MN–ITS Help Text – 837P – Service Line

The table below describes the individual fields on the Services screens used for line item billing, line item coordination of benefits reporting, and reporting other providers for a specific service line. * The Field Name column identifies X12 loops and elements 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 additional instruction for submitting claims for specific services using MN–ITS DDE.

Field Name*
(X12 Loop and element)

Valid Values

Character Length

Field Description

Date of Service (From)
(Loop: 2400, DTP03)

MMDDCCYY

8
(numeric)

The date, or begin date of a consecutive date range, the service was provided

Date of Service (To)
(Loop: 2400, DTP03 * RD8* required in DTP02 when TO date is reported)

MMDDCCYY

8
(numeric)

The date, or last date of a consecutive date range, the service was provided

Place of Service
(Loop: 2400, SV105)

Refer to the MN–ITS screen for values available

 

Code identifying the location where the service was rendered (unless otherwise indicated for the service) when different than what was reported on the Claim Information screen

Procedure Code
(Loop: 2400, SV101-2)

 

5
(alphanumeric)

Code (CPT or HCPCS) identifying the product or service

Procedure Code Modifier(s)
(Loop: 2400, SV101-3, SV101-4, SV101-5, SV101-6)

 

2
(alphanumeric)

Code(s) that clarifies or further identifies the service indicated in the procedure code field

Diagnosis Pointer
(Loop: 2400, SV107-1, SV107-2, SV107-3, SV107-4)

Refer to the MN–ITS screen for values available

 

Indicates, in the order of importance, the diagnosis code(s) from the Claim Information screen that apply to this service

Line Item Charge
(Loop: 2400, SV102)

 

10
(numeric)

The total charge for the service

Service Unit Count
(Loop: 2400, SV104)

 

1-15
(numeric)

The quantity of units, time, days, visits, services or treatments for the service

Other Payer

Other Payer Primary Identifier
(Loop: 2430, SVD01)

Refer to the MN–ITS screen for values available

 

Identifier of the insurance carrier or the Medicare contractor NPI

Service Line Paid Amount
(Loop: 2430, SVD02)

 

10
(numeric)

The total dollar amount paid for this service by the other payer

Adjudication - Payment Date
(Loop: 2430, DTP03)

 

1-35
(alphanumeric)

Date of payment or denial determination by Medicare payer for this service line

Paid Unit Count
(Loop: 2430, SVD05)

 

1-15
(numeric)

The number of units identified as being paid from the other payer’s EOB/EOMB

Claim Adjustment Group Code
(Loop: 2430, CAS01)

Refer to the MN–ITS screen for values available

 

Code identifying the general category of payment adjustment

Adjustment Reason Code
(Loop: 2430, CAS02)

 

1-5
(alphanumeric)

Code identifying the reason the adjustment was made

Adjustment Amount
(Loop: 2430, CAS03)

 

10
(numeric)

The total dollar amount of the adjustment made to this service line

Adjustment Quantity
(Loop: 2430, CAS04)

 

1-15
(numeric)

The number of units being adjusted for this service line

Situational Services

Prior Authorization
(Loop: 2400, REF02)

 

11
(numeric)

Authorization number for the service when different than the authorization number reported at the claim level

Certification Condition Indicator
(Loop: 2400, SV111)

  

Not used by MHCP

Ambulance Patient Count
(Loop: 2400, QTY02)

 

1-15
(numeric)

The number of patients, when more than one is transported in the same ambulance or non-emergency transportation service

Line Note
(Loop: 2400, NTE02)

 

1-80
(alphanumeric)

Free form description to provide additional information/clarification about the service

Qualifier
(Loop: 2400, K301)

JP – tooth number

JO – Oral cavity designation

1-80
(alphanumeric)

CDT code indicating type of value entered for the service

Value
(Loop: 2400, K301)

Refer to the ADA CDT Reference Guide for valid values

 

Tooth number(s) or oral cavity designation(s) for the service

Description
(Loop: 2400, SV101-7)

 

1-80
(alphanumeric)

Free form description to specifically identify the service

NDC
(Loop: 2410, LIN03)

Use the 5-4-2 NDC format

11
(numeric)

National Drug Code (NDC) that further specifies the HCPCS code used for the service

NDC Count
(Loop: 2410, CPT04)

 

1-15
(numeric)

Number specifying the drug quantity

CODE Qualifier
(Loop: 2410, CTP05-1)

Refer to the MN–ITS screen for values available

 

Code indicating type of measurement for the NDC count

Other Providers

Rendering Provider

NPI/UMPI
(Loop: 2420A, NM109)

 

10
(alphanumeric)

NPI/UMPI of the provider who performed the service

Referring Provider

NPI/UMPI
(Loop: 2420F, NM109)

 

10
(alphanumeric)

NPI/UMPI of the provider who made the referral for the service

Service Facility Location

NPI/UMPI
(Loop: 2420C, NM109)

 

10
(alphanumeric)

NPI/UMPI identifying one of the following:

Where the service was actually provided

The recipient’s or provider’s home/clinic location when the location of health care service is different than the billing provider

Ordering Provider

NPI/UMPI
(Loop: 2420E, NM109)

 

10
(alphanumeric)

NPI/UMPI of the provider who ordered the service