This article dives into the specifics of a Secondary Payer submission and assumes that you know how to read an EDI (837) file. If you are looking for a general outline of an EDI and how to read the basic structure, please see: How to read an EDI (837) File - Overview.

We will be using the following sample EDI file to break down this loop.

When you submit a claim to an additional payer, 4 loops are added:

• Loop 2300 - Claim Information
  
  • Loop 2320
  • Loop 2330A
  • Loop 2330B
• Loop 2400 - Service Line Information
  • Loop 2430

Loops 2320 - Other Subscriber Information

Segment SBR - Subscriber

Example: SBR*P*18*93774*Silver*****CI~

• Element 01 = Previous Payer Responsibility (P)
  • P = Primary
• Element 02 = Relationship to Insured (18)
  • 01 = Spouse
  • 18 = Self
  • 19 = Child
  • G8 = Other
• Element 03 = Policy/Group Number (93774) Box 9a
• Element 04 = Plan/Program Box 9d
• Element 05 = Medicare Secondary Payer (MSP) code
  • 12 = Working Age
  • 13 = End-Stage Renal
  • 14 = No-Fault Including Auto
  • 15 = Workers Compensation
  • 16 = Public Health or Federal
  • 41 = Secondary Black Lung
  • 42 = Veterans Administration
  • 43 = Disabled Under 65
  • 47 = Other Liability is Primary
• Element 09 = Plan Type
  
  • 12 = Preferred Provider Organization (PPO)
  • 13 = Point of Service (POS)
  • 14 = Exclusive Provider Organization (EPO)
  • 16 = Health Maintenance Organization (HMO) Medicare Risk
  • AM = Automobile Medical
  • BL = Blue Cross/Blue Shield
  • CH = Champus
  • CI = Commercial Insurance Co.
  • DS = Disability
  • FI = Federal Employee Program
  • HM = Health Maintenance Organization (HMO)
  • MB = Medicare Part B
  • MC = Medicaid
  • OF = Other Federal Program
  • WC = Workers' Compensation Health Claim

Segment AMT - Amount

Example: AMT*D*62.50~

• Element 01 = Qualifier Code - Hardcoded to D for Amount Paid
• Element 02 = Monetary Amount ($62.50) Box 29

Segment OI - Other Information

Example: OI***Y***Y~

• Element 03 = Provider Benefits Assignment Certification (Y)
• Element 06 = Release of Information Code (Y)

Loop 2330A - Other Subscriber Name

Segment NM1 - Name

Example: NM1*IL*1*SPEARS*BRITNEY****MI*C8342837464~

• Element 01 = Hardcoded to IL for Insured
• Element 02 = Hardcoded to 1 for Person
• Element 03 = Last Name (Spears) Box 9
• Element 04 = First Name (Britney) Box 9
• Element 05 = Middle Name/Initial Box 9
• Element 07 = Suffix
• Element 08 = Identification Code Qualifier
  • MI = Member ID
• Element 09 = Identification Code (C8342837464)

Segment N3 - Street Address

Example: N3*398 W STAFFORD RD.~

• Element 01 = Street Address (398 W Stafford Rd.)
• Element 02 = Street Address 2

Segment N4 - City, State, and ZIP

Example: N4*THOUSAND OAKS*CA*91361~

• Element 01 = City (Thousand Oaks)
• Element 02 = State (California)
• Element 03 = ZIP (91361)

Loop 2330B - Other Payer Name

Segment NM1 - Name

Example: NM1*PR*2*UNITEDHEALTHCARE COMMUNITY PLAN*****PI*E3457~ 

• Element 01 = Hardcoded to PR for Payer
• Element 02 = Hardcoded to 2 for Organization
• Element 03 = Payer Name (UnitedHealthcare Community Plan)
• Element 08 = Hardcoded to PI for Payer ID
• Element 09 = Identification Code/Payer ID (E3457)

Loops 2430 - Line Adjudication Information

Segment SVD - Service Line Adjudication

Example: SVD*E3457*62.50*HC:97124:GP**1~

• Element 01 = Identification Code of Payer (E3457)
• Element 02 = Monetary Amount ($62.50)
• Element 03-1 = Hardcoded to HC for Standard CPT Code
• Element 03-2 = CPT Code (97124)
• Element 03-(3-6) = Modifier (GP)
• Element 03-7 = Description/Line Note
• Element 05 = Quantity (1)

Segment CAS - Claim Adjustment

Example: CAS*CO*45*10.00~

• Element 01 = Group Code (CO)
  • CO = Contractual Obligation
  • PR = Patient Responsibility
  • OA = Other Adjustment
  • CR = Claim Reversal
  • PI = Payer Initiated Reduction
• Element 02 = Reason/Remark Code (45)
  • 1 = Deductible
  • 2 = Coinsurance
  • 3 = Copay
  • 45 = Contracted Rate
  • 253 = Sequestration
• Element 03 = Monetary amount ($10)

DTP - Date

Example: DTP*573*D8*20180718~

• Element 01 = Hardcoded to 573 for Remittance Date
• Element 02 = Format - Hardcoded to D8
• Element 03 = Date YYYYMMDD (2018/07/20)

Segment AMT - Amount

Example: AMT*EAF*2.50~

• Element 01 = Hardcoded to EAF for Remaining Client Liability
• Element 02 = Monetary Amount ($2.50)