Chonk 278 Carle 278 Incoming - chonk

Reference Identification (EMR transaction ID)

Required

String (AN)

Min 1Max 50

—

BHT-04

373

Date

Required

Date (DT)

CCYYMMDD format

—

BHT-05

337

Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

Heading end

Detail

HL HL - Loop ID 2000A - Utilization Management Organization Level

RequiredMax >1

0100

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

Hierarchical Level

RequiredMax use 1

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

20: Information Source

Hierarchical Child Code

Optional

Identifier (ID)

—

1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 NM1 - Loop ID 2010A - Payer Name

RequiredMax >1

1700

Detail > HL - Loop ID 2000A - Utilization Management Organization Level > NM1 - Loop ID 2010A - Payer Name > NM1

NM1 - Segment - Payer Name

RequiredMax use 1

—

Example

Entity Identifier Code (Payer name)

Required

Identifier (ID)

—

X3: Utilization Management Organization

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

Payer Name

Required

String (AN)

Min 1Max 60

—

Identification Code Qualifier

Required

Identifier (ID)

—

PI: Payor Identification

Identification Code - Payer ID

Required

String (AN)

Min 2Max 80

—

NM1 NM1 - Loop ID 2010A - Payer Name end

HL HL - Loop 2000B - Requester Level

RequiredMax >1

0100

Detail > HL - Loop ID 2000A - Utilization Management Organization Level > HL - Loop 2000B - Requester Level > HL

Hierarchical Level

RequiredMax use 1

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

21: Information Receiver

Hierarchical Child Code

Optional

Identifier (ID)

—

1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 NM1 - Loop ID 2010B - Requester Name

RequiredMax >1

—

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

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

1P: Provider

Entity Type Qualifier

Required

Identifier (ID)

Min 1Max 1

—

Name Last or Organization Name

Required

String (AN)

Min 1Max 60

—

Name First

Required

String (AN)

Min 1Max 35

—

Name Middle

Optional

String (AN)

Min 1Max 25

—

Identification Code Qualifier

Required

Identifier (ID)

—

XX: Centers for Medicare and Medicaid Services National Provider Identifier

Identification Code - Provider NPI

Required

String (AN)

Min 2Max 80

—

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

—

Example

Reference Identification Qualifier

Required

Identifier (ID)

—

EI: Employer's Identification Number
ZH: Carrier Assigned Reference Number

Reference Identification

Required

String (AN)

Min 1Max 50

—

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

—

Example

Address Information

Required

String (AN)

Min 1Max 55

—

Address Information

Optional

String (AN)

Min 1Max 55

—

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

—

Example

City Name

Required

String (AN)

Min 2Max 30

—

State or Province Code

Required

Identifier (ID)

Min 2Max 2

—

Postal Code

Required

Identifier (ID)

Min 3Max 15

—

N4-04

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

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

—

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

Contact Function Code

Required

Identifier (ID)

Min 2Max 2

—

PER-02

Name

Optional

String (AN)

Min 1Max 60

—

Communication Number Qualifier

Optional

Identifier (ID)

—

TE: Telephone

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-05

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

PER-06

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-07

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

PER-08

Communication Number

Optional

String (AN)

Min 1Max 256

—

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

—

Example

Provider Code

Required

Identifier (ID)

Min 1Max 3

—

NM1 NM1 - Loop ID 2010B - Requester Name end

HL HL - Loop 2000C - Subscriber Level

RequiredMax >1

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

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

22: Subscriber

Hierarchical Child Code

Optional

Identifier (ID)

—

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

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

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

IL: Insured or Subscriber

Entity Type Qualifier

Required

Identifier (ID)

Min 1Max 1

—

Name Last or Organization Name

Required

String (AN)

Min 1Max 60

—

Name First

Required

String (AN)

Min 1Max 35

—

Name Middle

Optional

String (AN)

Min 1Max 25

—

NM108 - Element - Identification Code Qualifier

Required

Identifier (ID)

