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Electronic Data Interchange (EDI)

This section describes the standard formats used for TFM's Electronic Data Interchange (EDI). These standards are used for all types of data interchange between TFM and payers. It will also show you how to process claims for EDI submission.

Mapping Claims - X12 837 Payments - X12 835

Mapping

TFM has a database designed to make information flow better within a medical office. The ANSI ASC X12 standards are designed to pass data between providers and payers. The translation of the TFM data to the X12 data is called mapping. The following two sections are a reference to the way TFM maps data to the X12 standard.

Claims - X12 837

The TFM posting process operates on a set of claims and all of the related data of each claim.

Loop Segment/Element TFM Data Element

Envelope Segments

- ISA01 "03"/"00" if no ISA02
- ISA02 Preferences [com.trefre.edi.transUsername]
- ISA03 "01"/"00" blank if no ISA04
- ISA04 Preferences [com.trefre.edi.transPassword]
ISA05 Preferences [com.trefre.edi.transSenderQual] Defaults to "ZZ"
ISA06 Preferences [com.trefre.edi.transSenderID]
ISA07 Preferences [com.trefre.edi.transReceiverQual] Defaults to "ZZ"
ISA08 Preferences [com.trefre.edi.transReceiverID]
GS02 Preferences [com.trefre.edi.appSender]
GS03 Preferences [com.trefre.edi.appReceiver]

837 Transaction

REF03 Preferences [com.trefre.edi.piloting]
1000A NM102 "1" if submitter is person, "2" otherwise
1000A NM103 Preferences [com.trefre.edi.submitterLast]
1000A NM104 Preferences [com.trefre.edi.submitterFirst] if submitter is person
1000A NM105 Preferences [com.trefre.edi.submitterMiddle] if submitter is person
1000A NM109 Preferences [com.trefre.edi.submitterID]
1000A PER02 Preferences [com.trefre.edi.submitterAContactName]
1000A PER03 Preferences [com.trefre.edi.submitterAContactType1]
1000A PER04 Preferences [com.trefre.edi.submitterAContact1]
1000A PER06 Preferences [com.trefre.edi.submitterAContactExt1]
1000B NM103 Preferences [com.trefre.edi.receiverName]
1000B NM109 Preferences [com.trefre.edi.receiverID]

Details

2000A - Billing Provider

2000A PRV03 PROVIDER_TF.SPECIALTY

2010AA

2010AA NM103 PROVIDER_TF.person.LNAME
2010AA NM104 PROVIDER_TF.person.FNAME
2010AA NM105 PROVIDER_TF.person.MNAME
2010AA NM109 PROVIDER_TF.TAX_ID if available PROVIDER_TF.person.SSN otherwise
2010AA N302 PROVIDER_TF.LOT<space>PROVIDER_TF.STREET
2010AA N401 PROVIDER_TF.CITY
2010AA N402 PROVIDER_TF.STATE
2010AA N403 PROVIDER_TF.ZIP
2010AA-1 REF02 PROVIDER_TF.person.SSN if available and TAX_ID used in NM109
2010AA-2 REF01 PROVIDERCODE_TF.PARTICIPATION_CODE
2010AA-2 REF02 PROVIDERCODE_TF.CODE
2010AA-3 REF02 PROVIDER_TF.UPIN if available

2010AB - Pay To Provider [Not Yet Implemented in TFM]

2000B/C - Subscriber/Patient

2000B SBR01 COVERAGECODE_TF.PRIORITY [First character only.]
2000B SBR03 COVERAGE_TF.GROUP_NUM
2000B SBR04 COVERAGE_TF.PLAN_NAME
2000B SBR05 PAYER_TF.INS_TYPE
2000B SBR09 PAYER_TF.IND_CODE
2000B SBR05 PAYER_TF.INS_TYPE
2000B/C PAT01 COVERAGECODE_TF.RELATIONSHIP if patient is not subscriber
2000B/C PAT06 PATIENT_TF.person.DECEASED_DATE
if PATIENT_TF.person.DECEASED is True
2000B/C PAT08 PATIENT_TF.WEIGHT if date of service is withing 29 days of patient birthdate
2000B/C PAT09 "Y" if PATIENT_TF.PREGNANT is True

2010(B/C)A

2010(B/C)A NM103 PERSON_TF.LNAME
2010(B/C)A NM104 PERSON_TF.FNAME
2010(B/C)A NM105 PERSON_TF.MNAME
2010(B/C)A NM109 COVERAGE_TF.CONTRACT_NUM
2010(B/C)A N302 PERSON_TF.LOT<space>PERSON_TF.STREET
2010(B/C)A N401 PERSON_TF.CITY
2010(B/C)A N402 PERSON_TF.STATE
2010(B/C)A N403 PERSON_TF.ZIP
2010(B/C)A DMG02 PERSON_TF.DOB
2010(B/C)A DMG03 PERSON_TF.SEX
2010(B/C)A REF02 PERSON_TF.SSN
2010(B/C)A DMG03 PERSON_TF.SEX

