Manual Pulmo-Aide
Bed Oscillator Hospital Bed, Semi-Electronic Pulse Machine
Bedside Rails Hoyer Lift Pulse Tachometer
Bilirubin Light Humidifier (for Oxygen use) Quad Cane
Bird Respirator (IPPB) Hydraulic Patient Lift Rectal Dilator
Blood Glucose Monitor I.V. Stands Respirators
Bone Stimulator (EBI) Infusion Pump Sphygmomanometer
Boston Brace Inhalators Stethoscope
Breast Pump Injectors Suction Machine
Canes IPPB Machines Traction Equipment
Centrifuge Readacrit Jobst Pneumatic Appliance Transcutaneous Electrical Nerve
Stimulator
Commodes Knee Brace Trapeze Bars
Continuous Passive Motion Machine Lymphedema Pump (Non-Segmental) Ultraviolet Cabinet
(CPM)
Continuous Positive Airway Pressure Lymphedema Pump (Segmental) Vaginal Dilator
(CPAP)
Crutches Maxi-Mist Vacillating Bed
Dialysis Equipment Mobile Monomatic Sanitation System Walkers
Diathermy Machine Muscle Stimulator Water and Pressure Pads and Mattresses
Dorsal Column Stimulators (PENS/TENS) Nebulizer Compressor Wheelchair, Motorized
Electric Continence Aid Negative Pressure Ventilators Wheelchair, Sport Model
Electro Cardio Corder Oscillating Bed Wheelchair, Manual
Esophageal Dilator Oxygen Regulators Whirlpool Bath, Portable
Flotation Pads and Mattresses Oxygen Tent

120

APPENDIX “C”
INFORMATION TO BE CAPTURED IN CLAIM LEVEL REMARKS
Comments may be found stamped, handwritten, or typed anywhere on a claim. The following is a list of comments which should
be captured, including variations and examples. These are listed in priority order. As many comments as possible should be
captured, based on space limitations. Any comments not included below should not be captured.
NOTE: Corrected Claim verbiage is now captured through the corrected claim indicator
STAMPED TEXT
“Bayer” (e.g. Bayer Drug, Bayer Extracts, Bayer Products)
Any combination of “Miles” and “Product” (e.g. All Miles Allergy Products Used, Elkhart Clinic Used A
Miles Product)
“Assigned”, “Assignment”, “Assign”, “Assigning”
“Discount” (e.g. Discount Applies, Prompt Pay Discount, PPO Discount)
“Prompt Pay”, “Payment”, “pmnt” – Do not capture information on the claim pertaining to previous
payments or partial payments.
“Reimburse Patient”, “Reimb Pat”, “Reimb PT”
“Pay Patient”, “Pay Pat”, “Pay PT”
“Paid”, “Not Paid”, “Unpaid”, “Pd”, “pay”, “payable”, “Unpd”, “Not Pd”
“PPO” (e.g. PPO Discount)
“Third Party Vendor”, “3rd Pty Vendor”, “TPV”
“PCP Fee For Service”, “PCP Fee for Svcs”
“Capitated” (e.g. Capitated Service)
“Authorization Number”, “Auth #”, usually followed by numeric data
“On Call Provider”, “On Call Prvdr”
“Preferred Provider”, “Prfrd Prvdr”
“Wrong Grouper”, “Wrong Grpr”
“Encounter”
“Resubmission”, “Resubmittal”, “Resubmitted”, “Resubmitting”, Resubmit”
“Claim Not Processed”, “Claim Not Prcsd”
Comments referring to the number of times the claim has been submitted (e.g. Second Notice, 2nd
Notice, Second Request, 2nd Request, Second Submission, 2nd Submission, Second Bill, 2nd Bill,
Second Billing, 2nd Billing, Secondary Billing, Second Filing, 2nd Filing) – Do not capture unless one of
the words above follows the number. For example, “Second Claim” should not be captured.
“Urgent”, usually followed by reference to payment within 30-days
“Rebill”, “Rebilling”, “Rebilled”
“Refile”, “Refiling”, “Refiled”
Medicare Opt Out
Patient Private Contract
Opt Out (variations: Opt-Out, Opts Out, Opted Out)
Medicare Opt Out Provider
MCR Opt Out Letter Attached
Medicare Opt Out Affidavit
Opt Out Affidavit
Opt Out of Medicare
Opt Out Physician/Practitioner
Opt Out Period
Private Contract
Provider decided to drop out of Medicare
HCPCS Modifier - GJ
HCPCS Modifier - 54
Alert
Reduced
Copay
In Network Provider

121

APPENDIX “C.1 ” - CBH INFORMATION TO BE CAPTURED IN CLAIM LEVEL REMARKS
Comments may be found stamped, handwritten, or typed anywhere on a claim. The following is a list of comments which should
be captured, including variations and examples. These are listed in priority order. As many comments as possible should be
captured, based on space limitations. Any comments not included below should not be captured.
Requirements:
 If a remark keyword is present on the claim in any field, output in the remarks field
Exception - Corrected Claim

 If the verbiage “corrected claim” is written anywhere on any claim form, capture corrected claim verbiage and output in
remarks.
 This applies to corrected claim verbiage written or typed in fields that are not normally captured (i.e. field 19 on a HCFA)
 When keying the remark keywords, only capture the actual keyword(s).
Example:
Phrase on claim – “Paid by Insured”
Phrase to be keyed – “Paid”
STAMPED TEXT
“Bayer” (e.g. Bayer Drug, Bayer Extracts, Bayer Products)
Any combination of “Miles” and “Product” (e.g. All Miles Allergy Products Used, Elkhart Clinic Used A
Miles Product)
“Assigned”, “Assignment”, “Assign”, “Assigning”
“Corrected”, “Corrected Claim” , “Crctd”, “Correct” (e.g. Corrected Bill); “Modified”, “Changed” “Fixed”,
“Amended” if indicated on claim, if not indicated see altered claim below
“Discount” (e.g. Discount Applies, Prompt Pay Discount, PPO Discount) Discounted/Adjusted or
reduction,
“Prompt Pay”, “Payment”, “pmnt” – Do not capture information on the claim pertaining to previous
payments or partial payments. (variations: pmnt, pd, payable)
“Reimburse Patient”, “Reimb Pat”, “Reimb PT”
“Pay Patient”, “Pay Pat”, “Pay PT”
“Paid”, “Not Paid”, “Unpaid”, “Pd”, “pay”, “payable”, “Unpd”, “Not Pd”
“PPO” (e.g. PPO Discount)
“Third Party Vendor”, “3rd Pty Vendor”, “TPV”
“PCP Fee For Service”, “PCP Fee for Svcs”
“Capitated” (e.g. Capitated Service)
“Authorization Number”, “Auth #”, usually followed by numeric data
“On Call Provider”, “On Call Prvdr”
“Preferred Provider”, “Prfrd Prvdr”
“Wrong Grouper”, “Wrong Grpr”
“Encounter”
“Resubmission”, “Resubmittal”, “Resubmitted”, “Resubmitting”, Resubmit” (variations: Resub,
Resubmiss) Final Submission
“Claim Not Processed”, “Claim Not Prcsd”
Comments referring to the number of times the claim has been submitted (e.g. Second Notice, 2nd
Notice, Second Request, 2nd Request, Second Submission, 2nd Submission, Second Bill, 2nd Bill,
Second Billing, 2nd Billing, Secondary Billing, Second Filing, 2nd Filing) – “Third request” or “3rd
Request”, Third Submission (variation: 3rd Submission)
DO NOT KEY SECOND OR SECONDARY UNLESS ONE OF THE KEYWORDS ABOVE IS WITH
IT.
TPV
“Urgent”, usually followed by reference to payment within 30-days
Any remarks indicating numerous filings (ie. 3rd filing 4th filing, 5th filing, or variations of this verbiage
should be captured in remarks.
“Rebill”, “Rebilling”, “Rebilled” “Resubmitted”
“Refile”, “Refiling”, “Refiled”
(Effective: 04/14/11 CR_EMR24CBH0311)
“Interpreter” or Interpreter Services
“No Show”, “Cancelled”, “Missed” (to show cancelled, missed or no show to scheduled appt)
“Non Medicare Provider”
“Student info” when information is attached to a claim ie: student transcript, Student info, college
hours
“Telephone Therapy”
“Travel”
“Ambulance “(if indicated by place of service 41 or 42 and/or as part of the billing provider name)
“Proof of Timely Filing”
“Medicaid” Medicare Recovery, Medicaid Reclamation, MA Paid
“Zero” applies to claims with zero charge amounts
Medicare Opt Out
Patient Private Contract
Opt Out (variations: Opt-Out, Opts Out, Opted Out)
Medicare Opt Out Provider
MCR Opt Out Letter Attached
Medicare Opt Out Affidavit
Opt Out Affidavit
Opt Out of Medicare
Opt Out Physician/Practitioner

122

Opt Out Period
Private Contract
Provider decided to drop out of Medicare
HCPCS Modifier - GJ
HCPCS Modifier - 54
Alert
Reduced
Copay
In Network Provider (
APPENDIX “C.2 ” – SPECIAL INVESTIGATION INFORMATION TO BE CAPTURED IN CLAIM LEVEL REMARKS
If any of the following remarks are present on a claim, regardless of where it is written or typed, should be captured and
keyed in the claim level remarks field.
 ACCEPTING IN NETWORK COST SHARING OBLIGATIONS

 The insured’s portion of this bill has been reduced in amount so the patient’s responsibility for the deductible and copay amount is
billed at in network rates
 IN NETWORK COST SHARING OBLIGATIONS ACCEPTED
 The insured’s portion of this bill has been reduced to correspond to in network benefit levels.
 Prompt Pay Discount May Apply
 A discount or waiver was provided to the patient for the service being billed
 Premier Surgery Center of Michigan will act as an in-network provider in regard to the beneficiary’s co-insurance co-payment and
deductibles
 Out of Network Discount Applies to Patients co-insurance
 Surgical Elite of Avondale will act as an in network provider to the beneficiary in regard to their co-payment. co-insurance and
deductibles
 PRE-PROVISION OF SERVICES AGREEMT IN EFFECT W INSRD FOR REDU DED /OR CO-INSUR
 The Patients Out of Network Penalty has been waived

123

APPENDIX “D”
RELATIONSHIP CODE MAPPING
Note: The first grid indicates the values which standardly appear on the HCFA form and can be identified.
Relationship Description ANSI Value

Spouse 01
Child 19
Unknown 21
Self 18 (ONLY in 2000B Loop)
Valid ANSI Relationship Codes

ANSI VALUE RELATIONSHIP DESCRIPTION
01 Spouse
19 Child
20 Employee
21 Unknown
39 Organ Donor
40 Cadaver
53 Life Partner
G8 Other Relationship