—

MI: Member Identification Number

Subscriber Member Number

Required

String (AN)

Min 2Max 80

—

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

—

Example

Reference Identification Qualifier

Required

Identifier (ID)

Min 2Max 3

—

Reference Identification

Required

String (AN)

Min 1Max 50

—

REF-03

352

Description

Optional

String (AN)

Min 1Max 80

—

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

—

Example

Address Information

Required

String (AN)

Min 1Max 55

—

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

—

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

—

Example

DMG-01

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

HL - Loop 2000E - Patient Event Level

DMG - Subscriber Date of Birth

Required

String (AN)

Min 1Max 35

—

DMG-03

1068

Gender Code

Required

Identifier (ID)

Min 1Max 1

—

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

—

Example

INS-01

1073

Yes/No Condition or Response Code

Required

Identifier (ID)

Min 1Max 1

—

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

Min 2Max 2

—

NM1 NM1 - Loop 2010C - Subscriber Name end

HL HL - Loop 2000D - Dependent Level

OptionalMax >1

—

Variants (all may be used)

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

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

23: Dependent

Hierarchical Child Code

Optional

Identifier (ID)

—

1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 NM1 - Loop 2010D - Dependent Name

RequiredMax >1

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

—

Example

If either Identification Code Qualifier (NM1-08) or Identification Code (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

QC: Patient

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

Name Last or Organization Name

Required

String (AN)

Min 1Max 60

—

Name First

Required

String (AN)

Min 1Max 35

—

Name Middle

Optional

String (AN)

Min 1Max 25

—

Identification Code Qualifier

Optional

Identifier (ID)

Min 1Max 2

—

Identification Code

Optional

String (AN)

Min 2Max 80

—

DMG

2500

Demographic Information

RequiredMax use 1

—

Example

DMG-01

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

DMG02 - Element - Dependent Date of Birth

Required

String (AN)

Min 1Max 35

—

DMG-03

1068

Gender Code

Required

Identifier (ID)

Min 1Max 1

—

INS

2600

Insured Benefit

OptionalMax use 1

—

Example

INS-01

1073

Yes/No Condition or Response Code

Required

Identifier (ID)

—

N: Insured is a dependent

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

—

01: Spouse
19: Child
G8: Other Relationship

NM1 NM1 - Loop 2010D - Dependent Name end

HL HL - Loop 2000E - Patient Event Level

RequiredMax >1

—

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

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

EV: Event

Hierarchical Child Code

Optional

Identifier (ID)

—

1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

TRN

0200

Trace

RequiredMax use 9

—

Example

TRN-01

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

TRN-02

TRN02 - Element - Epic Referral (RFL) ID - Reference Identification

Required

String (AN)

Min 1Max 50

—

TRN-03

509

Originating Company Identifier

Optional

String (AN)

Min 10Max 10

—

TRN-04

Reference Identification

Optional

String (AN)

Min 1Max 50

—

0400

Health Care Services Review Information

RequiredMax use 1

—

Example

UM-01

1525

Request Category Code

Required

Identifier (ID)

—

AR: Admission Review
HS: Health Services Review

UM-02

1322

Certification Type Code

Optional

Identifier (ID)

—

I: Initial

UM-03

1365

Service Type Code

Optional

Identifier (ID)

Min 1Max 2

—

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

—

C023-02

1332

Facility Code Qualifier

Required

Identifier (ID)

—

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

—

DTP

0700

DTP - Segment - Service Date

RequiredMax use 9

—

Example

DTP-01

374

Date/Time Qualifier

Required

Identifier (ID)

—

AAH: Event

DTP-02

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTP-03

Date Time Period

Required

String (AN)

Min 1Max 35

—

0800

HI - Segment - Patient Diagnosis - Health Care Information Codes

OptionalMax use 1

—

Example

HI-01

Health Care Code Information

RequiredMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-02

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-03

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-04

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-05

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-06

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-07

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-08

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-09

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-10

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-11

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-12

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HSD

0900

Health Care Services Delivery

OptionalMax use 1

—

Example

HSD-01

673

Quantity Qualifier

Required

Identifier (ID)

