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X12 837 Health Care Claim: Professional (X222A2)
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- * Element
- > Component
- ^ Repetition
EDI samples
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
CUR
0100
Foreign Currency Information
Max use 1
Optional
Billing Provider Name Loop
NM1
0150
Billing Provider Name
Max use 1
Required
N3
0250
Billing Provider Address
Max use 1
Required
N4
0300
Billing Provider City, State, ZIP Code
Max use 1
Required
REF
0350
Billing Provider Tax Identification
Max use 1
Required
REF
0350
Billing Provider UPIN/License Information
Max use 2
Optional
PER
0400
Billing Provider Contact Information
Max use 2
Optional
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Optional
Subscriber Name Loop
NM1
0150
Subscriber Name
Max use 1
Required
N3
0250
Subscriber Address
Max use 1
Optional
N4
0300
Subscriber City, State, ZIP Code
Max use 1
Optional
DMG
0320
Subscriber Demographic Information
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
REF
0350
Subscriber Secondary Identification
Max use 1
Optional
PER
0400
Property and Casualty Subscriber Contact Information
Max use 1
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Acute Manifestation
Max use 1
Optional
DTP
1350
Date - Admission
Max use 1
Optional
DTP
1350
Date - Assumed and Relinquished Care Dates
Max use 2
Optional
DTP
1350
Date - Authorized Return to Work
Max use 1
Optional
DTP
1350
Date - Disability Dates
Max use 1
Optional
DTP
1350
Date - Discharge
Max use 1
Optional
DTP
1350
Date - Hearing and Vision Prescription Date
Max use 1
Optional
DTP
1350
Date - Initial Treatment Date
Max use 1
Optional
DTP
1350
Date - Last Menstrual Period
Max use 1
Optional
DTP
1350
Date - Last Seen Date
Max use 1
Optional
DTP
1350
Date - Last Worked
Max use 1
Optional
DTP
1350
Date - Last X-ray Date
Max use 1
Optional
DTP
1350
Date - Onset of Current Illness or Symptom
Max use 1
Optional
DTP
1350
Date - Property and Casualty Date of First Contact
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Care Plan Oversight
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 1
Optional
REF
1800
Mammography Certification Number
Max use 1
Optional
REF
1800
Mandatory Medicare (Section 4081) Crossover Indicator
Max use 1
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 1
Optional
CR1
1950
Ambulance Transport Information
Max use 1
Optional
CR2
2000
Spinal Manipulation Service Information
Max use 1
Optional
CRC
2200
Ambulance Certification
Max use 3
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
CRC
2200
Homebound Indicator
Max use 1
Optional
CRC
2200
Patient Condition Information: Vision
Max use 3
Optional
HI
2310
Anesthesia Related Procedure
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Required
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Service Facility Location Name Loop
NM1
2500
Service Facility Location Name
Max use 1
Required
N3
2650
Service Facility Location Address
Max use 1
Required
N4
2700
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
2710
Service Facility Location Secondary Identification
Max use 3
Optional
PER
2750
Service Facility Contact Information
Max use 1
Optional
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Optional
AMT
3000
Coordination of Benefits (COB) Total Non-Covered Amount
Max use 1
Optional
AMT
3000
Remaining Patient Liability
Max use 1
Optional
OI
3100
Other Insurance Coverage Information
Max use 1
Required
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
N3
3320
Other Payer Address
Max use 1
Optional
N4
3400
Other Payer City, State, ZIP Code
Max use 1
Optional
DTP
3450
Claim Check or Remittance Date
Max use 1
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Prior Authorization Number
Max use 1
Optional
REF
3550
Other Payer Referral Number
Max use 1
Optional
REF
3550
Other Payer Secondary Identifier
Max use 2
Optional
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV1
3700
Professional Service
Max use 1
Required
SV5
4000
Durable Medical Equipment Service
Max use 1
Optional
PWK
4200
Durable Medical Equipment Certificate of Medical Necessity Indicator
Max use 1
Optional
PWK
4200
Line Supplemental Information
Max use 10
Optional
CR1
4250
Ambulance Transport Information
Max use 1
Optional
CR3
4350
Durable Medical Equipment Certification
Max use 1
Optional
CRC
4500
Ambulance Certification
Max use 3
Optional
CRC
4500
Condition Indicator/Durable Medical Equipment
Max use 1
Optional
CRC
4500
Hospice Employee Indicator
Max use 1
Optional
DTP
4550
Date - Begin Therapy Date
Max use 1
Optional
DTP
4550
DATE - Certification Revision/Recertification Date
Max use 1
Optional
DTP
4550
Date - Initial Treatment Date
Max use 1
Optional
DTP
4550
Date - Last Certification Date
Max use 1
Optional
DTP
4550
Date - Last Seen Date
Max use 1
Optional
DTP
4550
Date - Last X-ray Date
Max use 1
Optional
DTP
4550
Date - Prescription Date
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Required
DTP
4550
Date - Shipped Date
Max use 1
Optional
DTP
4550
Date - Test Date
Max use 2
Optional
QTY
4600
Ambulance Patient Count
Max use 1
Optional
QTY
4600
Obstetric Anesthesia Additional Units
Max use 1
Optional
MEA
4620
Test Result
Max use 5
