Chonk
/
Carle 278 Incoming - chonk
  • Specification
  • EDI Inspector
Import guide into your account
Chonk

X12 278 Carle 278 Incoming - chonk

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.

Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
  • None included
View the latest version of this implementation guide as an interactive webpage
https://www.stedi.com/app/guides/view/chonk/carle-278-incoming-chonk/01GJJGBYWN99967F4YBJVYK7J0
Powered by
Build EDI implementation guides at stedi.com
Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
HL - Loop ID 2000A - Utilization Management Organization Level
HL
0100
Hierarchical Level
Max use 1
Required
HL - Loop 2000B - Requester Level
HL
0100
Hierarchical Level
Max use 1
Required
HL - Loop 2000C - Subscriber Level
HL
0100
Hierarchical Level
Max use 1
Required
HL - Loop 2000D - Dependent Level
HL
0100
Hierarchical Level
Max use 1
Required
SE
2800
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

To start and identify an interchange of zero or more functional groups and interchange-related control segments

Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Authorization Information

00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Security Information

00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 15

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

ISA-07
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 15

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format

Date of the interchange

ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format

Time of the interchange

ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

^
Repetition Separator
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)

Code specifying the version number of the interchange control segments

00501
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA-13
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
Min 1Max 1

Code indicating sender's request for an interchange acknowledgment

0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

>
Component Element Separator

Functional Group Header

RequiredMax use 1

To indicate the beginning of a functional group and to provide control information

Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)

Code identifying a group of application related transaction sets

HI
Health Care Services Review Information (278)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

Code identifying party sending transmission; codes agreed to by trading partners

GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15

Code identifying party receiving transmission; codes agreed to by trading partners

GS-04
373
Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 2

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

005010
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

To indicate the start of a transaction set and to assign a control number

Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)

Code uniquely identifying a Transaction Set

  • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
278
Health Care Services Review Information
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set.

Must match SE02

ST-03
1705
Implementation Convention Reference
Optional
String (AN)
Min 1Max 35

Reference assigned to identify Implementation Convention

  • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
BHT
0200
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

0007
Information Source, Information Receiver, Subscriber, Dependent, Event, Services
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

13
Request
BHT-03
127
Reference Identification (EMR transaction ID)
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
  • Janus: EPIC transaction EMR
BHT-04
373
Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

  • BHT04 is the date the transaction was created within the business application system.
BHT-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

  • BHT05 is the time the transaction was created within the business application system.
Heading end

Detail

HL HL - Loop ID 2000A - Utilization Management Organization Level
RequiredMax >1
HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
20
Information Source
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
NM1 NM1 - Loop ID 2010A - Payer Name
RequiredMax >1
NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > NM1 - Loop ID 2010A - Payer Name > NM1

NM1 - Segment - Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
NM1-01
98
Entity Identifier Code (Payer name)
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

X3
Utilization Management Organization
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Payer Name
Required
String (AN)
Min 1Max 60

Healthcare plan/payer name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

PI
Payor Identification
NM1-09
67
Identification Code - Payer ID
Required
String (AN)
Min 2Max 80

Payer ID

NM1 NM1 - Loop ID 2010A - Payer Name end
HL HL - Loop 2000B - Requester Level
RequiredMax >1
HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
21
Information Receiver
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
NM1 NM1 - Loop ID 2010B - Requester Name
RequiredMax >1

The requester name, in this case the Ordering or Referring Provider.

NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > NM1 - Loop ID 2010B - Requester Name > NM1

NM1 - Segment - Requester Name

RequiredMax use 1

The requester is the Ordering or Referring Provider.

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

1P
Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
Min 1Max 1

Code qualifying the type of entity

  • NM102 qualifies NM103.
NM1-03
1035
Name Last or Organization Name
Required
String (AN)
Min 1Max 60

Referring Provider (provider submitting the patient event/referral)

NM1-04
1036
Name First
Required
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Name Middle
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure. See page 24 of https://www.cms.gov/files/document/esmd-x12n-278-companion-guide.pdf

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Identification Code - Provider NPI
Required
String (AN)
Min 2Max 80

National Provider ID (NPI)

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > NM1 - Loop ID 2010B - Requester Name > REF

Reference Information

OptionalMax use 9

To specify identifying information

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number
ZH
Carrier Assigned Reference Number
REF-02
127
Reference Identification
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

N3
2000
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > NM1 - Loop ID 2010B - Requester Name > N3

Party Location

OptionalMax use 1

To specify the location of the named party

Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Address Information
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > NM1 - Loop ID 2010B - Requester Name > N4