—

VS: Visits

HSD-02

Quantity

Required

Decimal number (R)

Min 1Max 15

—

1600

Message Text

RequiredMax use 1

—

Example

Variants (all may be used)

Patient MRN

Required

String (AN)

Min 1Max 264

—

1600

Message Text

OptionalMax use 1

—

Example

Variants (all may be used)

NM1 - Loop 2010EA - Service Facility Name

Precertification Status

Required

String (AN)

Min 1Max 264

PRECERT REQUIRED=(YES|NO) RegEx pattern

—

NM1 NM1 - Loop 2010EA - Provider Name

OptionalMax >1

—

Variants (all may be used)

1700

NM1 - Segment - Provider Name

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

77: Service Location
SJ: Service Provider

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

Name Last or Organization Name

Required

String (AN)

Min 1Max 60

—

Name First

Optional

String (AN)

Min 1Max 35

—

Name Middle

Optional

String (AN)

Min 1Max 25

—

NM1-07

1039

Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

XX: Centers for Medicare and Medicaid Services National Provider Identifier

National Provider ID (NPI)

Required

String (AN)

Min 2Max 80

—

1800

Reference Information

OptionalMax use 9

—

Example

Reference Identification Qualifier

Required

Identifier (ID)

Min 2Max 3

—

Reference Identification

Optional

String (AN)

Min 1Max 50

—

2000

N3 - Segment - Provider Address

RequiredMax use 1

—

Example

Address Information

Required

String (AN)

Min 1Max 55

—

Address Information

Optional

String (AN)

Min 1Max 55

—

2100

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

RequiredMax use 1

—

Example

City Name

Required

String (AN)

Min 2Max 30

—

State or Province Code

Required

Identifier (ID)

Min 2Max 2

—

Postal Code

Required

Identifier (ID)

Min 3Max 15

—

2200

Administrative Communications Contact

OptionalMax use 3

—

Example

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Communication Number Qualifier

Required

Identifier (ID)

—

TE: Telephone

Communication Number

Required

String (AN)

Min 1Max 256

—

2400

Provider Information

OptionalMax use 1

—

Example

NM1 - Loop 2010EA - Provider Name

Provider Code

Required

Identifier (ID)

Min 1Max 3

—

NM1 NM1 - Loop 2010EA - Provider Name end

NM1 NM1 - Loop 2010EA - Service Facility Name

OptionalMax >1

—

Variants (all may be used)

1700

NM1 - Segment - Service Facility Name

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

77: Service Location

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

Name Last or Organization Name

Required

String (AN)

Min 1Max 60

—

Identification Code Qualifier

Required

Identifier (ID)

—

XX: Centers for Medicare and Medicaid Services National Provider Identifier

Service Facility National Provider ID (NPI)

Required

String (AN)

Min 2Max 80

—

1800

REF - Segment - Service Facility Tax ID

OptionalMax use 9

—

Example

Variants (all may be used)

REFReference Information

Reference Identification Qualifier

Required

Identifier (ID)

Min 2Max 3

—

Reference Identification

Optional

String (AN)

Min 1Max 50

—

REFREF - Segment - Service Facility Tax ID

1800

Reference Information

OptionalMax use 9

—

Example

Variants (all may be used)

Reference Identification Qualifier

Required

Identifier (ID)

—

EI: Employer's Identification Number

Reference Identification

Optional

String (AN)

Min 1Max 50

—

2000

N3 - Segment - Service Facility Address

RequiredMax use 1

—

Example

Address Information

Required

String (AN)

Min 1Max 55

—

Address Information

Optional

String (AN)

Min 1Max 55

—

2100

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

RequiredMax use 1

—

Example

City Name

Required

String (AN)

Min 2Max 30

—

State or Province Code

Required

Identifier (ID)

Min 2Max 2

—

Postal Code

Required

Identifier (ID)