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
4700
Immunization Batch Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Mammography Certification Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
REF
4700
Referral Number
Max use 5
Optional
REF
4700
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
AMT
4750
Postage Claimed Amount
Max use 1
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
NTE
4850
Line Note
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
PS1
4880
Purchased Service Information
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Patient Name Loop
NM1
0150
Patient Name
Max use 1
Required
N3
0250
Patient Address
Max use 1
Required
N4
0300
Patient City, State, ZIP Code
Max use 1
Required
DMG
0320
Patient Demographic Information
Max use 1
Required
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
REF
0350
Property and Casualty Patient Identifier
Max use 1
Optional
PER
0400
Property and Casualty Patient Contact Information
Max use 1
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Acute Manifestation
Max use 1
Optional
DTP
1350
Date - Admission
Max use 1
Optional
DTP
1350
Date - Assumed and Relinquished Care Dates
Max use 2
Optional
DTP
1350
Date - Authorized Return to Work
Max use 1
Optional
DTP
1350
Date - Disability Dates
Max use 1
Optional
DTP
1350
Date - Discharge
Max use 1
Optional
DTP
1350
Date - Hearing and Vision Prescription Date
Max use 1
Optional
DTP
1350
Date - Initial Treatment Date
Max use 1
Optional
DTP
1350
Date - Last Menstrual Period
Max use 1
Optional
DTP
1350
Date - Last Seen Date
Max use 1
Optional
DTP
1350
Date - Last Worked
Max use 1
Optional
DTP
1350
Date - Last X-ray Date
Max use 1
Optional
DTP
1350
Date - Onset of Current Illness or Symptom
Max use 1
Optional
DTP
1350
Date - Property and Casualty Date of First Contact
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Care Plan Oversight
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 1
Optional
REF
1800
Mammography Certification Number
Max use 1
Optional
REF
1800
Mandatory Medicare (Section 4081) Crossover Indicator
Max use 1
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 1
Optional
CR1
1950
Ambulance Transport Information
Max use 1
Optional
CR2
2000
Spinal Manipulation Service Information
Max use 1
Optional
CRC
2200
Ambulance Certification
Max use 3
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
CRC
2200
Homebound Indicator
Max use 1
Optional
CRC
2200
Patient Condition Information: Vision
Max use 3
Optional
HI
2310
Anesthesia Related Procedure
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Required
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Service Facility Location Name Loop
NM1
2500
Service Facility Location Name
Max use 1
Required
N3
2650
Service Facility Location Address
Max use 1
Required
N4
2700
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
2710
Service Facility Location Secondary Identification
Max use 3
Optional
PER
2750
Service Facility Contact Information
Max use 1
Optional
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Optional
AMT
3000
Coordination of Benefits (COB) Total Non-Covered Amount
Max use 1
Optional
AMT
3000
Remaining Patient Liability
Max use 1
Optional
OI
3100
Other Insurance Coverage Information
Max use 1
Required
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
N3
3320
Other Payer Address
Max use 1
Optional
N4
3400
Other Payer City, State, ZIP Code
Max use 1
Optional
DTP
3450
Claim Check or Remittance Date
Max use 1
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Prior Authorization Number
Max use 1
Optional
REF
3550
Other Payer Referral Number
Max use 1
Optional
REF
3550
Other Payer Secondary Identifier
Max use 2
Optional
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV1
3700
Professional Service
Max use 1
Required
SV5
4000
Durable Medical Equipment Service
Max use 1
Optional
PWK
4200
Durable Medical Equipment Certificate of Medical Necessity Indicator
Max use 1
Optional
PWK
4200
Line Supplemental Information
Max use 10
Optional
CR1
4250
Ambulance Transport Information
Max use 1
Optional
CR3
4350
Durable Medical Equipment Certification
Max use 1
Optional
CRC
4500
Ambulance Certification
Max use 3
Optional
CRC
4500
Condition Indicator/Durable Medical Equipment
Max use 1
Optional
CRC
4500
Hospice Employee Indicator
Max use 1
Optional
DTP
4550
Date - Begin Therapy Date
Max use 1
Optional
DTP
4550
DATE - Certification Revision/Recertification Date
Max use 1
Optional
DTP
4550
Date - Initial Treatment Date
Max use 1
Optional
DTP
4550
Date - Last Certification Date
Max use 1
Optional
DTP
4550
Date - Last Seen Date
Max use 1
Optional
DTP
4550
Date - Last X-ray Date
Max use 1
Optional
DTP
4550
Date - Prescription Date
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Required
DTP
4550
Date - Shipped Date
Max use 1
Optional
DTP
4550
Date - Test Date
Max use 2
Optional
QTY
4600
Ambulance Patient Count
Max use 1
Optional
QTY
4600
Obstetric Anesthesia Additional Units
Max use 1
Optional
MEA
4620
Test Result
Max use 5
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
4700
Immunization Batch Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Mammography Certification Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
REF
4700