Geographic Location

OptionalMax use 1

To specify the geographic place of the named party

Example
N4-01
19
City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
State or Province Code
Required
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Postal Code
Required
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

PER
2200
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > NM1 - Loop ID 2010B - Requester Name > PER

Administrative Communications Contact

OptionalMax use 3

To identify a person or office to whom administrative communications should be directed

Example
If either Communication Number Qualifier (PER-03) or Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
Min 2Max 2

Code identifying the major duty or responsibility of the person or group named

PER-02
93
Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

TE
Telephone
PER-04
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PRV
2400
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > NM1 - Loop ID 2010B - Requester Name > PRV

Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
Min 1Max 3

Code identifying the type of provider

NM1 NM1 - Loop ID 2010B - Requester Name end
HL HL - Loop 2000C - Subscriber Level
RequiredMax >1
HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
22
Subscriber
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
NM1 NM1 - Loop 2010C - Subscriber Name
RequiredMax >1
NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > NM1 - Loop 2010C - Subscriber Name > NM1

NM1 - Segment - Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
Min 1Max 1

Code qualifying the type of entity

  • NM102 qualifies NM103.
NM1-03
1035
Name Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Name First
Required
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Name Middle
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-08
66
NM108 - Element - Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

MI
Member Identification Number
NM1-09
67
Subscriber Member Number
Required
String (AN)
Min 2Max 80

Dependent’s member ID, if different than the subscriber’s ID

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > NM1 - Loop 2010C - Subscriber Name > REF

Reference Information

OptionalMax use 9

To specify identifying information

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
Min 2Max 3

Code qualifying the Reference Identification

REF-02
127
Reference Identification
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF-03
352
Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

N3
2000
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > NM1 - Loop 2010C - Subscriber Name > N3

Party Location

OptionalMax use 1

To specify the location of the named party

Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > NM1 - Loop 2010C - Subscriber Name > N4

Geographic Location

OptionalMax use 1

To specify the geographic place of the named party

Example
DMG
2500
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > NM1 - Loop 2010C - Subscriber Name > DMG

Demographic Information

RequiredMax use 1

To supply demographic information

Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
DMG - Subscriber Date of Birth
Required
String (AN)
Min 1Max 35

Subscriber Date of Birth

DMG-03
1068
Gender Code
Required
Identifier (ID)
Min 1Max 1

Code indicating the sex of the individual

INS
2600
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > NM1 - Loop 2010C - Subscriber Name > INS

Insured Benefit

OptionalMax use 1

To provide benefit information on insured entities

Example
INS-01
1073
Yes/No Condition or Response Code
Required
Identifier (ID)
Min 1Max 1

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)
Min 2Max 2

Code indicating the relationship between two individuals or entities

NM1 NM1 - Loop 2010C - Subscriber Name end
HL HL - Loop 2000D - Dependent Level
OptionalMax >1

Dependent Level

Variants (all may be used)
HL - Loop 2000E - Patient Event Level
HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
23
Dependent
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
NM1 NM1 - Loop 2010D - Dependent Name
RequiredMax >1
NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > NM1 - Loop 2010D - Dependent Name > NM1

NM1 - Segment - Dependent Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
If either Identification Code Qualifier (NM1-08) or Identification Code (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

QC
Patient
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Name Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Name First
Required
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Name Middle
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
Min 1Max 2

Code designating the system/method of code structure used for Identification Code (67)

NM1-09
67
Identification Code
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

DMG
2500
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > NM1 - Loop 2010D - Dependent Name > DMG

Demographic Information

RequiredMax use 1

To supply demographic information

Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
DMG02 - Element - Dependent Date of Birth
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • DMG02 is the date of birth.
DMG-03
1068
Gender Code
Required
Identifier (ID)
Min 1Max 1

Code indicating the sex of the individual

INS
2600
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > NM1 - Loop 2010D - Dependent Name > INS

Insured Benefit

OptionalMax use 1

To provide benefit information on insured entities

Example
INS-01
1073
Yes/No Condition or Response Code
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
N
Insured is a dependent
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

01
Spouse
19
Child
G8
Other Relationship
NM1 NM1 - Loop 2010D - Dependent Name end
HL HL - Loop 2000E - Patient Event Level
RequiredMax >1

patient event loop

HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
EV
Event
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
TRN
0200
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > TRN