2010BB

2010BB NM103 PAYER_TF.FULL_NAME
2010BB NM109 PAYER_TF.PAYER_NUMBER
2010BB N3 PAYER_TF.ADDRESS
2010BB N401 PAYER_TF.CITY
2010BB N402 PAYER_TF.STATE
2010BB N403 PAYER_TF.ZIP
2010BB REF02 PAYER_TF.CLAIM_OFFICE_NUM

2010BC - Responsible Party Name [Not Implemented]

2010BC REF02 PAYER_TF.CLAIM_OFFICE_NUM

2010BD - Credit/Debit Card Holder [Not Implemented]

2300 - Claim Information

2300 CLM01 CLAIM_TF.ID
2300 CLM02 total(PROCEDURE_TF.CHARGE)
2300 CLM05-1 ENCOUNTER_TF.LOCATION_CODE
2300 CLM05-3 CLAIM_TF.FILE_STATUS
2300 CLM06 "Y" if first PROVIDERCODE_TF.SIGNATURE is True, "N" otherwise
2300 CLM07 CLAIM_TF.ASSIGN_CODE
2300 CLM08 "Y" if COVERAGE_TF.ASSIGN_BENE is True, "N" otherwise
2300 CLM09 PATIENT_TF.MED_RELEASE
2300 CLM10 PATIENT_TF.SIGN_SOURCE
2300 CLM11-1 ENCOUNTER_TF.REL_TO_AUTO
2300 CLM11-1/2 ENCOUNTER_TF.REL_TO_EMPLOYMENT
2300 CLM11-1/2/3 ENCOUNTER_TF.REL_TO_OTHER
2300 CLM11-4 ENCOUNTER_TF.ACCIDENT_STATE
2300 CLM12 ENCOUNTER_TF.PROGRAM_CODE
2300 CLM16 "P" if PROVIDERCODE_TF.PARTICPATION_CODE equals 'non-par'
2300 CLM20 CLAIM_TF.DELAY_CODE
2300 DTP03 ENCOUNTER_TF.FIRST_CONSULT -- DTP01 = 454
2300 DTP03 ENCOUNTER_TF.REFERRAL_DATE -- DTP01 = 330
2300 DTP03 ENCOUNTER_TF.SYMPTOM_ONSET -- DTP01 = 431
2300 DTP03 ENCOUNTER_TF.ACCIDENT_DATE -- DTP01 = 439
2300 DTP03 ENCOUNTER_TF.LAST_PERIOD -- DTP01 = 484
2300 DTP03 ENCOUNTER_TF.DUE_DATE -- DTP01 = ABC (Pre-Addenda only)
2300 DTP03 ENCOUNTER_TF.DISABILITY_FROM -- DTP01 = 360
2300 DTP03 ENCOUNTER_TF.DISABILITY_TO -- DTP01 = 361
2300 DTP03 ENCOUNTER_TF.ADMISSION_DATE -- DTP01 = 435
2300 DTP03 ENCOUNTER_TF.DISCHARGE_DATE -- DTP01 = 096
2300 DTP03 ENCOUNTER_TF.FIRST_CONSULT -- DTP01 = 454
2300 REF02 CLAIM_TF.AUTH_NUM -- REF01 = G1
2300 REF02 PATIENT_TF.ID -- REF01 = EA
2300 HI Mapped to first 8 PROCEDURE_TF.ICD9_x by selecting one from each unique PROCEDURE on the claim until they run out.

2310A - Referring Provider Name

2310A NM101 "DN"
2310A NM102 1
2310A NM103 ENCOUNTER_TF.ref_provider.person.LNAME
2310A NM104 ENCOUNTER_TF.ref_provider.person.FNAME
2310A NM105 ENCOUNTER_TF.ref_provider.person.MNAME
2310A NM108 "XX" if UPIN, "24" if ENCOUNTER_TF.Ref_provider.TAX_ID otherwise "34" for ENCOUNTER_TF.Ref_provider.SSN

2310B - Rendering Provider Name [Not Implemented]

2310C - Purchased Service Provider [Not Implemented]

2310D - Service Facility Location

2310D NM101 "FA"
2310D NM102 2
2310D NM103 ENCOUNTER_TF.facility.FULL_NAME
2310D N301 ENCOUNTER_TF.facility.ADDRESS
2310D N401 ENCOUNTER_TF.facility.CITY
2310D N402 ENCOUNTER_TF.facility.STATE
2310D N403 ENCOUNTER_TF.facility.ZIP

2310E - Supervising Provider Name [Not Implemented]