Min 3Max 15

—

2200

Administrative Communications Contact

OptionalMax use 3

—

Example

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Communication Number Qualifier

Required

Identifier (ID)

—

TE: Telephone

Communication Number

Required

String (AN)

Min 1Max 256

—

2400

Provider Information

OptionalMax use 1

—

Example

Provider Code

Required

Identifier (ID)

Min 1Max 3

—

NM1 NM1 - Loop 2010EA - Service Facility Name end

HL HL - Loop 2000F - Service Level

RequiredMax >1

—

0100

Hierarchical Level

RequiredMax use 1

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

SS: Services

Hierarchical Child Code

Optional

Identifier (ID)

—

0: No Subordinate HL Segment in This Hierarchical Structure.

SV1

0810

Professional Service

OptionalMax use 1

—

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

—

C003-02

Product/Service ID

Required

String (AN)

Min 1Max 48

—

SV1-03

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

Min 2Max 2

—

SV1-04

Quantity

Optional

Decimal number (R)

Min 1Max 15

—

SV2

0820

Institutional Service

OptionalMax use 1

—

Example

SV2-01

Product/Service ID

Required

String (AN)

Min 1Max 48

—

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)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

C003-02

HL - Loop 2000D - Dependent Level

SV201 - C003-02 - CPT or HCPCS Code

Required

String (AN)

Min 1Max 48

—

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

—

Variants (all may be used)

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

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

EV: Event

Hierarchical Child Code

Optional

Identifier (ID)

—

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

—

Example

TRN-01

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

TRN-02

TRN02 - Element - Epic Referral (RFL) ID - Reference Identification

Required

String (AN)

Min 1Max 50

—

TRN-03

509

Originating Company Identifier

Optional

String (AN)

Min 10Max 10

—

TRN-04

Reference Identification

Optional

String (AN)

Min 1Max 50

—

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

—

Example

UM-01

1525

Request Category Code

Required

Identifier (ID)

—

AR: Admission Review
HS: Health Services Review

UM-02

1322

Certification Type Code

Optional

Identifier (ID)

—

I: Initial

UM-03

1365

Service Type Code

Optional

Identifier (ID)

Min 1Max 2

—

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

—

C023-02

1332

Facility Code Qualifier

Required

Identifier (ID)

Min 1Max 2

—

UM-09

1363

Release of Information Code

Optional

Identifier (ID)

Min 1Max 1

—

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

—

Example

DTP-01

374

Date/Time Qualifier

Required

Identifier (ID)

—

AAH: Event

DTP-02

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTP-03

Date Time Period

Required

String (AN)

Min 1Max 35

—

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

—

Example

HI-01

Health Care Code Information

RequiredMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-02

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-03

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-04

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-05

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-06

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-07

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-08

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-09

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-10

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-11

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

HI-12

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Code List Qualifier Code

Required

Identifier (ID)

Min 1Max 3

—

Industry Code

Required

String (AN)

Min 1Max 30

—

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

—

Example

HSD-01

673

Quantity Qualifier

Required

Identifier (ID)

Min 2Max 2

—

HSD-02

Quantity

Required

Decimal number (R)

Min 1Max 15

—

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

—

Example

Variants (all may be used)

Patient MRN

Required

String (AN)

Min 1Max 264

—

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

—

Example

Variants (all may be used)

NM1 - Loop 2010EA - Service Facility Name

Precertification Status

Required

String (AN)

Min 1Max 264

PRECERT REQUIRED=(YES|NO) RegEx pattern

—

NM1 NM1 - Loop 2010EA - Provider Name

OptionalMax >1

—

Variants (all may be used)

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

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

77: Service Location
SJ: Service Provider

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

Name Last or Organization Name

Required

String (AN)

Min 1Max 60

—

Name First

Optional

String (AN)

Min 1Max 35

—

Name Middle

Optional

String (AN)

Min 1Max 25

—

NM1-07

1039

Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

XX: Centers for Medicare and Medicaid Services National Provider Identifier

Identification Code

Required

String (AN)

