UCD Real Time 837D Claim Submission Results Interpretation
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- Alfred Hilmar Ibsen
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1 UCD Real Time 837D Claim Submission Results Interpretation Prepared by: Dental & Visions Systems (4/2/08) vmay 15, 2015
2 UCD REAL TIME 837D CLAIM SUBMISSION RESULTS INTERPRETATION This document provides UCD Trading Partners guidance for interpreting the UCD Real Time 837D Claim Submission Results flat file. This document contains: The Claim Submission Results Copybook (TFERC265) Business descriptions of the data elements Example of Approved Pending Finalized Claim Submission Results o Flat File o Copybook layout with data Example of Rejected Pending Finalized Claim Submission Results o Flat File o Copybook layout with data Example of Pending Claim Submission Results o Flat File o Copybook layout with data Definition of Terms: Claim Submission Results - a file returned to the submitter containing the adjudication results. Pending Finalized - A claim is considered Pending Finalized when it has been routed to a finalized location within the Concordia Claims System, but has not been run through RENO. The returned Claim Submission Results will be at the claim and line level. Pending - A claim is considered Pending when it has not been routed to a finalized location with the Concordia Claims System. The returned Claim Submission Results will be at the claim level.
3 Claim Submission Results Copybook (TFERC265) 02 TFERC265-FORMAT. 03 TFERC265-FIXED-DATA. 05 EDI-CNTL-ID. 08 RT-CONTROL-ID PIC X(32) 08 RESP-TO-SUBMITTER PIC X(02) 08 RT-ABK-ID PIC X(11) 08 FILLER PIC X(15) 05 ERROR-MESSAGE OCCURS 2 TIMES 08 MESSAGE-FIELD PIC X(80) 05 CLAIM-LEVEL-DATA. 08 ADO-ID PIC X(09) 08 HP-NPI-ID PIC X(10) 08 ABD-NAME. 10 ABD-FST-NAME PIC X(25) 10 ABD-MID-NAME PIC X(25) 10 ABD-LAST-NAME PIC X(35) 08 TOT-AFV-PRV-CHG PIC X(10) 08 ABK-ORIG-REC-DATE PIC X(10) 08 CAR-NAME PIC X(53) 08 CODE-507 PIC X(03) 08 CODE-508 PIC X(03) 08 ABR-RSN-CODE PIC X(05) 08 ABR-RSN-DESC PIC X(400) 05 LINE-LEVEL-DATA OCCURS 20 TIMES. 08 AFV-ID PIC X(02) 08 AFV-BGN-DATE PIC X(10) 08 AFV-END-DATE PIC X(10) 08 AFV-PRO-CODE PIC X(05) 08 AGD-CODE PIC X(02) 08 AFV-SVC-CNT PIC X(03) 08 TOOTH-NUM-SURF OCCURS 5 TIMES. 