Trace

RequiredMax use 9

To uniquely identify a transaction to an application

Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers
TRN-02
127
TRN02 - Element - Epic Referral (RFL) ID - Reference Identification
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Originating Company Identifier
Optional
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
TRN-04
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • TRN04 identifies a further subdivision within the organization.
UM
0400
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > UM

Health Care Services Review Information

RequiredMax use 1

To specify health care services review information

Example
UM-01
1525
Request Category Code
Required
Identifier (ID)

Code indicating a type of request

AR
Admission Review
HS
Health Services Review
UM-02
1322
Certification Type Code
Optional
Identifier (ID)

Code indicating the type of certification

I
Initial
UM-03
1365
Service Type Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the classification of service

UM-04
C023
Health Care Service Location Information
OptionalMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Facility Code Value
Required
String (AN)
Min 1Max 2

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)

Code identifying the type of facility referenced

A
Uniform Billing Claim Form Bill Type
B
Place of Service Codes for Professional or Dental Services
UM-09
1363
Release of Information Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

DTP
0700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > DTP

DTP - Segment - Service Date

RequiredMax use 9

To specify any or all of a date, a time, or a time period

Example
DTP-01
374
Date/Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

AAH
Event
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Date Time Period
Required
String (AN)
Min 1Max 35

Default to today's date if visit is not scheduled

HI
0800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > HI

HI - Segment - Patient Diagnosis - Health Care Information Codes

OptionalMax use 1

Patient Diagnosis codes

Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-05
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-06
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-07
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-08
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-09
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-10
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-11
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-12
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HSD
0900
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > HSD

Health Care Services Delivery

OptionalMax use 1

To specify the delivery pattern of health care services

Example
HSD-01
673
Quantity Qualifier
Required
Identifier (ID)

Code specifying the type of quantity

VS
Visits
HSD-02
380
Quantity
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

MSG
1600
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > MSG

Message Text

RequiredMax use 1

To provide a free-form format that allows the transmission of text information

Example
MSG-01
933
Patient MRN
Required
String (AN)
Min 1Max 264

Patient MRN

MSG
1600
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > MSG

Message Text

OptionalMax use 1

To provide a free-form format that allows the transmission of text information

Example
Variants (all may be used)
MSGMessage Text
MSG-01
933
Precertification Status
Required
String (AN)
Min 1Max 264
PRECERT REQUIRED=(YES|NO) RegEx pattern

Patient MRN

NM1 NM1 - Loop 2010EA - Provider Name
OptionalMax >1

Provider Name (part of the Patient Event Loop 2000E)

NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > NM1

NM1 - Segment - Provider Name

RequiredMax use 1

To supply the full name of a provider.

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational facility

77
Service Location
SJ
Service Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Name Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Name First
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Name Middle
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
National Provider ID (NPI)
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > REF

Reference Information

OptionalMax use 9

To specify identifying information

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
Min 2Max 3

Code qualifying the Reference Identification

REF-02
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

N3
2000
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > N3

N3 - Segment - Provider Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Address Information
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > N4

N4 - Segment - Patient Event Provider City, State, Zip Code

RequiredMax use 1

To specify the geographic place of the named party

Example
N4-01
19
City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
State or Province Code
Required
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Postal Code
Required
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

PER
2200
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > PER

Administrative Communications Contact

OptionalMax use 3

To identify a person or office to whom administrative communications should be directed

Example
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

IC
Information Contact
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PRV
2400
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > PRV

Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
Min 1Max 3

Code identifying the type of provider

NM1 NM1 - Loop 2010EA - Provider Name end
NM1 NM1 - Loop 2010EA - Service Facility Name
OptionalMax >1

Service Facility Name (part of the Patient Event Loop 2000E)

Variants (all may be used)
NM1 - Loop 2010EA - Provider Name
NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > NM1

NM1 - Segment - Service Facility Name

RequiredMax use 1

To supply the full name of a service facility.

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational facility

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Name Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Service Facility National Provider ID (NPI)
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > REF

REF - Segment - Service Facility Tax ID

OptionalMax use 9

To specify identifying information

Example
Variants (all may be used)
REFReference Information
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
Min 2Max 3

Code qualifying the Reference Identification

REF-02
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > REF

Reference Information

OptionalMax use 9

To specify identifying information

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number
REF-02
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

N3
2000
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > N3

N3 - Segment - Service Facility Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Address Information
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > N4

N4 - Segment - Service Facility City, State, Zip Code

RequiredMax use 1

To specify the geographic place of the named party

Example
N4-01
19
City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
State or Province Code
Required
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Postal Code
Required
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

