Features of EDI 837P- Part IV

HL Segment:

HL stands for  Hierarchical Level. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data. HL Segment  indicates Hierarchical Level of Provider, Subscriber or Patient.  This is why this segment is followed by PRV segment or SBR segment or PAT segment.

Hierarchical ID is a unique number assigned by the sender to identify a particular data segment in a hierarchical structure. The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

First HL segment code example:

HL*1**20*1~ (BILLING PROVIDER)

1 = HL sequence number

**(blank)= there is no parent HL (characteristic of the billing provider HL)

20 = information source

1 = there is at least one child HL to this HL

First HL segment is followed by PRV segment. Sample PRV segment-

PRV*BI*PXC*207ND0900X~

PRV01=BI refers to  Billing

PRV02=PXC refers to Health Care Provider Taxonomy code identifier.

PRV03=207ND0900X refers to Provider's Taxonomy code

Note: Taxonomy code refers to the provider type and area of specialization for health care providers. Each taxonomy code is a unique ten character alphanumeric code that enables providers to identify their specialty at the claim level. The taxonomy code 207ND0900X means Dermatology

Second HL segment code example:

HL*2*1*22*1~(SUBSCRIBER)

2 = HL sequence number

1 = parent HL

22 = subscriber

1 = there is at least one child HL to this HL.

Second HL segment is followed by SBR segment. Sample SBR segment-

SBR✽P✽18✽GRP01020102✽✽✽✽✽✽BL~

SBR01=Payer Responsibility Sequence Number Code, P=Primary. S=Secondary, T= Tertiary, A=Payer Responsibility Four

SBR02=Individual Relationship Code, 18=self

SBR03= policy or group number

SBR09=Code identifying type of claim, BL = Blue Cross/Blue Shield

Some other examples:

AM= Automobile Medical, BL=Blue Cross/Blue Shield, CH=Champus, CI=Commercial Insurance Co., DS=Disability, FI=Federal Employees Program, HM=Health Maintenance Organization, LM =Liability Medical, MA=Medicare Part A, MB= Medicare Part B, MC= Medicaid, OF=Other Federal Program, it is usually used for Medicare Part D claims, TV= Title V, VA=Veterans Affairs Plan, WC=Workers’ Compensation Health Claim, ZZ= Mutually Defined, Use Code ZZ when Type of Insurance is not known.

Third HL segment code example:

HL*3*2*23*0~(PATIENT)

3 = HL sequence number

2 = parent HL

23 = dependent

0 = no subordinate HLs in this HL (there is no child HL to this HL - claim level data follows)

Third HL segment is followed by PAT segment. Sample PAT segment-

PAT*19~

PAT01= Specifies the patient’s relationship to the person insured.

Some Relationship code examples-

01=Spouse, 19=Child, 20=Employee, 21=Unknown, 3= Organ Donor, 53=Life Partner, G8=Other Relationship