Referral Number
Max use 5
Optional
REF
4700
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
AMT
4750
Postage Claimed Amount
Max use 1
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
NTE
4850
Line Note
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
PS1
4880
Purchased Service Information
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
SE
5550
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
—
Example
Required
Identifier (ID)
—
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Required
Identifier (ID)
—
- 00
- No Security Information Present (No Meaningful Information in I04)
Required
Identifier (ID)
—
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
Required
Identifier (ID)
Min 1Max 1
—
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Required
Identifier (ID)
Min 1Max 1
—
- I
- Information
- P
- Production Data
- T
- Test Data
GS
Functional Group Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
Min 1Max 2
—
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Heading
ST
0050
Heading > ST
Transaction Set Header
RequiredMax use 1
—
Example
BHT
0100
Heading > BHT
Beginning of Hierarchical Transaction
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 0019
- Information Source, Subscriber, Dependent
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
Usage notes
—
Required
Identifier (ID)
—
- 31
- Subrogation Demand—
- CH
- Chargeable—
- RP
- Reporting—
1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name LoopNM1
0200
Heading > Submitter Name Loop > NM1
Submitter Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)—
PER
0450
Heading > Submitter Name Loop > PER
Submitter EDI Contact Information
RequiredMax use 2
—
Usage notes
—
Example
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
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
1000A Submitter Name Loop end
1000B Receiver Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Name LoopNM1
0200
Heading > Receiver Name Loop > NM1
Receiver Name
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)
1000B Receiver Name Loop end
Heading end
Detail
2000A Billing Provider Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV
Billing Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR
Foreign Currency Information
OptionalMax use 1
—
Usage notes
—
Example
2010AA Billing Provider Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1
Billing Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3
Billing Provider Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4
Billing Provider City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider Tax Identification
RequiredMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider UPIN/License InformationREF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider UPIN/License Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Tax IdentificationPER
0400
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER
Billing Provider Contact Information
OptionalMax use 2
—
Usage notes
—
Example
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
Required
Identifier (ID)
—
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
2010AA Billing Provider Name Loop end
2010AB Pay-to Address Name Loop
OptionalMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1
Pay-to Address Name
RequiredMax use 1
—
Usage notes
—
Example
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3
Pay-to Address - ADDRESS
RequiredMax use 1
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4
Pay-To Address City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
2010AB Pay-to Address Name Loop end
2010AC Pay-To Plan Name Loop
OptionalMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > NM1
Pay-To Plan Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3
Pay-to Plan Address
RequiredMax use 1
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4
Pay-To Plan City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF
Pay-to Plan Secondary Identification
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFPay-To Plan Tax Identification NumberREF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF
Pay-To Plan Tax Identification Number
RequiredMax use 1
—
Example
Variants (all may be used)
REFPay-to Plan Secondary Identification2010AC Pay-To Plan Name Loop end
2000B Subscriber Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR
Subscriber Information
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
Usage notes
—
- A
- Payer Responsibility Four
- B
- Payer Responsibility Five
- C
- Payer Responsibility Six
- D
- Payer Responsibility Seven
- E
- Payer Responsibility Eight
- F
- Payer Responsibility Nine
- G
- Payer Responsibility Ten
- H
- Payer Responsibility Eleven
- P
- Primary
- S
- Secondary
- T
- Tertiary
- U
- Unknown—
Optional
Identifier (ID)
—
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
Required
Identifier (ID)
—
- 11
- Other Non-Federal Programs
- 12
- Preferred Provider Organization (PPO)
- 13
- Point of Service (POS)
- 14
- Exclusive Provider Organization (EPO)
- 15
- Indemnity Insurance
- 16
- Health Maintenance Organization (HMO) Medicare Risk
- 17
- Dental Maintenance Organization
- AM
- Automobile Medical
- BL
- Blue Cross/Blue Shield
- CH
- Champus
- CI
- Commercial Insurance Co.