PER
2200
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > PER

Administrative Communications Contact

OptionalMax use 3

To identify a person or office to whom administrative communications should be directed

Example
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

IC
Information Contact
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PRV
2400
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > PRV

Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
Min 1Max 3

Code identifying the type of provider

NM1 NM1 - Loop 2010EA - Service Facility Name end
HL HL - Loop 2000F - Service Level
RequiredMax >1

Service Level

HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > HL - Loop 2000F - Service Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
SS
Services
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
SV1
0810
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > HL - Loop 2000F - Service Level > SV1

Professional Service

OptionalMax use 1

To specify the service line item detail for a health care professional

Example
If either Unit or Basis for Measurement Code (SV1-03) or Quantity (SV1-04) is present, then the other is required
SV1-01
C003
Composite Medical Procedure Identifier
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product/Service ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

C003-02
234
Product/Service ID
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

SV1-03
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)
Min 2Max 2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SV1-04
380
Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

SV2
0820
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000D - Dependent Level > HL - Loop 2000E - Patient Event Level > HL - Loop 2000F - Service Level > SV2

Institutional Service

OptionalMax use 1

To specify the service line item detail for a health care institution

Example
SV2-01
234
Product/Service ID
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • SV201 is the revenue code.
SV2-02
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product/Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
C003-02
234
SV201 - C003-02 - CPT or HCPCS Code
Required
String (AN)
Min 1Max 48

Composite element containing either a CPT or HCPCS code.

HL HL - Loop 2000F - Service Level end
HL HL - Loop 2000E - Patient Event Level end
HL HL - Loop 2000D - Dependent Level end
HL HL - Loop 2000E - Patient Event Level
OptionalMax >1

patient event loop

Variants (all may be used)
HL - Loop 2000D - Dependent Level
HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
EV
Event
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
TRN
0200
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > TRN

Trace

RequiredMax use 9

To uniquely identify a transaction to an application

Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers
TRN-02
127
TRN02 - Element - Epic Referral (RFL) ID - Reference Identification
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Originating Company Identifier
Optional
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
TRN-04
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • TRN04 identifies a further subdivision within the organization.
UM
0400
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > UM

Health Care Services Review Information

RequiredMax use 1

To specify health care services review information

Example
UM-01
1525
Request Category Code
Required
Identifier (ID)

Code indicating a type of request

AR
Admission Review
HS
Health Services Review
UM-02
1322
Certification Type Code
Optional
Identifier (ID)

Code indicating the type of certification

I
Initial
UM-03
1365
Service Type Code
Optional
Identifier (ID)
Min 1Max 2

Code identifying the classification of service

UM-04
C023
Health Care Service Location Information
OptionalMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Facility Code Value
Required
String (AN)
Min 1Max 2

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)
Min 1Max 2

Code identifying the type of facility referenced

UM-09
1363
Release of Information Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

DTP
0700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > DTP

DTP - Segment - Service Date

RequiredMax use 9

To specify any or all of a date, a time, or a time period

Example
DTP-01
374
Date/Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

AAH
Event
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Date Time Period
Required
String (AN)
Min 1Max 35

Default to today's date if visit is not scheduled

HI
0800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > HI

HI - Segment - Patient Diagnosis - Health Care Information Codes

OptionalMax use 1

Patient Diagnosis codes

Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-05
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-06
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-07
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-08
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-09
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-10
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-11
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HI-12
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

HSD
0900
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > HSD

Health Care Services Delivery

OptionalMax use 1

To specify the delivery pattern of health care services

Example
HSD-01
673
Quantity Qualifier
Required
Identifier (ID)
Min 2Max 2

Code specifying the type of quantity

HSD-02
380
Quantity
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

MSG
1600
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > MSG

Message Text

RequiredMax use 1

To provide a free-form format that allows the transmission of text information

Example
Variants (all may be used)
MSGMessage Text
MSG-01
933
Patient MRN
Required
String (AN)
Min 1Max 264

Patient MRN

MSG
1600
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > MSG

Message Text

OptionalMax use 1

To provide a free-form format that allows the transmission of text information

Example
Variants (all may be used)
MSGMessage Text
MSG-01
933
Precertification Status
Required
String (AN)
Min 1Max 264
PRECERT REQUIRED=(YES|NO) RegEx pattern

Free-form message text

NM1 NM1 - Loop 2010EA - Provider Name
OptionalMax >1

Provider Name (part of the Patient Event Loop 2000E)

NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > NM1

NM1 - Segment - Provider Name

RequiredMax use 1

To supply the full name of a provider.