124

APPENDIX “E“
PLACE OF SERVICE
TRANSLATION TABLE
Code ANSI
on Value POS Description Notes
Claim Output
01 21 IN-PATIENT HOSPITAL
02 22 OUT-PATIENT HOSPITAL
03 11 OFFICE
04 12 HOME
05 53 DAY CARE FACILITY (PSY)
06 53 NIGHT CARE FACILITY (PSY)
07 32 NURSING HOME
08 31 SKILLED NURSING FACILITY
09 41 AMBULANCE
00 99 OTHER LOCATIONS
3 11 OFFICE
4 12 HOME
5 53 DAY CARE FACILITY (PSY)
6 53 NIGHT CARE FACILITY (PSY)
7 32 NURSING HOME
9 41 AMBULANCE
0 99 OTHER LOCATIONS
11 11 OFFICE
12 12 HOME
13 13 ASSISTED LIVING FACILITY
14 14 GROUP HOME
15 15 MOBILE UNIT
16 16 TEMPORARY LODGING
17 17 WALK-IN RETAIL HEALTH CLINIC
18 18 PLACE OF EMPLOYMENT - WORKSITE
19 19 OFF CAMPUS - OUTPATIENT HOSPITAL
20 20 URGENT CARE CENTER
23 23 HOSPITAL EMERGENCY DEPARTMENT
24 24 AMBULATORY SURGICAL CENTER
25 25 BIRTHING CENTER
26 26 MILITARY TREATMENT FACILITY
32 32 NURSING FACILITY
33 33 CUSTODIAL CARE FACILITY
34 34 HOSPICE
41 41 AMBULANCE - LAND
42 42 AMBULANCE - AIR OR WATER
49 49 INDEPENDENT CLINIC
50 50 FEDERALLY QUALIFIED HEALTH CENTER
51 51 PSYCHIATRIC FACILITY - IN-PATIENT
52 52 PSYCHIATRIC FACILITY – PARTIAL HOSPITALIZATION
53 53 COMMUNITY MENTAL HEALTH CENTER
54 54 INTERMEDIATE CARE FACILTIY / MENTALLY RETARDED
55 55 RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY
56 56 PSYCHIATRIC RESIDENTIAL TREATMENT CENTER
NON-RESIDENTIAL SUBSTANCE ABUSE TREATMENT
57 57
FACILITY
60 60 MASS IMMUNIZATION CENTER

125

61 61 COMPREHENSIVE IN-PATIENT REHABILITATION FACILITY
62 62 COMPREHENSIVE OUT-PATIENT REHABILITATION FACILITY
65 65 END STAGE RENAL DISEASE TREATMENT FACILITY
71 71 STATE OR LOCAL PUBLIC HEALTH CLINIC
72 72 RURAL HEALTH CLINIC
81 81 INDEPENDENT LAB
99 99 OTHER UNLISTED FACILITIES
A 81 INDEPENDENT LAB
B 24 AMBULATORY SURGICAL CENTER
C 55 RESIDENTIAL TREATMENT CENTER
D 99 SPECIALIZED TREATMENT FACILITY
E 62 COMP OUTPAT REHAB FACILITY
F 65 INDEP KIDNEY DISEASE TRTMT CNTR
IH 21 IN-PATIENT HOSPITAL
OH 22 OUT-PATIENT HOSPITAL
O 11 OFFICE
OV 11 OFFICE
OF 11 OFFICE
H 12 HOME
NH 32 NURSING HOME
SNF 31 SKILLED NURSING FACILITY
OL 99 OTHER LOCATIONS
IL 81 INDEPENDENT LAB
ASC 24 AMBULATORY SURGICAL CENTER
RTC 55 RESIDENTIAL TREATMENT CENTER
STF 99 SPECIALIZED TREATMENT CENTER
COR 62 COMP OUTPAT REHAB FACILITY
KDC 65 INDEP KIDNEY DISEASE TRTMT CNTR

126

APPENDIX “G”
Cigna VERBIAGE
NALC
Boilermakers
Boilermakers National
Boilermakers National Fund
Boilermakers First Health
BNF
Cigna (Even when used as part of a larger name, ie: Cigna HMO etc)
Cigna HealthCare
CHC
Connecticut General
Connecticut General Life Insurance Company
CG
Ct General
Conn General
Ct Gen
Conn Gen
CG Life Insurance Company
Ct General Life Insurance Company
Conn General Life Insurance Company
Ct Gen Life Insurance Company
Conn Gen Life Insurance Company
CG Life Ins Company
Ct General Life Ins Company
Conn General Life Ins Company
Ct Gen Life Ins Company
Conn Gen Life Ins Company
CG Life Insurance Co
Ct General Life Insurance Co
Conn General Life Insurance Co
Ct Gen Life Insurance Co
Conn Gen Life Insurance Co
CG Life Insurance Comp
Ct General Life Insurance Comp
Conn General Life Insurance Comp
Ct Gen Life Insurance Comp
Conn Gen Life Insurance Comp
CG Life Ins Co
Ct General Life Ins Co
Conn General Life Ins Co
Ct Gen Life Ins Co
Conn Gen Life Ins Co
CG Life Ins Comp
Ct General Life Ins Comp
Conn General Ins Comp
Ct Gen Life Ins Comp
Conn Gen Life Ins Comp
Healthsource
Healthsource Provident
Provident
HS
HS Provident
HS Prov
Healthsource Prov
Prov
Equicor
ONE HEALTH or ONEHEALTH
GENAM
GENERAL AMERICAN
THE NEW ENGLAND COMPANY
GREATWEST or GREAT WEST (Even when used as part of a larger name, ie:
GreatWest Helathcare etc)
GREATWEST LIFE & ANNUITY
GWH
GWHC
GWL
80705
GWFC

127

Appendix H:
Diagnosis Code Chart—Vision claims
 Presence of a vision claim form or vision receipts (Misc. Medical only)

 Rendering Provider (field 31) or Billing Provider (field 33) indicates Eye, Eyeglass, Eyeglasses, Vision, Ophthalmology,
Ophthalmologist, Optometry, Optometrist, or OD
 Procedure Code (field 24d) indicates codes within the range of V2020 - V2799, Eyeglass, Eyeglasses, Contact Lens, Contact
Lenses
 Diagnosis Code (field 21) indicates Eyeglass, Eyeglasses, Contact Lens, Contact Lenses
If the Principal Diagnosis Code is blank, and if any of the above criteria is met, output V720 as the Principal Diagnosis Code.
Once a claim has been identified as vision, based on the criteria indicated in Appendix H of the EMR Keying Requirements,
and a valid CPT4/Procedure code is not present on the claim form but one of the procedure code descriptions
indicated in the attached table is listed in the detail section of the document, key the corresponding CPT4 /
Procedure code listed on the attached table.
 If a CPT4/Procedure Code is not present on the claim form and ‘Single Lenses’, ‘Bifocal Lenses’, or ‘Trifocal Lenses’ is
indicated on the claim form as the procedure code description, use the corresponding default code indicated in the attached
table.
 If a CPT4/Procedure Code is not present on the claim form and the word ‘Lenses’ is indicated as the procedure code
description and single, bifocal, or trifocal is not specified, enter the default procedure code for single lenses,‘V2100’.
 Please Note: The procedure code description on the claim form must be an exact match to ‘Single Lenses’, ‘Bifocal Lenses’ or
Trifocal Lenses’, for the corresponding default procedure code to be used. If “Lenses’ is the only word present, use the default
for single lenses, ‘V2100’.
Svc Code Class Description Code Description Default Code

Indicator
S0592 ROUTINE VISION COMPREHENSIVE CONTACT LENS
EXAMS EVALUATION
S0620 ROUTINE VISION ROUTINE OPHTHALMOLOGICAL EXAM
EXAMS
S0621 ROUTINE VISION ROUTINE OPHTHALMOLOGICAL EXAM
EXAMS ESTABLISHED PATIENT
S0625 ROUTINE VISION DIGITAL SCREENING RETINAL
EXAMS
S0820 ROUTINE VISION COMPUTERIZED CORNEAL
EXAMS TOPOGRAPHY,UNILATERAL
92002 ROUTINE VISION OPHTHALMOLOGICAL SERVICES:
EXAMS MEDICAL EXAMINATION AND
EVALUATION WITH INITIATION OF
DIAGNOSTIC AND TREATMENT
PROGRAM; INTERMEDIATE, NEW
PATIENT
EVALUATION WITH INITIATION OF
DIAGNOSTIC AND TREATMENT
PROGRAM; COMPREHENSIVE, NEW
PATIENT, ONE OR MORE VISITS
EVALUATION, WITH INITIATION OR
CONTINUATION OF DIAGNOSTIC AND
TREATMENT PROGRAM; INTERMEDIATE,
ESTABLISHED PATIENT
92014 ROUTINE VISION OPHTHALMOLOGICAL SERVICES: ROUTINE VISION
EXAMS MEDICAL EXAMINATION AND EXAMS DEFAULT
EVALUATION, WITH INITIATION OR
CONTINUATION OF DIAGNOSTIC AND
TREATMENT PROGRAM;
COMPREHENSIVE, ESTABLISHED
PATIENT, ONE OR MORE VISITS
92015 ROUTINE VISION DETERMINATION OF REFRACTIVE STATE
EXAMS
92025 ROUTINE VISION CORNEAL TOPOGRAPHY
EXAMS
S0516 VISION FRAMES SAFETY EYEGLASS FRAMES
V2020 VISION FRAMES FRAMES; PURCHASES VISION FRAMES
DEFAULT
V2100 SINGLE VISION SPHERE; SINGLE VISION SINGLE LENSES
LENSES DEFAULT
V2121 SINGLE VISION LENTICULAR LENS, PER LENS, SINGLE
LENSES
S0506 BIFOCAL, GLASS BIFOCAL VISION PRESCRIPTION LENS
OR PLASTIC (SAFETY)
V2200 BIFOCAL, GLASS SPHERE; BIFOCAL BIFOCAL LENSES
OR PLASTIC DEFAULT
V2221 BIFOCAL, GLASS LENTICULAR LENS, PER LENS, BIFOCAL
OR PLASTIC

128

V2781 BIFOCAL, GLASS PROGRESSIVE LENS, PER LENS
OR PLASTIC
S0508 TRIFOCAL, GLASS TRIFOCAL VISION PRESCRIPTION LENS
OR PLASTIC (SAFETY ATHLETIC, OR SUNGLASS),
PER LENS
V2300 TRIFOCAL, GLASS SPHERE; TRIFOCAL TRIFOCAL LENSES
OR PLASTIC DEFAULT
V2321 TRIFOCAL, GLASS LENTICULAR LENS, PER LENS, TRIFOCAL
OR PLASTIC
V2399 TRIFOCAL, GLASS SPECIALTY TRIFOCAL (BY REPORT)
OR PLASTIC
S0500 CONTACT LENSES DISPOSABLE CONTACT LENS PER LENS
S0512 CONTACT LENSES DAILY WEAR SPECIALTY CONTACT LENS, CONTACT LENSES
PER LENS DEFAULT
92326 CONTACT LENSES REPLACEMENT OF CONTACT LENS
V2745 CONTACT LENSES Addition to lens; tint, any color, solid, gradient
or equal, excludes photochromatic, any lens
material, per lens
V2750 CONTACT LENSES Antireflective coating, per lens
V2755 CONTACT LENSES U-V lens, per lens
CONTACT LENSES Contact Lens prescription, fitting and follow
92310 up
92065 Orthoptic Therapy

129

APPENDIX “I”
DIAGNOSIS CODE VS. VERBIAGE LOGIC
ICD-9 Code Information:
There are a total of 22,183 codes contained within the Diagnosis Code table, with the following attributes:
 14,981 are all numeric
 7,202 contain at least one (1) alpha. Of the 7,202 claims with at least one (1) alpha, the breakdown is as follows:
 7,181 contain an alpha character in the first position followed by four (4) numerics
 21 contain more than one (1) alpha character
The following logic will be used to determine whether the information present in the Diagnosis Code field is a code or
verbiage:
 If both first and second characters are alpha, assume narrative.