2320 - Other Subscriber Information [Not Implemented]

2400 - Service Line

2400 SV101-1 "HC"
2400 SV101-2 PROCEDURE_TF.procedure_code.CODE
2400 SV101-3 PROCEDURE_TF.procedure_modifier_1.CODE
2400 SV101-4 PROCEDURE_TF.procedure_modifier_2.CODE
2400 SV101-5 PROCEDURE_TF.procedure_modifier_3.CODE
2400 SV102 PROCEDURE_TF.CHARGE
2400 SV103 "UN"
2400 SV104 1
2400 SV107-1 through 4 Pointer to ICD9 Code in HI segment in loop 2300
2400 SV109 "N" in Pre-addenda only.
2400 DTP02 ENCOUNTER_TF.SERVICE_DATE -- DTP01 = 472
2400 REF02 CLAIM_TF.AUTH_NUM -- REF01 = G1
2400 REF02 PROCEDURE_TF.ID -- REF01 = 6R

2420A - Rendering Provider Name [Not Implemented]

2420B - Purchased Service Provider [Not Implemented]

2420C - Service Facility Location

2420C NM101 "FA"
2420C NM102 2
2420C NM103 ENCOUNTER_TF.facility.FULL_NAME
2420C N301 ENCOUNTER_TF.facility.ADDRESS
2420C N401 ENCOUNTER_TF.facility.CITY
2420C N402 ENCOUNTER_TF.facility.STATE
2420C N403 ENCOUNTER_TF.facility.ZIP

2420D - Supervising Provider Name [Not Implemented]

2420E - Ordering Provider Name [Not Implemented]

2420F - Referring Provider Name [Not Implemented]

2420G - Other Payer Prior [Not Implemented]

2430 - Line Adjudication Information [Not Implemented]

2440 - Form Identification Code [Not Implemented]

Payments - X12 835

TFM imports

TFM Data Element Loop Segment/Element

Payer Identification

[Primary]
PAYER_TF.PAYER_NUMBER if N102 = "XV" 1000A N103
[Alternate]
PAYER_TF.FULL_NAME if N102 != "XV" 1000A N103

Payee Identification

[Primary]
PROVIDER_TF.UPIN if N102 = "XX" 1000B N103
[Alternate 1]
PROVIDER_TF.TAX_ID if N102 = "FI" 1000B N103
[Alternate 2]
PROVIDER_TF.GROUP_NAME if N102 != ("XX"||"FI") 1000B N103

Payer Payments

PAYERPAYMENT_TF.CHECK_NUM - TRN02
PAYERPAYMENT_TF.METHOD - "Check" if BPR04 is "CHK", "Direct Deposit" otherwise
PAYERPAYMENT_TF.PAYMENT_TYPE - "Fee for Service"
PAYERPAYMENT_TF.CHECK_DATE - BPR16
PAYERPAYMENT_TF.AMOUNT - BPR02 - SUM(each claim patient responsibility)
PAYERPAYMENT_TF.BALANCED - False

Payer Payment (Capitation)

Created if there are provider level adjustments reported in segment PLB

PAYERPAYMENT_TF.CHECK_NUM - TRN02
PAYERPAYMENT_TF.METHOD - "Check" if BPR04 is "CHK", "Direct Deposit" otherwise
PAYERPAYMENT_TF.PAYMENT_TYPE - "Capitation"
PAYERPAYMENT_TF.CHECK_DATE - BPR16
PAYERPAYMENT_TF.AMOUNT - BPR02
PAYERPAYMENT_TF.BALANCED - False

Payment

PAYMENT_TF.PAYER_PAYMENT_ID - ID of PayerPaymentTF created
PAYMENT_TF.CLAIM_ID - CLP01
PAYMENT_TF.PROCEDURE_CODE - SVC01
PAYMENT_TF.CHARGE - SVC02
PAYMENT_TF.ADJUSTMENT - SUM(CAS02 where CAS01 in ("OA","PI")) plus a percentage of claim level adjustments of type ("OA" and "PI").
PAYMENT_TF.DEDUCTIBLE - SUM(CAS02 where CAS01 is "PR") plus a percentage of claim level adjustments of type "PR".
PAYMENT_TF.DEDUCTIBLE - SUM(CAS02 where CAS01 in ("CO","CR")) plus a percentage of claim level adjustments of type ("CO" and "CR").
PAYMENT_TF.PAID_AMT - PAYMENT_TF.CHARGE - (PAYMENT_TF.ADJUSTMENT + PAYMENT_TF.DEDUCTIBLE + PAYMENT_TF.WITHHOLD)
PAYMENT_TF.ALLOWED - PAYMENT_TF.CHARGE - (PAYMENT_TF.ADJUSTMENT + PAYMENT_TF.WITHHOLD)

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