Min 2Max 80

—

1800

Reference Information

OptionalMax use 9

—

Example

Reference Identification Qualifier

Required

Identifier (ID)

Min 2Max 3

—

Reference Identification

Optional

String (AN)

Min 1Max 50

—

2000

N3 - Segment - Provider Address

RequiredMax use 1

—

Example

Address Information

Required

String (AN)

Min 1Max 55

—

Address Information

Optional

String (AN)

Min 1Max 55

—

2100

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

RequiredMax use 1

—

Example

City Name

Required

String (AN)

Min 2Max 30

—

2200

Administrative Communications Contact

OptionalMax use 3

—

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

Contact Function Code

Required

Identifier (ID)

Min 2Max 2

—

PER-02

Name

Optional

String (AN)

Min 1Max 60

—

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-05

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

PER-06

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-07

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

PER-08

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-09

443

Contact Inquiry Reference

Optional

String (AN)

Min 1Max 20

—

2400

Provider Information

OptionalMax use 1

—

Example

NM1 - Loop 2010EA - Provider Name

Provider Code

Required

Identifier (ID)

Min 1Max 3

—

NM1 NM1 - Loop 2010EA - Provider Name end

NM1 NM1 - Loop 2010EA - Service Facility Name

OptionalMax >1

Variants (all may be used)

1700

NM1 - Segment - Service Facility Name

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

77: Service Location

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

Name Last or Organization Name

Required

String (AN)

Min 1Max 60

—

Identification Code Qualifier

Required

Identifier (ID)

—

XX: Centers for Medicare and Medicaid Services National Provider Identifier

Identification Code

Required

String (AN)

Min 2Max 80

—

1800

REF - Segment - Service Facility Tax ID

OptionalMax use 9

—

Example

Variants (all may be used)

REFReference Information

Reference Identification Qualifier

Required

Identifier (ID)

Min 2Max 3

—

Reference Identification

Optional

String (AN)

Min 1Max 50

—

REFREF - Segment - Service Facility Tax ID

1800

Reference Information

OptionalMax use 9

—

Example

Variants (all may be used)

Reference Identification Qualifier

Required

Identifier (ID)

—

EI: Employer's Identification Number

Reference Identification

Optional

String (AN)

Min 1Max 50

—

2000

N3 - Segment - Service Facility Address

RequiredMax use 1

—

Example

Address Information

Required

String (AN)

Min 1Max 55

—

Address Information

Optional

String (AN)

Min 1Max 55

—

2100

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

RequiredMax use 1

—

Example

City Name

Required

String (AN)

Min 2Max 30

—

State or Province Code

Required

Identifier (ID)

Min 2Max 2

—

Postal Code

Required

Identifier (ID)

Min 3Max 15

—

2200

Administrative Communications Contact

OptionalMax use 3

—

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

Contact Function Code

Required

Identifier (ID)

Min 2Max 2

—

PER-02

Name

Optional

String (AN)

Min 1Max 60

—

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-05

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

PER-06

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-07

Communication Number Qualifier

Optional

Identifier (ID)

Min 2Max 2

—

PER-08

Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-09

443

Contact Inquiry Reference

Optional

String (AN)

Min 1Max 20

—

2400

Provider Information

OptionalMax use 1

—

Example

Provider Code

Required

Identifier (ID)

Min 1Max 3

—

NM1 NM1 - Loop 2010EA - Service Facility Name end

HL HL - Loop 2000F - Service Level

RequiredMax >1

—

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

—

Example

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

Hierarchical Level Code

Required

Identifier (ID)

—

SS: Services

Hierarchical Child Code

Optional

Identifier (ID)

—

0: No Subordinate HL Segment in This Hierarchical Structure.

SV1

0810

Professional Service

OptionalMax use 1

—

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

—

C003-02

Product/Service ID

Required

String (AN)

Min 1Max 48

—

SV1-03

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

Min 2Max 2

—

SV1-04