 If five (5) or less characters are present:
 if all numeric, assume Diagnosis Code
 if one (1) alpha followed by numerics, assume Diagnosis Code
 otherwise, validate against table of 21 codes containing more than one (1) alpha character
– if code is present in table, assume Diagnosis Code
– if code is not present in table, assume narrative
 If (6) or more characters are present:
 if first five (5) characters are numeric, assume first (5) are diagnosis code, all subsequent data is narrative
 if first character is alpha, and any subsequent character is numeric (up to 5), assume Diagnosis Code
followed by narrative
 otherwise, assume narrative
ICD-10 Code Information:

There are approximately 68,000 available codes in the ICD-10 format.
 ICD-10 field length 3-7 characters
o Digit 1= alpha
o Digit 2 = numeric
o Digit 3-7 = alpha or numeric
The following logic will be used to determine whether the information present in the Diagnosis Code field is a code or
verbiage:
 If both first and second characters are alpha, assume narrative

 If both first and second characters are numeric, assume narrative
 If seven or less characters are present:
o If one (1) is alpha, two (2) is numeric, assume Diagnosis code
 If 8 or more characters are present::
o If the first (1) digit is an alpha, second (2) digit is numeric and third (3) through seventh (7) is alpha or
numeric, assume first seven (7) digits are diagnosis code, all subsequent data is narrative

130

APPENDIX “J”
CENTURY LOGIC
 For DOB:
– If year is >= 39, century is 19.
– If year is < 39, century is 20.
– If this makes it a future date, subtract 1 from century.
 For Other Dates:

– If year < 18 + current year, century is 20.
– If year >= 18 + current year, century is 19.

131

APPENDIX “K”
GROUP VS. FACILITY LOGIC
For following are examples to be used as a guide in determining whether the provider is a group or facility:
Group
associates
group
medical associates
medical group
doctors associates
doctors group
foundation
specialists
Facility
hospital
center
clinic
facility

132

APPENDIX “L”
OTHER INSURED INSURANCE PLAN NAME OR PROGRAM NAME
The following is the list of terms to be excluded from field 9d as Other Insured Insurance types:
ALSTOM
ALSTROM
N/A
NO OTHER COVERAGE
NONE
PATIENT PAYMENT
NA
NO OTHER INSURANCE
NO INSURANCE
NO OTHER COVERAGE ON FILE
NO SECONDARY COVERAGE
NONE REPORTED
AUTHORIZATION REQUIRED
SELF PAY
CO PAY
COPAY

133

APPENDIX “M”
Cigna Attachment Code List
Attachment Codes –
 EMR will key a ‘-‘ in the first position of the NTE segment/loop on all claims, except for Healthlink
institutional claims.
 EMR will key “H” or “N” or “P” in the first position of the NTE on all Healthlink institutional claims.
 EMR will key at least 1 (but no more than 2) attachment code on each claim from the following list:
Attachment Code Description

AS Admission Summary
B2 Durable Medical Equipment Prescription
CT
 Itemized Bill
 Letter
 Medical records
 Oxygen Therapy Certification
 Possible Fraud
 Repricing Charges
 Eligibility
DA  Periodontal Charting
 Dental Models
DG Diagnostic Report
DS Discharge Summary
EB Explanation of Benefits
 If Medicare EOB, output Insurance Indicator as MB.
 If Commercial OI EOB (including Cigna EOB), output
Insurance Indicator as CI.
 If Medicare EOB and Commercial OI EOB, output
Insurance Indicator as MB.
MT Models
NN Nursing Notes
OB Operative Notes or Reports
OZ  Support Data for Claim
 Attachment
 Medicaid
PN
 Physical Therapy Notes
 Chiropractic Justification
PO Prosthetics or Orthotic Certification

PZ Physical Therapy Certification
RB
 X-Ray Received
 Radiology Films
 Photographs
RR Radiology Reports
RT
 Ambulance Certification
 Emergency Room Report
 Laboratory Results
 Physician’s Report
 Report of Tests and Analysis Report
 Parenteral or Enteral Certification
BM By Mail
(Value passed in PWK02)
MEDICAID
An attachment will be coded as A if the keyer can identify that the claim is billed by a Medicaid provider for reimbursement
purposes. Another reason for using attachment code A is when there is an indicator in Box 24k (reserved on local use) that the
claim has been priced or there is an allowable amount from a Medicaid organization.
MULTIPLE ATTACHMENT (MORE THAN 2)
An attachment will be coded as B if we see more than 2 attachments of different types.
Note:
Medicaid Exception - If the claim meets the criteria to be coded as Medicaid and there are multiple attachments, give
preference to the Medicaid and code as AB.
Other Insurance (EOB) Exception – If one of the attachments is an EOB from another insurance company give
preference to the EOB and code as DB.

134

Repricing Exception - If the claim contains repricing allowed amounts, give preference to the repricing and code as KB.
Possible Fraud Exception - If the keyer determines that there is a possible fraud, count this determination as an
attachment, give preference, and code as SB.
If there are multiple attachments that are included in the exceptions listed above, always give preference to repricing and code
as KB. If one of the codes is not repricing then all other exception codes hold equal weight and can be used when appropriate
as the first attachment code.
CLAIM FORM
An attachment will be coded as C if the claim is accompanied by the GWH claim form.
 Exception – RX claims
OI EOB (DUPLICATE COVERAGE)

An attachment will be coded as D if the attachment is an explanation of payment made by another insurance carrier or
Medicare. An explanation of benefits (EOB), explanation of Medicare benefits (MEOB or EOMB), or explanation of payment
(EOP) may include the following information:
 Patient/Member Name
 Member ID
 DOS
 Other Carrier Name or address
 Total Charges
 Total Allowed
 Amount applied to deductible
 Total Payment made to provider or member
 Remarks explaining how the payment was determined or what charges were excluded
EMERGENCY ROOM REPORT
An attachment will be coded as E if we see that an Emergency Room Report is attached. This report is often handwritten and
contains information about the patients’ current health status and a description of the reason for visit.
ITEMIZED BILL
An attachment will be coded as I if it has an itemized bill which can be identified by the presence of the following elements:
 Patient name
 Date of service
 Procedure, CPT, HCPCS codes, and units
 Itemized listing of supplies, drugs, or service description
 Charges listed at a line item level
 Wording such as Itemized bill, Summary by service, Demand bill
REPRICING CHARGES
An attachment will be coded as K if it has repricing allowed amounts listed on the HCFA form or a repricing sheet is attached
to the claim. K always has preference over any other attachment code letter so it should be keyed in the 1 st position.
LETTER
An attachment will be coded L if we see any letters or handwritten notes attached to the claim form.
MEDICAL RECORDS
An attachment will be coded as M if we have attachments that reference to medical records from the hospital, provider, or
nursing notes.
OPERATIVE REPORTS
An attachment will be coded as O if it refers to reports about an operation that was performed. Some key words to identify this
type of report are:
 Operation record
 Pre-operation date
 Pre-operation room
 Operation date
 Surgery
PROVIDER TREATMENT PLAN (PRESCRIPTION FOR SERVICES OR MEDICAL NECESSITY STATEMENT)
An attachment will be coded as P when they refer to a recommended treatment from the doctor to the patient or a description
of the treatment itself. Key words to identify:
 Medical necessity statement

 Provider treatment
 Treatment record

135

 Medical treatment
 S.O.A.P (Subjective Objective Assessment Plan)
 Any prescriptions that are presented as attachments are coded as P
REFERRAL FORM
An attachment will be coded as R if we see that the document has information regarding the referral to another doctor. Most
of these have the title of REFERRAL in the heading.
POSSIBLE FRAUD
A document will be coded as S if we see any alterations in the TOTAL CHARGE or line item charge fields which can indicate a
possible fraud. We will only code as S if the charge that was substituted is greater than the one on the claim, if this is not met,
DO NOT CODE AS S.
PERIODONTAL CHARTING
An attachment will be coded as T when it refers to chartings done by the dentists in order to be able to treat. They are easy to
distinguish since we will see a print off with teeth numbers from 1-32 and marks on each teeth were the work was done.
RADIOLOGY REPORT
An attachment will be coded as X if we see that it refers to X-rays or reports from radiology. Some key words for identification
are:
 IMAGING
 MRI
 X-RAY
NO ATTACHMENT
We will code an attachment as Y when we see that we do not have any attachment.
MISC / OTHER / DISCOUNTS

We will code an attachment with Z when we see that the attachment presented is not mentioned above. If a claim includes a
discounted amount, use attachment code Z.