10 AFP-TTH-CODE PIC X(02) 10 AFN-CODE PIC X(06) 08 AFV-PRV-CRG-AMT PIC X(10) 08 AFV-ALW-CRG-AMT PIC X(10) 08 AFV-TOT-APV-AMT PIC X(10) 08 NON-CHARGE-DATA OCCURS 8 TIMES. 10 ANT-TYPE-CODE PIC X(03) 10 ANT-AMT PIC X(10) 10 ANT-DESC PIC X(45) 08 SUB-LIABILITY-DATA OCCURS 8 TIMES. 10 ANR-TYPE-CODE PIC X(03) 10 ANR-AMT PIC X(10) 10 ANR-DESC PIC X(45) 08 AF5-AMT PIC X(10) 08 AC1-RSN-CODE PIC X(05) 08 ACI-DESC PIC X(408) 08 CODE-507 PIC X(03) 08 CODE-508 PIC X(03)
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6 Approved Pending Finalized Claim Submission Results Flat File and Layout Example LVL FIELD NAME FORMAT PDS DATA 02 TFERC265-FORMAT G 1 03 TFERC265-FIXED-DATA G 1 05 EDI-CNTL-ID G 1 08 RT-CONTROL-ID C 32 1 E4D5E22CEFDE D20EBC411DC 08 RESP-TO-SUBMITTER C RT-ABK-ID C FILLER C MESSAGES(1) G 61 OCCURS 2 TIMES 08 MESSAGE-FIELD(1) C MESSAGES(2) G MESSAGE-FIELD(2) C CLAIM-LEVEL-DATA G ADO-ID C HP-NPI-ID C ABD-NAME G ABD-FST-NAME C APPROVED 10 ABD-MID-NAME C RT 10 ABD-LAST-NAME C CLAIM 08 TOT-AFV-PRV-CHG C ABK-ORIG-REC-DATE C CAR-NAME C United Concordia Companies Incorporated 08 CODE-507 C Fl 08 CODE-508 C ABR-RSN--CODE C ABR-RSN-DESC C
7 05 LINE-LEVEL-DATA(1) G 809 NOTE: This layout shows the starting OCCURS 20 TIMES position for only one 1) occurrence. 08 AFV-ID(1) C AFV-BGN-DATE(1) C /01/ AFV-END-DATE(1) C /01/ AFV-PRO-CODE(1) C D AGD-CODE(1) C AFV-SVC-CNT(1) C TOOTH-NUM-SURF(1,1) G 841 OCCURS 5 10 AFP-TTH-CODE(1,1) C AFN-CODE(1,1) C TOOTH-NUM-SURF(1,2) G AFP-TTH-CODE(1,2) C AFN-CODE(1,2) C TOOTH-NUM-SURF(1,3) G AFP-TTH-CODE(1,3) C AFN-CODE(1,3) C TOOTH-NUM-SURF(1A) G AFP-7TH-CODE(1,4) C AFN-CODE(1A) C TOOTH-NUM-SURF(1,5) G AFP-TTH-CODE(1,5) C AFN-CODE(1,5) C AFV-PRV-CRG-AMT(1) C AFV-ALW-CRG-AMT(1) C AFV-TOT-APV-AMT( 1) C NON-CHARGE-DATA(1,1) G 911 OCCURS 8 TIMES 10 ANT-TYPE-CODE(1,1) C ANT-AMT(1,1) C ANT-DESC(1,1) C NON-CHARGE-DATA(1,2) G ANT-TYPE-CODE(1,2) C ANT-AMT(1,2) C ANT-DESC(1,2) C NON-CHARGE-DATA(1,3) G ANT-TYPE-CODE(1,3) C ANT-AMT(1,3) C ANT-DESC(1,3) C NON-CHARGE-DATA(1,4) G ANT-TYPE-CODE(1,4) C ANT-AMT(1,4) C ANT-DESC(1,4) C NON-CHARGE-DATA(1,5) G ANT-TYPE-CODE(1,5) C ANT-AMT(1,5) C ANT-DESC(1,5) C NON-CHARGE-DATA(1,6) G ANT-TYPE-CODE(1,6) C ANT-AMT(1,6) C ANT-DESC(1,6) C