- DS
- Disability
- FI
- Federal Employees Program
- HM
- Health Maintenance Organization
- LM
- Liability Medical
- MA
- Medicare Part A
- MB
- Medicare Part B
- MC
- Medicaid
- OF
- Other Federal Program—
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined—
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > PAT
Patient Information
OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required
If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required
Optional
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
2010BA Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Payer Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1
Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3
Subscriber Address
OptionalMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4
Subscriber City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG
Subscriber Demographic Information
OptionalMax use 1
—
Usage notes
—
Example
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF
Property and Casualty Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFSubscriber Secondary IdentificationREF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF
Subscriber Secondary Identification
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim NumberPER
0400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > PER
Property and Casualty Subscriber Contact Information
OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
2010BA Subscriber Name Loop end
2010BB Payer Name Loop
RequiredMax 1
Variants (all may be used)
Subscriber Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1
Payer Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3
Payer Address
OptionalMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4
Payer City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF
Billing Provider Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFPayer Secondary IdentificationREF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF
Payer Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Secondary Identification2010BB Payer Name Loop end
2300 Claim Information Loop
OptionalMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM
Claim Information
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax 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
Required
Identifier (ID)
—
Usage notes
—
- A
- Assigned—
- B
- Assignment Accepted on Clinical Lab Services Only—
- C
- Not Assigned—
Required
Identifier (ID)
—
Usage notes
—
- N
- No
- W
- Not Applicable—
- Y
- Yes
Required
Identifier (ID)
—
Usage notes
—
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes—
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim—
Optional
Identifier (ID)
—
- P
- Signature generated by provider because the patient was not physically present for services—
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
—
Optional
Identifier (ID)
—
- 02
- Physically Handicapped Children's Program—
- 03
- Special Federal Funding—
- 05
- Disability—
- 09
- Second Opinion or Surgery—
Optional
Identifier (ID)
—
- 1
- Proof of Eligibility Unknown or Unavailable
- 2
- Litigation
- 3
- Authorization Delays
- 4
- Delay in Certifying Provider
- 5
- Delay in Supplying Billing Forms
- 6
- Delay in Delivery of Custom-made Appliances
- 7
- Third Party Processing Delay
- 8
- Delay in Eligibility Determination
- 9
- Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
- 10
- Administration Delay in the Prior Approval Process
- 11
- Other
- 15
- Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Accident
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Acute Manifestation
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Admission
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Assumed and Relinquished Care Dates
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Authorized Return to Work
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Disability Dates
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateRequired
Identifier (ID)
—
- 314
- Disability—
- 360
- Initial Disability Period Start—
- 361
- Initial Disability Period End—
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Discharge
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Hearing and Vision Prescription Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Initial Treatment Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Menstrual Period
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Seen Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Worked
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last X-ray Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Onset of Current Illness or Symptom
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Property and Casualty Date of First Contact
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Repricer Received Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactPWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK
Claim Supplemental Information
OptionalMax use 10
—
Usage notes
—
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
Required
Identifier (ID)
—
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Required
Identifier (ID)
—
- AA
- Available on Request at Provider Site—
- BM
- By Mail
- EL
- Electronically Only—
- EM
- FT
- File Transfer—
- FX
- By Fax
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1
Contract Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 01
- Diagnosis Related Group (DRG)
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other