136

APPENDIX S:
CLAIM SORTING CRITERIA
Claims should be sorted as single page, multi page, single page with attachments, and multi page with attachments using the
following guidelines for each form type:
HCFA / Medicaid
Single Page
 one HCFA page
 no attachments*
Multi Page
 two or more HCFA pages
 no attachments*
 Total Charge may appear only on last page
 Total Charge may appear on each page, as long as all data, other than the service line data and the Patient Account Number
field, is identical on each page
Single Page with Attachment(s)
 one HCFA page
 one or more attachment pages*
 if there is more than one single page HCFA, and the attachment(s) pertain to each single page HCFA, the attachment(s) will
be copied so that they can be included with each single page HCFA
Multi Page with Attachments(s)
 two or more HCFA pages
 if there is more than one multi page HCFA, and the attachment(s) pertain to each multi page HCFA, the attachment(s) will be
copied so that they can be included with each multi page HCFA
UB / Medicaid
Single Page
 one UB page
 no attachments*
Multi Page
 two or more UB pages
 no attachments*
 one UB page
 if there is more than one single page UB, and the attachment(s) pertain to each single page UB, the attachment(s) will be
copied so that they can be included with each single page UB
 two or more UB pages
 if there is more than one multi page UB, and the attachment(s) pertain to each multi page UB, the attachment(s) will be
copied so that they can be included with each multi page UB
Miscellaneous Medical/Hospital
Single Page
 one Miscellaneous Medical/Hospital page
 no attachments*
Multi Page
 two or more Miscellaneous Medical/Hospital pages
 one or more Miscellaneous Medical/Hospital page and one or more HCFA pages which all pertain to the same claim
 one or more Miscellaneous Medical/Hospital page and one or more UB pages which all pertain to the same claim
 no attachments*
 if a HCFA page(s) is included, Total Charge may appear on HCFA page(s)
 if a UB page(s) is included, Total Charge may appear on UB page(s)
 if there are two or more single and/or multi page HCFAs, and a Miscellaneous Medical/Hospital page(s) (i.e. a claim form)
exists which pertains to each single and/or multi page HCFA, the Miscellaneous Medical/Hospital page(s) will be copied so
that they can be included with each single and/or multi page HCFA
 if there are two or more single and/or multi page UBs, and a Miscellaneous Medical/Hospital page(s) (i.e. a claim form) exists
which pertains to each single and/or multi page UB, the Miscellaneous Medical/Hospital page(s) will be copied so that they
can be included with each single and/or multi page UB
 one Miscellaneous Medical/Hospital page
 if there is more than one single page Miscellaneous Medical/Hospital, and the attachment(s) pertain to each single page
Miscellaneous Medical/Hospital, the attachment(s) will be copied so that they can be included with each single page
 two or more Miscellaneous Medical/Hospital pages
 one or more Miscellaneous Medical/Hospital page and one or more HCFA pages which all pertain to the same claim
 one or more Miscellaneous Medical/Hospital page and one or more UB pages which all pertain to the same claim

137

 if a HCFA page(s) is included, Total Charge may appear on HCFA page(s)
 if a UB page(s) is included, Total Charge may appear on UB page(s)
 if there are two or more single and/or multi page HCFAs, and a Miscellaneous Medical/Hospital page(s) (i.e. a claim form)
exists which pertains to each single and/or multi page HCFA, the Miscellaneous Medical/Hospital page(s) will be copied so
that they can be included with each single and/or multi page HCFA
 if there are two or more single and/or multi page UBs, and a Miscellaneous Medical/Hospital page(s) (i.e. a claim form) exists
which pertains to each single and/or multi page UB, the Miscellaneous Medical/Hospital page(s) will be copied so that they
can be included with each single and/or multi page UB
 if there is more than one multi page Miscellaneous Medical/Hospital, and the attachment(s) pertain to each multi page
Miscellaneous Medical/Hospital, the attachment(s) will be copied so that they can be included with each multi page
COB Claims
o Claims that have Cigna EOBs attached
Pre-Existing Information Requests

 Received with Cigna letterhead (routed as Corr)
 Received without Cigna letterhead (routed as 837)
Correspondence
 If a document is received without any codes or charges, it is considered to be a correspondence document
Checks
 Documents that are non-claim types
Colorado Early Intervention Invoices

 Documents received that are titled Colorado Early Intervention forms, are to be processed under the Miscellaneous Medical
Form type.
HAP Claims
 If a HAP Preferred Explanation of Pricing Sheet is received with a claim form, the entire document will continue to be
processed as Miscellaneous, and only the detail lines present on the claim form will be keyed.
 If a HAP Preferred Explanation of Pricing Sheet is received without a claim form, the document will continue to be processed
as Miscellaneous, and the detail lines present on the pricing sheet will be keyed.
 Both the HAP Preferred Explanation of Pricing Sheet and the claim form will continue to be considered non-attachments, and
no attachment indicator will be output.
*An attachment is defined as a non-claim document, which is received along with a claim document. Attachment types are
defined within the Electronic Mailroom Keying Requirements: Attachments.
APPENDIX ‘T’:
CLAIM SPLITTING CRITERIA

138

 When multiple page claim forms are received in the EMR, the fields listed in the below tables are reviewed to determine if the
information submitted in those fields is the same on all forms.
 If it is the same, keep the forms together and process all as one claim.
 If any of the key fields are blank on the additional pages, keep the forms together and process all as one claim.
 If the data in any of the fields below is different, split the claim and process as separate claim forms.
HCFA Split Criteria

F2 - Patient Name
F3 - Patient Date of Birth
F6 - Patient Relationship to Insured
F8 - Patient Status
F9D - Insurance Plan or Program Name
F10 - Is Patient Condition Related To:
F10D - Reserved for Local Use
F11D - Is There Another Health Benefit Plan?
F13 - Insured's or Authorized Person's Signature
F17 - Name of Referring Physician
F17A - I.D. Number of Referring Physician
F21 - Diagnosis Code (Must be in Same Order)
F23 - Prior Authorization Number
F23a- Date of Service (ICD-10 New Rule—see guidelines
below)
F25 - Federal Tax ID
F31 - Physician's Signature
F32 - Rendering Facility
F33 - Billing Organization / Billing Provider

139

Appendix ‘U’
Renaissance Claims Keying Requirements

140

APPENDIX ‘V’
Examples of Provider Name Formats
 If unable to determine the first name, last name and credentials for Field 17, Referring Physician, Field 31, Rendering Provider, or
any miscellaneous name field where the format of the name is not specified on the form, utilize the below criteria in making the
determination of how to key.
 If the name does not meet any of the below criteria or if unable to determine the correct format, key all in the last name field.
Example # 1: Last Name Credential, First Name

(i.e. Cook MD, Paul) – Key Cook for the Last Name, Key Paul for the First Name, Key MD for Specialty
Example # 2:
First Name, Last Name Credential
(i.e. Cook, Paul MD) – Key Cook for the Last Name, Key Paul for the First Name, Key MD for Specialty
Example # 3:
Last Name, First Name Middle Initial Credential
(i.e. Cook, Paul T MD) – Key Cook for the Last Name, Key Paul for the First Name, Key MD for the Specialty
Example # 4:
Last Name Credential, First Name Middle Initial
(i.e. Cook MD, Paul T) – Key Cook for the Last Name, Key Paul for the First Name, Key MD as the Specialty
Example # 5:
First Name Last Name
(i.e. Cook Paul) – Key Paul as the Last Name, Key Cook as the First Name
Example # 6:
Last Name, First Name
(i.e. Cook, Paul) – Key Cook for the Last Name, Key Paul for the First Name
Example # 7:
First Name Last Name Credential
(i.e. Cook Paul MD) - Key Paul for the Last Name, Key Cook for the First Name, Key MD for the Specialty
Example # 8:
First Name Last Name Credential
(i.e. Paul Cook, MD) – Key Paul for the First Name, Key Cook for the Last Name, Key MD for the Specialty
Example # 9:
Last Name First Name Middle Initial Credential
(i.e. Cook JR Paul T MD) – Key Cook JRfor the Last Name, Key Paul for the First Name, Key MD for the Specialty
Example # 10:
Last Name Credential First Name
(i.e. Cook MD Paul) – Key Cook for the Last Name, Key Paul for the First Name, Key MD for the Specialty
Example # 11:
First Name Middle Initial Last Name
(i.e. Cook T Paul) – Key Paul for the Last Name, Key Cook for the First Name
Example # 12:
(i.e. T Paul Cook) – Key Cook for the Last Name, Key T for the First Name
Example # 13:
First Name Last Name
(i.e. DR Paul Cook) – Key Cook for the Last Name, Key Paul for the First Name
Example # 14:
(i.e. Paul T Cook III) – Key Cook III for the Last Name, Key Paul for the First Name
Example # 15:
Last Name, First Name Middle Initial
(i.e. Cook, T Paul) – Key Cook for the Last Name, Key T for the First Name
Example # 16:
First Middle Initial Last Name Credential
(i.e. DR Paul T Cook MD) – Key Cook for the Last Name, Key Paul for the First Name, Key MD for the Specialty
Example # 17
First Name, Last Name Credential
(i.e. P.T. Cook DR) – key Cook for the Last Name, Key P for the First Name, Key DR for the Specialty
Example # 18:
(i.e. P.T. Cook) – Key Cook for the Last Name, Key P for the First Name
Example # 19:
Last Name First Name Middle Initial
(i.e. Avery Shannon R) - Key Avery for the Last Name, Key Shannon for the First Name.

141

APPENDIX V.1
Sample HCFA 1500 Claim Form
(next page)

142

143

APPENDIX V.2
Sample CMS 1500 Claim Form
(next page)

144

145

APPENDIX W
Inpatient Codes
HCFA (Professional):
Place of service field is used to determine inpatient vs. outpatient
 Valid inpatient codes:11,18, 21, 22, 52, 65,66, 86
UB (Institutional):
Type of Bill field is used to determine inpatient vs. outpatient
 Valid inpatient codes: 11, 41, 65, 66, 86.

146

EOB KEYING REQUIREMENTS:
Required EDI Gateway’s

ANSI
to Common Claim
HCFA-MM Claim Form Loop ANSI
Submit Record Field
Field # Field Name Current Requirements Segment Element Number
to EDI Name, Size, Claim
Data Element
Gateway or Detail Level
N/A OI Charges Cigna Business Requirements N/A N/A N/A

(detail)  Compare to Charge amount from claim.
 If there are two or three fields on the EOB which have the same meaning (per the variations listing), and contain a
CBH Proclaim value of “0” or greater, match either amount (do not add them together) to the Charge amount from the claim. If
Field Name: there are four or more fields on the EOB which have the same meaning (per the variations listing), and contain a
N/A value of “0” or greater, do not output any data from EOB.
 If Charge amounts do not match, do not output any data from EOB.
CBH Common  Do not output data from this field.
Claim Field
Name:
N/A
N/A OI Charges Cigna Business Requirements N/A N/A N/A

(claim)  Compare to Charge amount from claim.
 If there are two or three fields on the EOB which have the same meaning (per the variations listing), and contain a
CBH Proclaim value of “0” or greater, match either amount (do not add them together) to the Charge amount from the claim. If
Field Name: there are four or more fields on the EOB which have the same meaning (per the variations listing), and contain a
N/A value of “0” or greater, do not output any data from EOB.
 If Charge amounts do not match, do not output any data from EOB.
CBH Common  Do not output data from this field.
Claim Field
Name:
N/A
N/A OI Disallowed Cigna Business Requirements 2430 ADJ-OI-GROUP-