8 08 NON-CHARGE-DATA(1,7) G ANT-TYPE-CODE(1,7) C 10 ANT-AMT(1,7) C 10 ANT-DESC(1,7) C 08 NON-CHARGE-DATA(1,8) G 10 ANT-TYPE-CODE(1,8) C 10 ANT-AMT(1,8) C 10 ANT-DESC(1,8) C 08 SUB-LIABILITY-DATA(1,1) G OCCURS 8 10 ANR-TYPE-CODE(1,1) TIMES C 10 ANR-AMT(1,1) C 10 ANR-DESC(1,1) C 08 SUB-LIABILITY-DATA(1,2) G 10 ANR-TYPE-CODE(1,2) C 10 ANR-AMT(1,2) C 10 ANR-DESC(1,2) C 08 SU6-LIABILITY-DATA(1,3) G 10 ANR-TYPE-CODE(1,3) C 0 ANR-AMT(1,3) C 10 ANR-DESC(1,3) C 08 SUB-LIABILITY-DATA(1,4) G 10 ANR-TYPE-CODE(1,4) C 10 ANR-AMT(1,4) C 10 ANR-DESC(1,4) C 08 SU6-LIABILITY-DATA(1,5) G 10 ANR-TYPE-CODE(1,5) C 10 ANR-AMT(1,5) C 10 ANR-DESC(1,5) C 08 SUB-LIABILITY-DATA(1,5) G 10 ANR-TYPE-CODE(1,6) C 10 ANR-AMT(1,6) C 10 ANR-DESC(1,6) C 08 SUB-LIABILITY-DATA(1,7) G 10 ANR-TYPE-CODE(1,7) C 10 ANR-A1v1T(1,7) C 10 ANR-DESC(1,7) C 08 SUB-LIABILITY-DATA(1,8) G 10 MR-TYPE-CODE(1,8) C 10 ANR-AMT(1,8) C 10 ANR-DESC(1,8) C 08 AF5-AMT(1) C 08 AC1-RSN-CODE(1) C 08 AC1-DESC(1) C 08 CODE-507(1) C 08 CODE-508(1) C Fl
9 Rejected Pending Finalized Claim Submission Results Flat File and Layout Example LVL FIELD NAME FORMAT POS DATA 02 TFERC265-FORMAT 03 TFERC265-FIXED DATA 05 EDI-CNTL RT-CONTROL-ID C 32 1 E4D5F22CEFDE D2OEBC411DC 08 RESP-TO-SUBM1TTER C RT-ABK-ID C FILLER C MESSAGES(1) 61 OCCURS 2 TIMES 08 MESSAGE-FIELD(1) C MESSAGES(2) G MESSAGE-FIELD(2) C CLAIM-LEVEL-DATA G ADO-ID C HP-NPI-ID C ABD-NAME G ABD-FST-NAME C REJECT 10 ABD-MID-NAME C RT 10 ABD-LAST-NAME C CLAIM 08 TOT-AFV-PRV-CHG C ABK-ORIG-REC-DATE C CAR-NAME C United Concordia Companies Incorporated 08 CODE-507 C F2 08 CODE-508 C ABR-RSN-CODE C ASR-RSN-DESC C LINE-LEVEL-DATA(1) G 809 NOTE: This layout shows the starting OCCURS 20 TIMES position for only one (1) occurrence. 08 AFV-ID(1) C
10 08 AFV-BGN-DATE(1) C /01/ AFV-END-DATE(1) C /01/ AFV-PRO-CODE(1 ) C D AGD-CODE(1) C AFV-SVC-CNT(1) C TOOTH NUM-SURF(1,1) G 841 OCCURS 5 TIMES 10 AFP-TTH-CODE(1,1) C AFN-CODE(1,1) C TOOTH-NUM-SURF(1,2) G AFP-TTH-CODE(1,2) C AFN-CODE(1,2) C TOOTH-NUM-SURF(1,3) G AFP-TTH-CODE(1,3) C AFN-CODE(1,3) C TOOTH-NUM-SURF(1,4) G AFP-T'1H-CODE(1,4) C AFN-CODE(1,4) C TOOTH-NUM-SURF(1,5) G AFP-TTH-CODE(1,5) C AFN-CODE(1,5) C AFV-PRV-CRG-AMT(1) C AFV-ALW-CRG-AMT(1) C AFV-TOT-APV-AMT(1) C NON-CHARGE-DATA(1,1) G 911 OCCURS 8 