837 vs CMS-1500: Inclusion Rules

When a claim is submitted electronically, the system will still allow you to generate a CMS-1500 version of your submission. However, the information that you see on the CMS-1500 might not exactly reflect what was submitted electronically. The system uses different sets of rules when creating a CMS-1500 and when creating an EDI file. Let's review the differences.

Box 5 and 7

When you create a claim, the client's and insured's phone numbers are displayed in Box 5 and 7, respectively. However, these phone numbers are not included in the 837 file.

Box 9, 9a, and 9d - Primary Claims

When you submit a claim to a primary insurance and the client has a secondary insurance, that secondary information will populate Box 9, 9a, and 9d. However, this information is not included in the 837 file.

Box 24j Shaded

In order to populate the shaded portion of Box 24j, there needs to be a REF segment in Loop 2310B. However, there are instances when the system can be coded to use the PRV segment of this loop instead. This is the case with the Medicaid plan type. The WebPT Support team constantly reviews EDI requirements for payers and their plan types and updates the format accordingly.

Box 26

Based on Insurance Company Settings, the CMS-1500 will show one of the following:

• Insured's Primary ID
• Patient's SSN
• Patient's External ID
• Medical Record Number

The 837 file will always use a unique Claim Identifier in lieu of this field to assist with ERA matching.

Box 29

When a claim is submitted to a secondary or other additional payers, the amount paid that has been paid will populate into Box 29. If the additional payer is Medicare, this field will be populated as 0.00 according to their specifications.

While it may reflect as being unpaid on the CMS-1500, the 837 file will include the payment information from the previous payers along with the corresponding remark codes.

Box 33b

By default, the Billing Provider's taxonomy will populate Box 33b on a CMS-1500. Per Medicaid plan type requirements, a PRV segment will be generated in loop 2000A to include this information in the 837 file.

If Box 33b needs to be included electronically for other payers and plan types, a Box 33 Edit can be made to create an additional REF segment in loop 2010AA (although it will appear directly before Loop 2300).

However, if 33b needs to be included in the PRV segment for a payer other then Medicaid, send a request to support@webpt.com.