Amount (detail)  Key if present, from EOB only. CAS01=CO 1033 CODE
 If "0" or "0.00" is present, do not output information from this field (leave blank) CAS02=96 1034 PIC X(02)
CBH Proclaim  If there are two or three fields on the EOB which have the same meaning (per the variations listing), and CAS03= 782 DETAIL LEVEL
Field Name: contain a value of “0” or greater, they should be added together. If there are four or more fields on the EOB Not Covered
N/A which have the same meaning (per the variations listing), and contain a value of “0” or greater, do not output Charges XCCR: ADJ-OI-
any data from EOB. M60-ADJ-AMT1 ADJUSTMENT-
 If a Medicare EOB is present, and Medicare Reason Codes and Amounts are present at the detail level, key as ECHCF: REASON-CODEA1
CBH Common Medicare Reason Codes and Amounts and do not consider as Disallowed Amount. The Medicare Reason Claim/ PIC X(05)
Claim Field Code Amounts may appear before or after the Medicare Reason Codes and are to be considered as Medicare echcf:ServiceLineInf DETAIL LEVEL
Name: Reason Code Amounts not Disallowed Amounts. o/

ANSI
to Common Claim
Submit Record Field
Data Element
ADJ DET  If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. hcfd:OtherPayerProc ADJ-OI-
GROUPA1: CO  If EOB does not contain any detail lines, output claim level data only from EOB. essedInfo/ DISALLOWED-
DISALLOWED hcfd:ServiceAdjustm AMOUNT
AMOUNTA1: EDI Requirements ent/hcfd:GroupCode PIC 9(08)V99
ADJ REASON  Must be numeric. DETAIL LEVEL
CDA1: 96  Remove special characters. Claim/
SERVICES  If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the echcf:ServiceLineInf Xnet Field Name:
ADJUSTEDA1 Cigna on-site representative for further processing instruction. o/ ADJ DET
hcfd:OtherPayerProc GROUPA1: CO
essedInfo/ DISALLOWED
hcfd:ServiceAdjustm AMOUNTA1:
ent/ ADJ REASON
hcfd:ReasonCode CDA1: 96
SERVICES
Claim/ ADJUSTEDA1:
echcf:ServiceLineInf
o/ ECR field:
hcfd:OtherPayerProc E3-ADJ-OI-
essedInfo/ DISALLOWED-
hcfd:ServiceAdjustm AMOUNTA(1,1)
ent/hcfd:Amount
N/A OI Disallowed Cigna Business Requirements Loop 2320 TOTAL-DENIED-

Amount (Claim  Key if present, from EOB only. AMT AMOUNT
Level)  If "0" or "0.00" is present, output "0" or "0.00". AMT01=A8 522 PIC X(02)
 If not present, output as the sum of the OI Disallowed Amounts from the detail lines. AMT02=Disallowed 782 PIC 9(08)V99
CBH Proclaim  If there are two or three fields on the EOB which have the same meaning (per the variations listing), and Amt. CLAIM LEVEL
Field Name: contain a value of “0” or greater, they should be added together. If there are four or more fields on the EOB XCCR:
MED-OC-NOT- which have the same meaning (per the variations listing), and contain a value of “0” or greater, do not output S00-APPRVD-AMT Xnet Field Name:
COV any data from EOB. This field is TOTAL DENIED
 If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. removed and will
CBH Common  If EOB does not contain any detail lines, output claim level data only from EOB. not be populated ECR field:
Claim Field for 5010: E3-ADJ-OI-
Name: NOTE: In the 5010 environment, if both OI Disallowed Amount and OI Paid Amount (claim levels) are present, we are DISALLOWED-
ADJ CLM requesting that the Paid Amount always be prioritized over the Disallowed Amount. If both are present, always send OI AMOUNTA(1,1)
GROUPA1: CO Paid Amount. This was driven by a business observation in integrated testing (Test: MM097U_UB04_MCR_PCLM) that
ADJ CLM Paid Amount is a critical field to properly process COB where Disallowed Amount is not.
REASON
CODEA1: 45 EDI Requirements
ADJ CLM  Must be numeric.
AMOUNTA1:
ADJ CLM
QUANTITYA1:

ANSI
to Common Claim
Submit Record Field
Data Element
N/A OI Allowed No longer keyed—not applicable in 5010 N/A N/A N/A

Amount (detail)
N/A OI Allowed No longer keyed—not applicable in 5010 N/A N/A N/A

Amount (claim)
N/A OI Coinsurance/ Cigna Business Requirements 2430 OI-ALLOWED-

Copayment  Key if present, from EOB only. CAS01=PR 1033 AMOUNT
Amount (detail)  If "0" or "0.00" is present, do not output information from this field (leave blank) CAS02=2 1034 PIC X(02)
 If there are two or three fields on the EOB which have the same meaning (per the COB Field variations list CAS03= 782 PIC 9(08)V99
seen below), and contain a value of “0” or greater, they should be added together. Coinsurance or DETAIL LEVEL
 If there are four or more fields on the EOB which have the same meaning (per the COB Field variations list Copayment Amount
seen below), and contain a value of “0” or greater, do not output any data from EOB. ECR field:
 If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. E2-OI-ALLOWED-
 If EOB does not contain any detail lines, output claim level data only from EOB. AMT
EDI Requirements
 Must be numeric. XCCR:
 Remove special characters. S00-APPRVD-AMT
 If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the This field is
Cigna on-site representative for further processing instruction. removed and will
not be populated
for 5010.
N/A OI Coinsurance/ Cigna Business Requirements 2320 OI-ALLOWED-

Copayment  Key if present, from EOB only. CAS01=PR 1033 AMOUNT
Amount (claim)  If "0" or "0.00" is present, do not output information from this field (leave blank) CAS02=2 1034 PIC X(02)V99
 If there are two or three fields on the EOB which have the same meaning (per the variations listing), and CAS03= 782 CLAIM LEVEL
contain a value of “0” or greater, they should be added together. If there are four or more fields on the EOB Coinsurance or
which have the same meaning (per the variations listing), and contain a value of “0” or greater, do not output Copayment Amount ECR field:
any data from EOB. E2-OI-ALLOWED-
 If a Medicare EOB is present, and Medicare Reason Codes and Amounts are present at the detail level, key as AMT
Medicare Reason Codes and Amounts and do not consider as Coinsurance/Copayment Amount.
 The Medicare Reason Code Amounts may appear before or after the Medicare Reason Codes and are to be XCCR:
considered as Medicare Reason Code Amounts not Copayment/Coinsurance Amounts. S00-APPRVD-AMT
 If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. This field is
 If EOB does not contain any detail lines, output claim level data only from EOB. removed and will
not be populated
EDI Requirements for 5010.
NOTE (output rule): If two CAS PR 1 or CAS PR2 claim level values are present, and those two values are the exact

ANSI
to Common Claim
Submit Record Field
Data Element
same amounts, remove one of the values so only one CAS PR 1 or 2 is sent at the claim level.
If two CAS PR 1 or CAS PR2 claim level values are present and DIFFERENT values, set EOB Match = N. This will
cause the claim to bypass AA and drop to a manual processor downstream in the Cigna claim platform. The mapping
will show the following: EOB Match = N, COB Indicator = Y, COB Type = MB or CI, Attachment Code = EB, Primacy
Code Loop 2320 = T.
N/A OI Applied Cigna Business Requirements: 2430 ADJ-OI-GROUP-

Toward  Key if present, from EOB only. CAS01=PR 1033 CODE
Deductible  If "0" or "0.00" is present, do not output information from this field (leave blank) CAS02=1 1034 PIC X(02)
Amount (detail)  If there are two or three fields on the EOB which have the same meaning (per the variations listing), and CAS03= 782 DETAIL LEVEL
contain a value of “0” or greater, they should be added together. If there are four or more fields on the EOB Not Covered
CBH Proclaim which have the same meaning (per the variations listing), and contain a value of “0” or greater, do not output Charges ECR field: OI-ADJ-REASON-
Field Name: any data from EOB. E3-ADJ-OI-ADJ- CODEA1 ADJ-OI-
N/A  If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. ECHCF: REASON- ADJ-REASON-
 If EOB does not contain any detail lines, output claim level data only from EOB. Claim/ CODEA(1,1) CODEA2 ADJ-OI-
EDI Requirements echcf:ServiceLineInf E3-ADJ-OI-ADJ- ADJ-REASON-
 Must be numeric. o/ REASON- CODEA3 ADJ-OI-
CBH Common  If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the hcfd:OtherPayerProc CODEA(1,2) ADJ-REASON-
Claim Field Cigna on-site representative for further processing instruction. essedInfo/ E3-ADJ-OI-ADJ- CODEA4 ADJ-OI-
Name: hcfd:ServiceAdjustm REASON- ADJ-REASON-
ADJ DET GROU ent/hcfd:GroupCode CODEA(1,3) CODEA5 ADJ-OI-
PA1: PR DISAL E3-ADJ-OI-ADJ- ADJ-REASON-
LOWED AMOU Claim/ REASON- CODEA6
NTA1: echcf:ServiceLineInf CODEA(1,4) PIC X(05)
ADJ REASON C o/ E3-ADJ-OI-ADJ- DETAIL LEVEL
DA1: 1 hcfd:OtherPayerProc REASON-
essedInfo/ CODEA(1,5) ADJ-OI-
hcfd:ServiceAdjustm E3-ADJ-OI-ADJ- DISALLOWED-
ent/ REASON- AMOUNTB1 ADJ-
hcfd:ReasonCode CODEA(1,6) OI-DISALLOWED-
E3-ADJ-OI-ADJ- AMOUNTB2 ADJ-
Claim/ REASON- OI-DISALLOWED-
echcf:ServiceLineInf CODEA(1,7) AMOUNTB3 ADJ-
o/ E3-ADJ-OI-ADJ- OI-DISALLOWED-
hcfd:OtherPayerProc REASON- AMOUNTB4 ADJ-
essedInfo/ CODEA(1,8 OI-DISALLOWED-
hcfd:ServiceAdjustm AMOUNTB5 ADJ-
ent/hcfd:Amount OI-DISALLOWED-
XCCR : AMOUNTB6 PIC
C00-ADJ-CLM- 9(08)V99
RSN-CD DETAIL LEVEL

ANSI
to Common Claim
Submit Record Field
Data Element
Xnet Field Name

ADJ DET GROUPA
1: CO DISALLOW
ED AMOUNTA1
ADJ REASON CDA
1: 96
N/A OI Applied Cigna Business Requirements 2320 PATIENT-

Toward  Key if present, from EOB only. CAS01=PR RESPONSIBILITY-
Deductible  If "0" or "0.00" is present, do not output information from this field (leave blank) CAS02=1 522 AMOUNT
Amount (claim)  If not present, output as the sum of the OI Applied Toward Deductible Amounts from the detail lines. CAS03=Adjusted 782 PIC X(02)
 If there are two or three fields on the EOB which have the same meaning (per the variations listing), and Amount PIC 9(08)V99
CBH Proclaim contain a value of “0” or greater, they should be added together. If there are four or more fields on the EOB CLAIM LEVEL
Field Name: which have the same meaning (per the variations listing), and contain a value of “0” or greater, do not output (Updated: CR-
MED-OC-DED any data from EOB. EMR0700913) ECR Field
N/A  If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. E2-PATIENT-
 If EOB does not contain any detail lines, output claim level data only from EOB. RESPONS-AMT(1)
CBH Common EDI Requirements Xnet Field Name:

Claim Field  Must be numeric. PATIENT RESP
Name:  If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the
PAT RESP Cigna on-site XCCR :
C25-COB-AMT
NOTE (output rule): If two CAS PR 1 or CAS PR2 claim level values are present, and those two values are the exact
same amounts, remove one of the values so only one CAS PR 1 or 2 is sent at the claim level.
If two CAS PR 1 or CAS PR2 claim level values are present and DIFFERENT values, set EOB Match = N. This will
cause the claim to bypass AA and drop to a manual processor downstream in the Cigna claim platform. The mapping
will show the following: EOB Match = N, COB Indicator = Y, COB Type = MB or CI, Attachment Code = EB, Primacy
Code Loop 2320 = T.
N/A OI Paid Amount Cigna Business Requirements Loop 2430 ADJ-AMT-PAID-

(detail)  Key if present, from EOB only. SVD01 = 000000000 67 BY-OTHER-
 If "0" or "0.00" is present, output "0" or "0.00". SVD02 = AMT 782 CARRIER
CBH Proclaim  If this field is blank, output “.00”. SVD03 = HC 235 PIC 9(08)V99
Field Name:  If paid amount is greater than 0 and allowed amount is 0 or cannot be determined, do not output anything in Proc Code 234 DETAIL LEVEL
N/A the allowed amount field* SVD05 = Units 380
 If there are two or three fields on the EOB which have the same meaning (per the variations listing), and DTP01 = 573 374 ADJ-OI-DTE-
CBH Common contain a value of “0” or greater, they should be added together. If there are four or more fields on the EOB DTP02 = D8 1250 SERV-FROM PIC
Claim Field which have the same meaning (per the variations listing), and contain a value of “0” or greater, do not output DTP03 = Adjustment 1251 X(08)

ANSI
to Common Claim
Submit Record Field
Data Element
Name: any data from EOB. date (date service DETAIL LEVEL
OI PAID AMT  If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. line was adjudicated)
 If EOB does not contain any detail lines, output claim level data only from EOB. Xnet Field Name:
EDI Requirements OI PAID AMT
 Must be numeric. ECHCF:
 If the SVD is output, must also output the claim Date of Service (From) in the DTP03. Claim/ We Do not have
 Date must be valid and in CCYYMMDD format. echcf:ServiceLineInf this field at detail
 If a value greater than $9,999,999.99 is presented, the claim will be removed from batch and forwarded to the o/ (2400) level
Cigna on-site representative for further processing instruction. hcfd:OtherPayerProc
 Exclude OI Paid Amount at the claim level and detail level when no CAS segments are present and EB essedInfo/
attachment code/COB indicator are present or when EOBMatch = N but the ‘EB’ attachment code and COB hcfd:LinePaidAmoun
indicator are present. This would include when no CAS segments are present and EOBMatch=Y. This should t
only be applied to claims being processed under the standard submitter ID.
Claim/
echcf:ServiceLineInf
o/
hcfd:OtherPayerProc
essedInfo/
hcfd:PaymentOrAdju
dicationDate
N/A OI Paid Amount Cigna Business Requirements 2320 OI-PAID-AMOUNT

(claim)  Key if present, from EOB only. AMT01=D 522 PIC X(02)
 If "0" or "0.00" is present, output "0" or "0.00". AMT02= amount 782 PIC 9(08)V99
CBH Proclaim  If paid amount is greater than 0 and allowed amount is 0 or cannot be determined, do not output anything in CLAIM LEVEL
Field Name: the allowed amount field*
MED-OC-PAID  If not present, output as the sum of the OI Paid Amounts from the detail lines. ECHCF: ECR Field :
 If there are two or three fields on the EOB which have the same meaning (per the variations listing), and Claim/ E2-OI-PAID-AMT
contain a value of “0” or greater, they should be added together. If there are four or more fields on the EOB echcf:ClaimCOBInfo/
CBH Common which have the same meaning (per the variations listing), and contain a value of “0” or greater, do not output hcfd:OtherPayerAdju Xnet Field Name:
Claim Field any data from EOB. dicationInfo/ OI PAID
Name:  If claim contains additional detail line(s) not present on EOB, do not output any data from EOB. hcfd:OtherPayerPaid
OI PAID  If EOB does not contain any detail lines, output claim level data only from EOB. Amount XCCR:
C25-COB-AMT
NOTE: In the 5010 environment, if both OI Disallowed Amount and OI Paid Amount (claim levels) are present, we are
requesting that the Paid Amount always be prioritized over the Disallowed Amount. If both are present, always send OI
Paid Amount. This was driven by a business observation in integrated testing (Test: MM097U_UB04_MCR_PCLM) that
Paid Amount is a critical field to properly process COB where Disallowed Amount is not. (Updated: CR-EMR0680913)
EDI Requirements

ANSI
to Common Claim
Submit Record Field
Data Element
 Exclude OI Paid Amount at the claim level and detail level when no CAS segments are present and EB
attachment code/COB indicator are present or when EOBMatch = N but the ‘EB’ attachment code and COB
indicator are present. This would include when no CAS segments are present and EOBMatch=Y. This should
only be applied to claims being processed under the standard submitter ID.
N/A Medicare Cigna Business Requirements 2430 ADJ-OI-GROUP-

Reason Code  Key if present, from EOB only. CAS01 1033 CODE
(detail)  Key from Medicare EOB only, not from OI EOB. CAS02 1034 PIC X(02)
 Key all CAS segments that are present, if first two characters match any of the following: DETAIL LEVEL
CBH Proclaim  CO
Field Name:  CR ECHCF: Not in xccr ADJ-OI-
N/A  OA Claim/ ADJUSTMENT-
 PI echcf:ServiceLineInf REASON-CODEA1
 PR o/ PIC X(05)
 If first two characters do not match, do not output Medicare Reason Code and Medicare Reason Amount (other hcfd:OtherPayerProc DETAIL LEVEL
CBH Common data may still be output from EOB). essedInfo/
Claim Field  If both the Group Code (first two characters) and Adjustment Reason Code (remaining characters, up to five) are hcfd:ServiceAdjustm ADJ-OI-
Name: not present, do not output the Medicare Reason Code or Medicare Reason Amount (other data may still be output ent/hcfd:GroupCode DISALLOWED-
ADJ DET from EOB). AMOUNTA1
GROUPA1:  If Medicare Reason Code is not present, do not output Medicare Reason Amount (other data may still be Claim/
DISALLOWED output from EOB). echcf:ServiceLineInf Xnet Field Name:
AMOUNTA1:  If Medicare Reason Amount is not present, do not output Medicare Reason Code (other data may still be output o/ ADJ DET
ADJ REASON from EOB). hcfd:OtherPayerProc GROUPA1:
CDA1:  If a Medicare EOB is present, and Medicare Reason Codes and Amounts are present at the detail level, key as essedInfo/ DISALLOWED
SERVICES Medicare Reason Codes and Amounts and do not consider as Disallowed Amount. hcfd:ServiceAdjustm AMOUNTA1:
ADJUSTEDA1  The Medicare Reason Code Amounts may appear before or after the Medicare Reason Codes and are to be ent/ ADJ REASON
considered as Medicare Reason Code Amounts not Disallowed Amounts. hcfd:ReasonCode CDA1:
 If there is more than one Medicare Reason Code along with a single Medicare Reason Amount, do not output SERVICES
Medicare Reason Code or Medicare Reason Amount (other data may still be output from EOB). ADJUSTEDA1:
 Output up to five Medicare Reason Amounts (each with one Medicare Reason Code) per detail line.
 If claim contains additional detail line(s) not present on EOB, do not output any data from EOB.
 If EOB does not contain any detail lines, output claim level data only from EOB.
 If not present, output as the sum of the OI Paid Amounts from the detail lines.
 If not present, output as the sum of the OI Paid Amounts from the detail lines.
Key Words:
Reason Code 253
Example: 17338306220702

ANSI
to Common Claim
Submit Record Field
Data Element
Example: 17338401571362
Intermediary
Example: 17338306220702
Abbreviation “MCR”
Example: 18022400385862
Code MA01
Example: 17338401571362
Example: 18022400385862
EDI Requirements
 Output first two characters as the Group Code.
 Output remaining characters as the Adjustment Reason Code.
 Output each set of one Medicare Reason Code and one Medicare Reason Amount in a separate CAS segment.
N/A Medicare Cigna Business Requirements 2320 ADJ-CLM-GROUP-

Reason Code  Key if present, from EOB only. CAS01 1033 CODE

ANSI
to Common Claim
Submit Record Field
Data Element
(claim)  Key from Medicare EOB only, not from OI EOB. CAS02 1034 PIC X(02)
 Key all CAS segments that are present, if first two characters match any of the following: CLAIM LEVEL
CBH Proclaim  CO
Field Name:  CR ECHCF: ADJ-CLM-
N/A  OA Claim/ REASON-CODE
 PI echcf:ClaimCOBInfo/ PIC X(05)
CBH Common  PR hcfd:OtherPayerAdju CLAIM LEVEL
Claim Field  If first two characters do not match, do not output Medicare Reason Code and Medicare Reason Amount (other dicationInfo/
Name: data may still be output from EOB). hcfd:ClaimAdjustmen ECR FIELD: not
N/A  If there are more than one Group Code (first two characters) and Adjustment Reason Code (remaining characters, t/hcfd:GroupCode mapped at claim
up to five) that are identical at the claim level, output the sum amount of the amounts and only output the code and level
amount once (Updated: CR-EMR0771013) Claim/
 Only sum amounts if both the group and adjustment reason code are identical on the EOB (Updated: CR- echcf:ClaimCOBInfo/ XCCR:
EMR0771013) hcfd:OtherPayerAdju M60-ADJ-AMT1
 If both the Group Code (first two characters) and Adjustment Reason Code (remaining characters, up to five) are dicationInfo/
not present, do not output the Medicare Reason Code or Medicare Reason Amount (other data may still be output hcfd:ClaimAdjustmen
from EOB). t/hcfd:ReasonCode
 If Medicare Reason Code is not present, do not output Medicare Reason Amount (other data may still be
output from EOB).
 If Medicare Reason Amount is not present, do not output Medicare Reason Code (other data may still be output
from EOB).
 If there is more than one Medicare Reason Code along with a single Medicare Reason Amount, do not output
Medicare Reason Code or Medicare Reason Amount (other data may still be output from EOB).
 Output up to five Medicare Reason Amounts (each with one Medicare Reason Code) at the claim level.
EDI Requirements
 Output first two characters as the Group Code.
 Output remaining characters as the Adjustment Reason Code.
N/A Medicare Cigna Business Requirements 2430 ADJ-OI-