TIMES 10 ANT-TYPE-CODE(1,1) C ANT-AMT(1,1) C ANT-DESC(1,1) C NON-CHARGE-DATA(1,2) G ANT-TYPE-CODE(1.2) C ANT-AMT(1,2) C ANT-DESC(1,2) C NON-CHARGE-DATA(1,3) G ANT-TYPE-CODE(1,3) C ANT-AMT(1,3) C ANT-DESC(1,3) C NON-CHARGE-DATA(1,4) G ANT-TYPE-CODE(1,4) C ANT-AMT(1,4) C ANT-DESC(1,4) C NON-CHARGE-DATA(1,5) G ANT-TYPE-CODE(1,5) C ANT-AMT(1,5) C ANT-DESC(1,5) C NON-CHARGE-DATA(1,6) G ANT-TYPE-CODE(1,6) C ANT-AMT(1,6) C ANT-DESC(1,6) C
11 08 NON-CHARGE-DATA(1,7) G ANT-TYPE-CODE(1,7) C ANT-AMT(1,7) C ANT-DESC(1,7) C NON-CHARGE-DATA(1,8) G ANT-TYPE-CODE(1,8) C ANT-AMT(1,8) ANT-DESC(1,8) C SLJB-LIABILITY- G 1375 OCCURS ( ) 8 10 ANR-TYPE-CODE(1,1) TIMES C ANR-AMT(1,1) C ANR-DESC(1,1) C SUB-LIABILITY-DATA(1,2) G ANR-TYPE-CODE(1,2) C ANR-AMT(1,2) C ANR-DESC(1,2) C SUB-LIAB1LITY-DATA(1,3) G ANR-TYPE-CODE(1,3) C ANR-AMT(1,3) C ANR-DESC(1,3) C SUB-LIABILITY-DATA(1,4) G ANR-TYPE-CODE(1,4) C ANR-AMT(1,4) C ANR-DESC(1,4) C SUB-LIABILITY-DATA(1,5) G ANR-TYPE-CODE(1,5) C ANR-AMT(1,5) C ANR-DESC(1,5) C SUB-LIABILITY-DATA(1,6) G ANR-TYPE-CODE(1.6) C ANR-AMT(1,6) C ANR-DESC(1,6) C SUB-LIABILITY-DATA(1,7) G ANR-TYPE-CODE(1,7) C ANR-AMT(1,7) C ANR-DESC(1,7) SUB-LIABIL1TY-DATA(1,8) G ANR-TYPE-CODE(1,8) C ANR-AMT(1,8) C ANR-DESC(1,8) C AF5-AMT(1) C AC1-RSN-CODE(1) H5152 No payment can be made. This is a duplicate service that was reported 08 AC1-DESC(1) C another claim. 08 CODE-507(1) C F2 08 CODE-508(1) C
12 Pending Claim Submission Results Flat File and Layout Example LVL FIELD NAME FORMAT POS 02 TFERC265-FORMAT DAT 03 TFERC265-FIXED-DATA 05 EDI-CNTL-ID G A 08 RT-CONTROL-ID C 32 1 E4D5E22CEFDE9658A4FD3FDOEBC411DC 08 RESP-TO-SUBMITTER C RT-ABK-ID C FILLER C MESSAGES(1) G 61 OCCURS 2 TIMES 08 MESSAGE-FIELD(1) C THIS CLAIM IS CURRENTLY IN PROCESS 05 MESSAGES(2) G MESSAGE-FIELD(2) C CLAIM-LEVEL-DATA G ADO-ID C HP-NPI-ID C ABD-NAME G ABD-FST-NAME C PENDING 10 ABD-MID-NAME C RT 10 ABD-LAST-NAME C CLAIM 08 TOT-AFV-PRV-CHG C ABK-ORIG-REC-DATE C CAR-NAME C United Concordia Companies Incorporated 08 CODE-507 C P1 08 CODE-508 C ABR-RSN-CODE C ABR-RSN-DESC C LINE-LEVEL-DATA(1) G 809 NOTE: No line level information is returned OCCURS 20 TIMES for a pending claim. 08 AFV-ID(1 ) C AFV-BGN-DATE(1) C AFV-END-DATE(1) C AFV-PRO-CODE(1) C AGD-CODE(1) C AFV-SVC-CNT(1) C TOOTH-NUM-SURF(1,1) G 841 OCCURS 5 TIMES 10 AFP-TTH-CODE(1,1) C AFN-CODE(1,1) C TOOTH-NUM-SURF(1,2) G AFP-TTH-CODE(1,2) C 2 849
