MN–ITS Help – 837I Institutional Claim Information
The table below describes the individual fields on the Claim Information screen. The Field Name column identifies X12 loops and segments only for fields that display in the MN–ITS screens. Refer to the X12 HIPAA Companion Guides available through the WPC X12 Registry for additional instruction when submitting batch claims.
Select MN–ITS User Guides to obtain instruction for submitting claims for specific services using MN–ITS direct Data Entry (DDE).
Field Name | Valid Values | Character Length | Field Description |
Type of Bill | 3 | Identifies the type of facility where services were performed | |
Statement Date (From) | MMDDCCYY | 8 | The single date of service or the start date of the service when the From and To dates are different |
Statement Date (To) | MMDDCCYY | 8 | The last date of service reported on the claim |
Patient Control Number | 1-20 | A unique identifier, assigned by the provider, that will be reported on the remittance advice to help identify this claim for this patient | |
Assignment/Plan Participation | Assigned -provider has a participation agreement with MHCP Assignment Accepted - provider accepts assignment only for clinical lab services Not Assigned - neither assigned nor assignment accepted apply | Code indicating whether the provider accepts payment from MHCP Default is Assigned | |
Benefits Assignment | Yes - Benefits assigned to the provider No - Benefits not assigned to the provider Not Applicable - Patient refuses to assign benefits | The determination of the policy holder or person authorized to act on their behalf, to give MHCP permission to pay the provider directly Default is Yes | |
Release of Information | Yes - Signature collected or required Informed Consent - Signature not collected and not required | The determination of whether the provider has on file a signed statement by the recipient authorizing the release of medical data to other organizations Default is Yes | |
Admission Type | Refer to the MN–ITS screen for values available | Code indicating the priority of this admission | |
Admission Source | Refer to the MN–ITS screen for values available | Code indicating the point of location/origin for this admission or visit | |
Patient Status | Refer to the MN–ITS screen for values available | Code indicating the disposition or discharge status of the recipient on the date entered in the Statement Date (To) field | |
Admission Date | MMDDCCYY | 8 | The date the episode of care began or the admission date to the facility |
Admission Time | HHMM | 4 | The time the episode of care began or admission to the facility |
Discharge Time | HHMM | 4 | The time the recipient was discharged from the inpatient care |
Diagnosis Type Code | ICD-9 ICD-10 | Identifies whether the diagnosis code reported on this claim is in the ICD-9 or ICD-10 classification. | |
Principal Diagnosis Code | 3-5 | ICD or other industry accepted code(s) that best describes the condition/reason the recipient needed the service(s) | |
POA | Y-Yes N-No U-Unknown W-Not Applicable | Indicates if Principal Diagnosis Code was present on admission | |
Admitting Diagnosis Code | 3-5 | ICD or other industry accepted code(s) that best describes the condition/reason the recipient needed the service(s) | |
Patient Reason For Visit | 3-5 | The diagnosis code describing the recipient’s reason for visit at the time of outpatient registration | |
External Cause of Injury Code | Refer to the Internal Classification of Diseases, Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) | 3-5 | Code indicating a code from a specific industry code list |
POA | Y-Yes N-No U-Unknown W-Not Applicable | Indicates if the External Cause of Injury Code was present at time of admission | |
Other Diagnosis Code | 3-5 | ICD or other industry accepted code(s) that best describes the additional condition/reason the recipient needed the service(s) Up to 24 diagnosis codes can be added to the claim. | |
POA | Y-Yes N-No U-Unknown W-Not Applicable | Indicates if the Other Diagnosis Code was present at time of admission | |
Situational Claim Information | |||
Principal Procedure Code | 5 | Code (ICD) identifying the procedure | |
Date | MMDDCCYY | 8 | Date the Principal Procedure was performed |
Other Procedure Code | 5 | Additional Code (ICD) identifying the other procedure | |
Date | MMDDCCYY | 8 | Date the Other Procedure Code was performed |
Prior Authorization Number | 11 | The number assigned to the authorization that indicates MHCP has reviewed and determined medical necessity criteria has been met for the service(s) on this claim | |
Medical Record Number | 1-50 | A number to identify the actual medical record of the patient, assigned by the provider | |
Reference | Refer to the MN–ITS screen for values available | Code identifying the functional area or purpose for which the claim note applies | |
Text | 1-80 | Free form description to provide additional claim note information/clarification about this claim’s Reference Code | |
Attachment Control Number | 2-50 | Code/number assigned by the provider, identifying an attachment for this claim | |
Attachment Type | Refer to the MN–ITS screen for values available | Code indicating the type ID and description of the attachment | |
Situational (Continued) Claim Information | |||
Occurrence Code | 2 | A code defining a significant event relating to this bill that may affect payer processing | |
Date | MMDDCCYY | 8 | Date associated with the Occurrence Code |
Occurrence Span Code | 2 | Code that identifies an event, occurring over a span of days, that relates to payment of the claim | |
From Date | MMDDCCYY | 8 | Beginning date associated with the Occurrence Span |
To Date | MMDDCCYY | 8 | End date associated with the Occurrence Span |
Value Code | Refer to the UB04 Manual for the values available | 2 | A code that identifies data necessary for processing this claim as required by the payer organization |
Amount | 1-10 | Amount associated with the value code | |
Condition Code | 2 | Code to identify a condition/event related to the bill that may affect processing of the claim | |
Patient Responsibility Amt | 1-10 | Amount determined to be the recipient’s responsibility for payment | |
Auto Accident State or Province | Refer to the MN–ITS screen for values available | State or Province where auto accident occurred | |
Delay Reason | Refer to the MN–ITS screen for values available | Code indicating the reason why an auto accident request was delayed | |
Other Providers (Claim Level) | |||
Rendering Provider | |||
NPI/UMPI | 10 | NPI/UMPI of the provider who performed the service | |
Pay-To Provider | |||
NPI/UMPI | 10 | NPI/UMPI of the provider to be paid when the address is different than that of the Billing Provider | |
Referring Provider | |||
NPI/UMPI | 10 | NPI/UMPI of the provider who made the referral for the service | |
Attending Provider | |||
NPI/UMPI | 10 | NPI/UMPI of the provider who is attending the service | |
Operating Provider | |||
NPI/UMPI | 10 | NPI/UMPI of the provider who did the operating for the service | |
Service Facility Location | |||
NPI/UMPI | 10 | NPI/UMPI identifying one of the following: Where the services were actually provided The recipient’s or provider’s home/clinic location when the location of health care service is different than the billing provider | |