Reason Amount  Key if present, from EOB only. CAS03 782 DISALLOWED-
(detail)  Key from Medicare EOB only, not from OI EOB. AMOUNT
 If "0" or "0.00" is present, do not output information from this field (leave blank) PIC 9(08)V99
CBH Proclaim  If Medicare Reason Code is not present, do not output Medicare Reason Amount (other data may still be ECR field :
Field Name: output from EOB). ECHCF: E3-ADJ-OI-
N/A  If Medicare Reason Amount is not present, do not output Medicare Reason Code (other data may still be Claim/ DISALLOWED- Xnet Field Name:
output from EOB). echcf:ServiceLineInf AMOUNTA(1,1) ADJ DET

ANSI
to Common Claim
Submit Record Field
Data Element
 If a Medicare EOB is present, and Medicare Reason Codes and Amounts are present at the detail level, key as o/ GROUPA1:
Medicare Reason Codes and Amounts and do not consider as Disallowed Amount. hcfd:OtherPayerProc DISALLOWED
CBH Common  The Medicare Reason Code Amounts may appear before or after the Medicare Reason Codes and are to be essedInfo/ AMOUNTA1:
Claim Field considered as Medicare Reason Code Amounts not Disallowed Amounts. hcfd:ServiceAdjustm ADJ REASON
Name:  If there is more than one Medicare Reason Code along with a single Medicare Reason Amount, do not output ent/hcfd:Amount CDA1:
ADJ DET GROU Medicare Reason Code or Medicare Reason Amount (other data may still be output from EOB). SERVICES
PA1: DISALLO  Output up to five Medicare Reason Amounts (each with one Medicare Reason Code) per detail line. ADJUSTEDA1:
WED  If claim contains additional detail line(s) not present on EOB, do not output any data from EOB.
AMOUNTA1: 25.  If EOB does not contain any detail lines, output claim level data only from EOB.
06 ADJ REASO
N CDA1: SERVI EDI Requirements
CES ADJUSTE  Output each set of one Medicare Reason Code and one Medicare Reason Amount in a separate CAS segment.
DA1  Must be numeric.
N/A Medicare Cigna Business Requirements 2320 ADJ-CLM-

Reason Amount  Key if present, from EOB only. CAS03 782 AMOUNT
(claim)  Key from Medicare EOB only, not from OI EOB. PIC 9(08)V99
 If "0" or "0.00" is present, do not output information from this field (leave blank) CLAIM LEVEL
CBH Proclaim  If Medicare Reason Code is not present, do not output Medicare Reason Amount (other data may still be ECHCF:
Field Name: output from EOB). Claim/ ECR FIELD: NOT XCCR:
N/A  If Medicare Reason Amount is not present, do not output Medicare Reason Code (other data may still be echcf:ClaimCOBInfo/ MAPPED AT M60-ADJ-AMT1
output from EOB). hcfd:OtherPayerAdju CLAIM LEVEL
CBH Common  If there are more than one Group Code (first two characters) and Adjustment Reason Code (remaining characters, dicationInfo/
Claim Field up to five) that are identical at the claim level, output the sum amount of the Medicare reason amount lines and hcfd:ClaimAdjustmen
Name: only output the code and amount once t/hcfd:Amount
N/A  Only sum amounts if both the group and adjustment reason code are identical on the EOB
 Do not output multiple data elements with the same group code and adjustment codes at the claim level, values
must be summed and only one data element should be sent
 If there is more than one Medicare Reason Code along with a single Medicare Reason Amount, do not output
Medicare Reason Code or Medicare Reason Amount (other data may still be output from EOB).
 Output up to five Medicare Reason Amounts (each with one Medicare Reason Code) at the claim level.
EDI Requirements

ANSI
to Common Claim
Submit Record Field
Data Element
N/A ESRD (End Cigna Business Requirements N/A N/A N/A

Stage Renal  For Medicare EOBs only, if this field is present and contains a dollar amount greater than 0.00, do not output any
Disease) data from EOB.
Do not output data from this field.
CBH Proclaim
Field Name:
N/A
CBH Common
Claim Field
Name:
N/A
Establish hierarchy for EMR to key line level information if present; only key claim data if line level Applies to—
is not present OI Charges (detail and claim level)
OI Disallowed (Detail and claim level)
OI Coinsurance/Copayment (Detail and claim level)
OI Applied Toward Deductible (detail and claim level)
OI Paid (detail and claim level)
Medicare Reason Code (detail and claim level)
Medicare Reason Amount (detail and claim level)
New Requirements:
 If line level data is present, key line level information only. Do not key claim level data.
 If line level data is not present, key claim data.
Create an output rule that removes the duplicate dollar value if it is found in the same CAS Applies to—
segment OI Charges (detail and claim level)
OI Disallowed (Detail and claim level)
OI Coinsurance/Copayment (Detail and claim level)
OI Applied Toward Deductible (detail and claim level)
OI Paid (detail and claim level)
Medicare Reason Code (detail and claim level)
Medicare Reason Amount (detail and claim level)
New Requirements:
• If the same CAS segment at the detail or line level has the exact same value, only output one value
in that CAS segment.
• Example: If there are two column headers that both mean “OI Coinsurance/Copayment Amount”
according to the COB Variation list and both outline a $50 amount at the detail or claim level, only
output $50 once in the Coinsurance/Copayment CAS segment


Appendix N:
EOB Determination Guidelines
 Definition: Explanation of Benefits - A document, usually received from an insurance carrier, indicating how a
claim was paid.
 An Explanation of Benefits is a form from an insurance carrier indicating how much was paid on the claim.
 EOBs may contain other patient names.
 EOBs give a breakdown of what was covered through the insurance and may, but not always, contain the following
keywords:
 Billed charges
 Amount not covered
 Deductible
 Coinsurance amount
 Co-payment amount
 Allowed amount
 Covered amount
 Provider Claim Summary
 EOBs may, but not always, contain the following headings:

 Medicare
 Remittance Advice
 Remittance Notice
 This is not a bill
 Explanation of (Medicare) Payment
Indicators:
 Insurance company name
 Possible headings:
 Medicare
 Remittance Advice/Notice
 This is not a bill
 Explanation of (Medicare) Payment
 (Provider) Claim Summary/Status
 Breakdown of what was covered/not covered by the insurance carrier.

 Terms listed on the “Field Name Variation List” may be present.
 May contain detail level data, claim level data, or both detail and claim level data.
Important Notes:
 If the document contains EOB indicators and there is a ‘Web Address’ present, consider the document to be
an EOB.
 If the document contains EOB indicators and there is not ‘Web Address’ present, consider the document to be
an EOB.
 Screen Shots of a provider/claim billing system are not EOBs.
 If the document contains EOB indicators but ‘Function Command Keys’ are present, do not consider the document to be an
EOB.
Compsych Pricing Sheets:
The below document numbers are examples of Compsych pricing sheets. These are not EOBs. When these pricing sheets are received,
they should be keyed as an attachment and not as an EOB.

159


APPENDIX O:
COB Field Name Variation List
Requirements:
 Words may not be added or removed from terms indicated on the list.
 Variations and abbreviations are acceptable
 Terms containing two words may be reversed. 'Billed Amount' can also be accepted as 'Amount Billed'.
 Terms containing more than two words can be reversed as long as the EXACT Words are present in the Variation List (not
necessarily the same order)---ex. “Total Paid Amount” and “Total Amount Paid” are the same
 The addition and subtraction of the letter 's' is acceptable. If 'Total Charges' is submitted on the EOB, it should be considered as
an acceptable term due to the term 'Total Charge' being indicated on the list.
 The addition or subtraction of special characters/spaces is acceptable. If Coinsurance Co – Pay is submitted on the EOB, it
should be considered as an acceptable term due to the term “Coinsurance / Copay” being indicated on the Field Name Variation
list.
 ‘Non' and 'Not' should be considered the same. If 'Non Payable' is submitted on the EOB, it should be considered as an
acceptable term due to the term 'Not Payable' being indicated on the Field Name Variation list.
Total Charge OI Copay/Coinsurance OI Disallowed Amount OI Deductible (PR1) OI Paid

(PR2) (non-covered field)
Amount Billed Coinsurance Actual Contract Adjustment Applied To Deductible % Paid
Amount
Coinsurance + Copayment Adjusted Amount Blood Deductible Delta Payment
Charged
Patient Payment (Delta
Amount Filed Coinsurance Amount Adjustments Cash Deductible
Form)
Allowable/
Billed Coinsurance/Copay Adjustments Amount Copay/Deductible Reimbursement (detail
level only)
Allowance (Medicare EOB
Billed Charges Copay Ded Allow/Reimbursement
only)
Charge Copay Amount C/A Amt Deduct Allow/Reim
Contract (Medicare EOB
Charge Amount Copayment Deductible Allowable/Reimbursement
only)
Charged Copayment Amount Contract Adjustment Met Deductible Amount Allowable/Reim
Charged
Delta Co-Pay Contract Diff Deductible Applied Amount Paid
Amount
Charges Delta Co-Payment amount Contract Write Off Deductible Charges Amount Paid Patient
Charges Contractual (Medicare EOB
Patient Responsible Deduct/Ovr Max (3/26) Amount Paid Provider
Reported only)
Claimed Patient Responsibility Contractual Adjustment Less Deductible Benefit
Claimed Contractual Adjustment
Subscribers Liability Patient Deductible Benefit Amount
Amount Amount
Covered
Charges
Contractual Difference Patient Deductible/Copay Benefit Available
(Medicare EOB
only)
Original
Charged Contractual Obligation Total Deduct Benefit Paid
Amount
Fee Charge Deducted Amount Benefit Paid Amount
Deduction Benefit Payable
Fee Charged\
Original Charge
(May be
abbreviated as Deduction Amount Benefits
OrgCharge or
Org Charge)
Org Charge Deductions Benefits Amount
Provider Billed Deductions/Ineligible Claim Paid
Provider Billed
Deductions/Other Ineligible Claim Paid Amount
Amount
Provider
Denied Claim Payment
Charges
Provider
Denied Amount Delta Dental Paid
Request
Provider
Denied Charges Claim Payment Amount
Submitted
Provider Total
Disallowance Issued
Charges
Reported Disallowed Issued Amount
Reported
Disallowed Amount Medicare Paid Amount
Amount
Reported Medicare Paid Provider
Disallowed Charges
Charges
Requested Disallowed or Pended
Member Portion
Amount Amount