13 10 AFN-CODE(1,2) C 08 TOOTH-NUM-SURF(1,3) G 10 AFP-ITH-CODE(1,3) C 10 AFN-CODE(1,3) C 08 TOOTH-NUM-SURF(1,4) G 10 AFP-TTH-CODE(1,4) C 10 AFN-CODE(1,4) C 08 TOOTH-NUM-SURF(1,5) G 10 AFP-TTH-CODE(1,5) C 10 AFN-CODE(1,5) C 08 AFV-PRV-CRG-AMT(1) C 08 AFV-ALW-CRG-AMT(1) C 08 AFV-TOT-APV-AMT(1) C 08 NON-CHARGE-DATA(1,1) G OCCURS 8 TIMES 10 ANT-TYPE-CODE(1,1) C 10 ANT-AMT(1,1) C 10 AN I-DESC(1,1) C 08 NON-CHARGEDATA(1,2) G 10 ANT-TYPE-CODE(1,2) C 10 ANT-AMT(1,2) C 10 ANT-DESC(1,2) C 08 NON-CHARGE-DATA(1,3) G 10 ANT-TYPE-CODE(1,3) C 10 ANT-AMT(1,3) C 10 ANT-DESC(1,3) C 08 NON-CHARGE-DATA(1,4) G 10 ANT-TYPE-CODE(1,4) C 10 ANT-AMT(1,4) C 10 ANT-DESC( 1,4) C 08 NON-CHARGE-DATA(1,5) G 10 ANT-TYPE-CODE(1,5) C 10 ANT-AMT(1,5) C 10 ANT-DESC(1,5) C 08 NON-CHARGE-DATA(1,6) G 10 ANT-TYPE-CODE(1.6) C 10 ANT-AMT(1,6) C 10 ANT-DESC(1,6) C 08 NON-CHARGE-DATA(1,7) G 10 ANT-TYPE-CODE(1,7) C 10 ANT-AMT(1,7) C 10 ANT- ESC(1,7) C 08 NON-CHARGE-DATA(1,8) G 10 ANT-TYPE-CODE(1,8) C 10 ANT-AMT(1,8) C 10 ANT-DESC(1,8) C
14 08 SUB-LIABILITY-DATA(1,1) G 1375 OCCURS 8 TIMES 10 ANR-TYPE-CODE(1.1) C ANR-AMT(1,1) C ANR-DESC(1,1) C SUB-LIABILITY-DATA(1,2) G ANR-TYPE-CODE(1,2) C ANR-AMT(1,2) C ANR-DESC(1,2) C S U B-L IABIL ITY-DATA( G ) ANR-TYPE-CODE(1,3) C ANR-AMT(1,3) C ANR-DESC(1,3) C SUB-LIABILITY-DATA(1,4) G ANR-TYPE-CODE(1,4) C ANR-AMT(1,4) C ANR-DESC(1,4) C SUB-LIABILITY-DATA(1,5) G ANR-TYPE-CODE(1,5) C ANR-AMT(1,5) C ANR-DESC(1,5) C SUB-LIABILITY-DATA(1,6) G ANR-TYPE-CODE(1,6) C ANR-AMT(1,6) C ANR-DESC(1,6) C SUB-E IABILITY DATA(1 10 ANR-TYPE-CODE(1,7) C ANR-AMT(1,7) C ANR-DESC(1,7) C SUB-LIABILITY-DATA(1,8) G ANR-TYPE-CODE(1,8) C ANR-AMT(1,8) C ANR-DESC(1,8) C AF5-AIMT(1) C AC1-RSN-CODE(1) C AC1-DESC(1) C CODE-507(1) C C8 CODE-508(1) C
15 UCD Real Time 837 Testing CTRL Default Claim Submission Results LVL FIELD NAME FORMAT POS DATA 02 TFERC265-FORMAT G 1 03 TFERC265-FIXED-DATA G 1 05 EDI-CNTL-ID G 1 08 RT-CONTROL-ID C RESP-TO-SUBMITTER C RT-ABK-1D C FILLER C MESSAGES(1) 0 61 OCCURS 2 TIMES 08 MESSAGE-FIELD(1) C MESSAGES(2) MESSAGE-FIELD(2) C CLAIM-LEVEL-DATA ADO-ID C HP-NPI-ID C ABD-NAME G ABD-FST-NAME C UCC IRT837D 10 A8D-MID-NAME C AM-LAST-NAME C DEFAULTCLAIMSUBMISSIONRESULT 08 TOT-AFV-PRV-CHG C ABK-ORIG-REC-DATE C CAR-NAME C United Concordia Companies Incorporated 08 CODE-507 C P1 08 CODE-508 C ABR-RSN-CODE C ABR-RSN-DESC C