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
SJ
Service Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Name Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Name First
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Name Middle
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Identification Code
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > REF

Reference Information

OptionalMax use 9

To specify identifying information

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
Min 2Max 3

Code qualifying the Reference Identification

REF-02
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

N3
2000
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > N3

N3 - Segment - Provider Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Address Information
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > N4

N4 - Segment - Patient Event Provider City, State, Zip Code

RequiredMax use 1

To specify the geographic place of the named party

Example
N4-01
19
City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
PER
2200
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > PER

Administrative Communications Contact

OptionalMax use 3

To identify a person or office to whom administrative communications should be directed

Example
If either Communication Number Qualifier (PER-03) or Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
Min 2Max 2

Code identifying the major duty or responsibility of the person or group named

PER-02
93
Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-04
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-09
443
Contact Inquiry Reference
Optional
String (AN)
Min 1Max 20

Additional reference number or description to clarify a contact number

PRV
2400
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Provider Name > PRV

Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
Min 1Max 3

Code identifying the type of provider

NM1 NM1 - Loop 2010EA - Provider Name end
NM1 NM1 - Loop 2010EA - Service Facility Name
OptionalMax >1
Variants (all may be used)
NM1 - Loop 2010EA - Provider Name
NM1
1700
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > NM1

NM1 - Segment - Service Facility Name

RequiredMax use 1

To supply the full name of a provider.

Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Name Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Identification Code
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > REF

REF - Segment - Service Facility Tax ID

OptionalMax use 9

To specify identifying information

Example
Variants (all may be used)
REFReference Information
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
Min 2Max 3

Code qualifying the Reference Identification

REF-02
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
1800
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > REF

Reference Information

OptionalMax use 9

To specify identifying information

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number
REF-02
127
Reference Identification
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

N3
2000
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > N3

N3 - Segment - Service Facility Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Address Information
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > N4

N4 - Segment - Service Facility City, State, Zip Code

RequiredMax use 1

To specify the geographic place of the named party

Example
N4-01
19
City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
State or Province Code
Required
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Postal Code
Required
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

PER
2200
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > PER

Administrative Communications Contact

OptionalMax use 3

To identify a person or office to whom administrative communications should be directed

Example
If either Communication Number Qualifier (PER-03) or Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
Min 2Max 2

Code identifying the major duty or responsibility of the person or group named

PER-02
93
Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-04
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
Min 2Max 2

Code identifying the type of communication number

PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-09
443
Contact Inquiry Reference
Optional
String (AN)
Min 1Max 20

Additional reference number or description to clarify a contact number

PRV
2400
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > NM1 - Loop 2010EA - Service Facility Name > PRV

Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
Min 1Max 3

Code identifying the type of provider

NM1 NM1 - Loop 2010EA - Service Facility Name end
HL HL - Loop 2000F - Service Level
RequiredMax >1

Service Level

HL
0100
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > HL - Loop 2000F - Service Level > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

  • HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

  • HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
SS
Services
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

Code indicating if there are hierarchical child data segments subordinate to the level being described

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
SV1
0810
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > HL - Loop 2000F - Service Level > SV1

Professional Service

OptionalMax use 1

To specify the service line item detail for a health care professional

Example
SV1-01
C003
Composite Medical Procedure Identifier
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product/Service ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

C003-02
234
Product/Service ID
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

SV1-03
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)
Min 2Max 2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SV1-04
380
Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

SV2
0820
Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL - Loop 2000C - Subscriber Level > HL - Loop 2000E - Patient Event Level > HL - Loop 2000F - Service Level > SV2

Institutional Service

OptionalMax use 1

To specify the service line item detail for a health care institution

Example
HL HL - Loop 2000F - Service Level end
HL HL - Loop 2000E - Patient Event Level end
HL HL - Loop 2000C - Subscriber Level end
HL HL - Loop 2000B - Requester Level end
HL HL - Loop ID 2000A - Utilization Management Organization Level end
SE
2800
Detail > SE

Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Example
SE-01
96
Number of Included Segments
Required
Numeric (N0)
Min 1Max 10

Total number of segments included in a transaction set including ST and SE segments

SE-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Detail end

Functional Group Trailer

RequiredMax use 1

To indicate the end of a functional group and to provide control information

Example
GE-01
97
Number of Transaction Sets Included
Required
Numeric (N0)
Min 1Max 6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

GE-02
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Example
IEA-01
I16
Number of Included Functional Groups
Required
Numeric (N0)
Min 1Max 5

A count of the number of functional groups included in an interchange

IEA-02
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.