161

Submitted Discount Net Paid
Submitted
Discount Amount Net Payment
Amount
Submitted
Excluded Net Payment Amount
Charges
Submitted Fee Excluded Amount Net Payment for Claim
Submitted Line
Expenses Excluded Net Reimbursement
Charge
Total Billed Net Reimbursement
Fee Adjustment
Charges Amount
Net Reimbursement
Total Charge Ineligible
Charges
Total Charge Other Insurance Carrier
Ineligible Amount
Amount Paid
Total Charges Ineligible Amount &
Paid
Submitted Remarks
Total Expense Ineligible Charges Paid Amount
Total Expense Ineligible Charges &
Messages (Updated in CR- Paid Charges
Amount EMR0761013)
Ineligible/Discount Paid Provider
Ineligible-Member Paid to Provider
Ineligible-Provider Patient Benefit Liability
Line Adjustment Amount Pay Provider
Line Item Adjustment Payable
NCVD / Denied (Medicare
Payable Amount
EOBs only)
Non Allowed Payable Charges
Non-covered Payment
Non-Covered Amount Payment Amount
Non-Covered Charges Payment Charges
Not Allowed Payment to Doctor
Not Allowed Amount Plan Benefit
Not Considered Plan Liability
Not Considered Amount Plan Paid
Not Covered Plan Paid Amount
Not Covered Amount Plan Payment
Not Payable Plan Pays
Not Payable by Plan Provider Paid
Other Adjustment Provider Paid Amount
Other Adjustment Amount Provider Payment
Other Ineligible Reimbursed
Other Ineligible Amount Reimbursement
Other Not Paid Amount Reimbursement Amount
Over Usual & Customary To-Pay Amount
Patient Non-Covered Total Benefits
Pended Total Benefits Approved
Pended Amount Total Benefits Paid
Per Doctor(s) adjustment Total Paid

Per facility(s) adjustment Total Paid Amount
Per provider(s) adjustment Total Payment
Provider Adjusted Discount What we paid
Provider Adjustment Withhold
Provider Adjustment
Withhold Amount
Amount
Provider Agreement
Provider Agreement
Amount
Provider Discount
Provider Discount Amount
Provider Liability
Provider Liability Amount
Provider Non Billable
Provider Responsibility
Provider Write-off
Provider Write-off Amount
RC-Amt
Reduced By
Reduction
Reduction Amount
Write-off

162

Write-off Amount

163

APPENDIX “P”
CBH Common Claim and Proclaim Print COB Match Criteria
* CBH Common Claim Prints Only
CBH COB Match Criteria Requirements:

 Key the total charge amount on the claim as the EOB total charge amount.
 Claims with COB data present will always be considered as a match.
CBH Common Claim COB Field Name Variation List
OI Allowed Medicare Reason

OI Disallowed Amount OI Deductible OI Paid Medicare Reason Amount
Amount Code
OI ALLOWED ADJ CLM GROUPA1: PAT RESP OI PAID ADJ DET ADJ DET GROUPA1: DIS
(HCFA Claim Level) CO ADJ CLM REASON (HCFA Claim Level) (HCFA Claim GROUPA1: XX ALLOWED AMOUNTA1: $
CODEA1: 45 ADJ Level) DISALLOWED $$$ ADJ REASON CDA1:
CLM AMOUNTA1: AMOUNTA1: SERVICES ADJUSTEDA1
ADJ CLM ADJ REASON
QUANTITYA1: CDA1: XX (HCFA Detail Level)
(HCFA Claim Level) SERVICES
ADJUSTEDA1
(HCFA Detail
Level)
MED ALLOWED AMT ADJ DET GROUPA1: ADJ DET GROUPA1: OI PAID AMT ADJ DET ADJ DET GROUPA1: DIS
(HCFA Detail Level) CO PR DISALLOWED AM (HCFA Detail GROUPA1: XX ALLOWED AMOUNTA1: $
DISALLOWED AMOUN OUNTA1: Level) DISALLOWED $$$
TA1: ADJ REASON CDA1: AMOUNTA1: ADJ REASON CDA1: SE
ADJ REASON CDA1:96 1 ADJ REASON RVICES ADJUSTEDA1
(HCFA Detail Level) (HCFA Detail Level) CDA1: XX
SERVICES (UB Detail Level)
ADJUSTEDA1
(UB Detail Level)

OI ALLOWED ADJ CLM GROUPA1: OI PAID
(UB Claim Level) TOTAL DENIED PR ADJ CLM REASO (UB Claim
(UB Claim Level) N CODEA1 Level)
ADJ CLM AMOUNTA1
(UB Claim Level)
ADJ DET GROUPA1: C OI PAID AMT

O DISALLOWED AMO (UB Detail
UNTA1: ADJ REASON Level)
CDA1: 96 SERVICES A
DJUSTEDA1
(UB Detail Level)
CBH Proclaim COB Field Name Variation List
*Applicable to CBH Proclaim Prints:
OI Allowed OI Disallowed
OI Deductible OI Paid
Amount Amount
MED-OC-COV MED-OC-NOT-COV MED-OC-DED MED-OC-PAID

164

APPENDIX Q:
Medicare vs Commercial EOB Criteria
An EOB should initially be considered Medicare or a Commercial, based on the carrier name listed on the EOB. If Medicare is not
listed as the carrier name on the EOB, but the following references to Medicare are listed, it should be considered a Medicare EOB:
Medicare Remittance Advice, Medicare Payer Advice Notification, Payer: Medicare, Part A, Part B.
If you cannot determine whether or not it is a Commercial or Medicare EOB from the carrier name on the EOB or no carrier name is
listed on the EOB, check the following:
 The EOB has a HIC Number (Medicare Beneficiary Identifier, MBI, Medicare Number) listed (HIN, HICN or HIC # (Medicare
Beneficiary Identifier, MBI, Medicare Number, Medicare ID, MID)), it should be considered a Medicare EOB.
 If a UB92 is attached, and Medicare is listed in the Other health insurance field 50, it should be considered a Medicare EOB.
 If there is a HCFA attached, and Medicare is listed in the Other health insurance field 9d, it should be considered a Medicare
EOB.
If none of the above criteria match for Commercial or Medicare, key as Commercial

165

Attachment R:
COB SORTING / MATCHING CRITERIA
 Basic Match Criteria: Match patient name on claim to name on EOB to consider for match. For each detail line on the claim, match a
line on the EOB with dos, procedure code/rev code (when available), and charges. The claim drives the EOB. If all the detail lines on
the claim are found on the EOB, consider a match. If only claim level information is present, consider totals on claim to determine
match and key claim level EOB data.
 Expectation: If detail lines on the claim(s) match detail lines on the EOB, consider as match and key the data.
 EOBs will be sorted as either Medicare (MB) or Commercial OI (CI).
 Cigna EOBs should be considered as Commercial OI EOBs (CI), but no data should be output from the EOB (Attachment Indicator
should be output as EB and Insurance Indicator as CI).
 If a Cigna EOB is received with a Medicare EOB, consider the Medicare EOB for match. Output insurance indicator as MB and key
the COB information from the Medicare EOB. No data will be keyed or considered for match from the Cigna EOB.
 If a Cigna EOB is received with a Commercial OI EOB consider the Commercial EOB for match. Output insurance indicator as CI
and key the COB information from the Commercial OI EOB. No data will be keyed or considered for match from the Cigna EOB.
 If both a Medicare EOB and a Commercial EOB are present, send EB as attachment indicator and MB as insurance indicator. No
data should be output from either EOB. (Attachment Indicator should be output as EB and insurance indicator should be output as
MB)
 The following is the criteria to be used when matching the claim to the EOB:
 Patient Name (variations allowed), Date of Service (From), and Charge Amount must be present on the EOB and must match
the claim. Key Detail Level for each detail line. Key Claim level when only claim level data is present on the EOB or when both
detail and claim level data is present on one EOB and matches the claim exactly.
 For HCFA/Misc. Medical, if the Date Of Service (From) on the claim is at the detail level and the Date Of Service (From) on the
EOB is at the claim level, as long as the Date Of Service (From) on all detail lines of the claim matches the Date Of Service
(From) at the claim level on the EOB, then it would be considered a match. If a Date Of Service (From) on any of the detail lines
of the claim does not match the Date Of Service (From) at the claim level on the EOB, then it would not be considered a match.
 For UB/Misc. Hospital, if the EOB is at the claim level, the Statement Covers Period (From) field (6) should be used as the Date
Of Service. If the EOB is at the detail level, the Service Date field (45) should be used as the Date Of Service. If the Service
Date field is blank, use the Statement Covers Period (From) field.
 If there are multiple detail lines present on the EOB and the Date Of Service (From) is only present on the first detail line,
consider the Date Of Service (From) from the first detail line as the Date Of Service (From) for the additional detail lines.
 If the Date of Service (From) at the detail level does not contain the year, use the year from the Date Of Service (From) at the
claim level, as long as the month and day match. If the Date Of Service (From) at the claim level does not contain the year, use
the year from the Date Of Service (From) at the detail level, as long as the month and day match.
 If Procedure Code is present on the EOB, it must match the claim. If it is not present, it will not be used as part of the matching
criteria. For UB/Misc. Hospital, if Procedure Code is not present, but Revenue Code is present, use Revenue Code for matching
detail lines. If Revenue code is not present it will not be used as part of the matching criteria.
 If there are two detail lines with the same Date of Service and Charge Amount and there is no Procedure Code/Rev Code on the
EOB, this should not be considered as a match. For UB/Misc. Hospital, if Procedure Code is not present, but Revenue Code is
present, use Revenue Code.
 The claim form drives the match to EOB. There may be additional lines on the EOB that do not match the detail lines on the
claim. (Example: 3 detail lines on the HCFA, 4 detail lines on the EOB. 3 lines of HCFA match 3 of the 4 detail lines on the EOB,
consider as match, key detail lines. Claim level information will not be keyed. System will calculate claim level COB information
based on current rules)
 If there are more lines on the Claim than on the EOB, this is not considered a match (Example: 5 lines on a HCFA, 3 lines
present on EOB that match the HCFA. Only 3 of the 5 lines have an EOB match. This is only a partial match. Consider as ‘no
match’. Do not send EOB data, the applicable attachment indicator and insurance indicator should still be output. Remember, the
claim form drives the EOB match.
 Claim information may be present on one page or on multiple pages.
 COB information may be present on one EOB or on multiple EOBs. (Must be the same type EOB to be considered for match)
 If keying detail level EOB data from multiple EOBs do not key the claim level information, key detail level information only.
Exception: Key claim level data when a complete EOB is present and matches the claim exactly (example: If one EOB or
segment is present, and matches exactly to the number of detail lines on the claim, and claim level data is present, key claim
level data).
 If only claim level EOB data is present (example: UBs), consider match criteria, determine if match and key.
 If multiple EOBs or segments are present, and they are exact duplicates, consider a match to one of the EOBs and key the detail
level information. If it is a single EOB and matches the claim exactly, and claim level information is present, key claim level data).
 If multiple sets of EOBs or segments are present and all match criteria has been applied, yet a definite match cannot be made,
consider ‘no match’ and no EOB data will be output (example: HCFA has 3 detail lines, 3 Medicare EOBs are present, matching

166

the 3 detail lines, but EOB field information is different on each of the EOBs. Operator cannot make determination. Consider as
‘no match’. Do not output EOB data).
 If data is not being output from the EOB, all other COB related data from the claim as well as the Attachment Indicator and Insurance
Indicator should still be output.

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