16 05 LINE-LEVEL-DATA(1) G 809 NOTE: This layout shows the starting OCCURS 20 TIMES position for only one (1} occurrence. 08 AFV-1D(1) C AFV-BGN-DATE(1) C AFV-END-DAT E(1) C AFV-PRO-CODE(1) C AGD-CODE(1) C AFV-SVC-CNT(1) C TOOTH-NUM-SURF(1,1) G 841 OCCURS 5 TIMES 10 AFP-TTH-CODE(1,1) C AFN-CODE(1,1) C TOOTH-NUM-SURF(1,2) G AFP-TTH-CODE(1,2) C AFN-CODE(1,2) C TOOTH-NUM-SURF(1,3) G AFP-TTH-CODE(1,3) C AFN-CODE(1,3) C TOOTH-NUM-SURF(1 G AFP-TTH-CODE(1,4) C AFN-CODE(1,4) C TOOTH-NUM-SURF(1,5) G AFP-TTH-CODE(1,5) C AFN-CODE(1,5) C AFV-PRV-CRG-AMT(1) C AFV-ALW-CRG-AMT(1) C AFV-TOT-APV-AMT(1) C NON-CHARGE-DATA(1,1) G 911 OCCURS 8 TIMES 10 ANT-TYPE-CODE(1,1) C ANT-AMT(1,1) C ANT-DESC(1,1) C NON-CHARGE-DATA(1,2) G ANT-TYPE-CODE(1,2) C ANT-AMT(1,2) C ANT-DESC(1,2) C NON-CHARGE-DATA(1,3) G ANT-TYPE-CODE(1,3) C ANT-AMT(1,3) C ANT-DESC(1,3) C NON-CHARGE-DATA(1,4) G ANT-TYPE-CODE(1,4) C ANT-AMT(1,4) C ANT-DESC(1,4) C NON-CHARGE-DATA(1,5) G ANT-TYPE-CODE(1,5) C ANT-AMT(1,5) C ANT-DESC(1,5) C NON -CHARGE-DATA(1,6) G ANT-TYPE-CODE(1,6) C ANT-AMT(1,6) C ANT-DESC(1,6) C
17 08 NON-CHARGE-DATA(1,7) G ANT-TYPE-CODE(1,7) C ANT-AMT(1,7) 10 ANT C DESC(1,7) C NON-CHARGE-DATA(1,8) G ANT-TYPE-CODE(1,8) C ANT-AMT(1,8) 10 ANT C DESC(1,8) C SUB-LIABILITY-DATA(1,1) G 1375 OCCURS 8 TIMES 10 ANR-TYPE-CODE(1,1) C ANR-AMT(1,1) C ANR-DESC(1,1) C SUB-LIABILITY-DATA(1,2) G ANR-TYPE-CODE(1,2) C ANR-AMT(1,2) 10 ANR C DESC(1,2) C SUB-LIABILITY-DATA(1,3) G ANR-TYPE-CODE(1,3) C AN R-AMT(1,3) 10 C ANR-DESC(1,3) C SUB-LIABILITY-DATA(1,4) G ANR-TYPE-CODE(1,4) C ANR-AMT(1,4) 10 ANR C DESC(1,4) C SUB-LIABILITY-DATA(1,5) G ANR-TYPE-CODE(1,5) C ANR-AMT(1,5) 10 ANR C DESC(1,5) C SUS-LIABILITY-DATA(1,6) G ANR-TYPE-CODE(1,6) C ANR-AMT(1,6) 10 ANR C DESC(1,6) C SUB-LIABILITY-DATA(1,7) G ANR-TYPE-CODE(1,7) C ANR-AMT(1,7) 10 ANR C DESC(1,7) C SUB-LIABILITY-DATA(1,8) G ANR-TYPE-CODE(1,8) C ANR-AMT(1,8) 10 ANR C DESC(1,8) C AF5-AMT(1) C ,00 08 AC1-RSN-CODE(1) C AC1-DESC(1) C CODE-507(1) C P1 08 CODE-508(1) C
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