X12 HIPAA
/
Data Reporting Acknowledgment (X364)
  • Specification
  • EDI Inspector
Import
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X12 277 Data Reporting Acknowledgment (X364)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Information Status Notification Transaction Set (277) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a health care claim or encounter or to request additional information from the provider regarding a health care claim or encounter, health care services review, or transactions related to the provisions of health care. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, will not be used for account payment posting. The notification may be at a summary or service line detail level. The notification may be solicited or unsolicited.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    detail
    Information Source Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Information Receiver Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Billing/Service Provider Hierarchical Level Loop
    SE
    2700
    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

    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
    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

    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
    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
    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
    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
    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
    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
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    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

    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
    Min 9Max 9

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    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
    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
    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

    Code identifying a group of application related transaction sets

    HN
    Health Care Information Status Notification (277)
    GS-02
    142
    Application Sender's Code
    Required
    Min 2Max 15

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

    GS-03
    124
    Application Receiver's Code
    Required
    Min 2Max 15

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

    GS-04
    373
    Date
    Required
    CCYYMMDD format

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

    GS-05
    337
    Time
    Required
    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
    Min 1Max 9

    Assigned number originated and maintained by the sender

    GS-07
    455
    Responsible Agency Code
    Required
    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

    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

    005010X364

    Heading

    ST
    0100

    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

    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).
    277
    Health Care Information Status Notification
    ST-02
    329
    Transaction Set Control Number
    Required
    Min 4Max 9

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

    Usage notes
    • The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Submitter could begin sending transactions using the number 0001 in this element and increment from there. The number must be unique within a specific functional group (GS to GE) and interchange (ISA to IEA), but can be repeated in other groups and interchanges.
    ST-03
    1705
    Version, Release, or Industry Identifier
    Required

    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.
    Usage notes
    • This field contains the same value as data element GS08. The value is 005010X364. Some translator products strip off the ISA and GS segments prior to application (ST - SE) processing. Providing the information from GS08 at this level will help ensure the appropriate application mapping is utilized at translation time.
    005010X364
    BHT
    0200

    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

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

    0085
    Information Source, Information Receiver, Provider of Service, Patient
    BHT-02
    353
    Transaction Set Purpose Code
    Required

    Code identifying purpose of transaction set

    08
    Status
    BHT-03
    127
    Reference Identification
    Required
    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.
    Usage notes
    • The inventory file number of the transmission assigned by the Information Source's system. This number operates as a transaction (batch) control number.
    BHT-04
    373
    Transaction Set Creation Date
    Required
    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
    Transaction Set Creation Time
    Required
    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.

    Detail

    2000A Information Source Level Loop
    RequiredMax 1
    HL
    0100

    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
    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

    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

    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.
    2100A Information Source Name Loop
    RequiredMax 1
    NM1
    0500

    Information Source Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    ACV
    Information Source
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Information Source Name
    Required
    Min 1Max 60

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    46
    Electronic Transmitter Identification Number (ETIN)
    NM1-09
    67
    Information Source Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    2200A Transmission Receipt Control Identifier Loop
    RequiredMax 1
    TRN
    0900

    Transmission Receipt Control Identifier

    RequiredMax use 1

    To uniquely identify a transaction to an application

    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers
    TRN-02
    127
    Information Source Application Trace Identifier
    Required
    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.
    Usage notes
    • This is a unique trace number that identifies a specific transaction. This number is assigned by the Information Source.
    DTP
    1200

    Information Source Receipt Date

    RequiredMax use 1

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

    Example
    Variants (all may be used)
    DTPInformation Source Process Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    050
    Received
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Information Source Receipt Date
    Required
    Min 1Max 35

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

    Usage notes
    • This is the receipt date of the 837 by the entity creating the 277 acknowledgment. This date may or may not be the same date as the Information Source Process Date.
    DTP
    1200

    Information Source Process Date

    RequiredMax use 1

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

    Usage notes
    • The Information Source Process Date applies to the processing of the 837 claim transaction file through a processing system. This date may or may not be the same date as the Information Source Receipt Date.
    Example
    Variants (all may be used)
    DTPInformation Source Receipt Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    009
    Process
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Information Source Process Date
    Required
    Min 1Max 35

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

    2000B Information Receiver Level Loop
    RequiredMax 1
    HL
    0100

    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
    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
    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

    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

    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.
    2100B Information Receiver Name Loop
    RequiredMax 1
    NM1
    0500

    Information Receiver Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    40
    Receiver
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Information Receiver Last or Organization Name
    Required
    Min 1Max 60

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    46
    Electronic Transmitter Identification Number (ETIN)
    NM1-09
    67
    Information Receiver Primary Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    2200B Information Receiver Application Trace Identifier Loop
    RequiredMax 1
    TRN
    0900

    Information Receiver Application Trace Identifier

    RequiredMax use 1

    To uniquely identify a transaction to an application

    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    2
    Referenced Transaction Trace Numbers
    TRN-02
    127
    Claim Transaction Batch Number
    Required
    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.
    Usage notes
    • This element contains the value submitted in the BHT03 data element from the 837.
    STC
    1000

    Information Receiver Status Information

    RequiredMax use >1

    To report the status, required action, and paid information of a claim or service line

    Usage notes
    • This segment will be used to convey information about an entire unit of work (e.g., single transaction of claims). Information contained at this level will be summary details pertaining to the unit of work being acknowledged. Examples include, but are not limited to, accepted for processing, and trading partner not authorized to submit to the Information Source's system.
    • See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
    Example
    STC-01
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    40
    Receiver

    Use when identifying the receiver entity in Loop 1000B of the 837.

    41
    Submitter

    Use when identifying the submitter entity in Loop 1000A of the 837.

    STC-02
    373
    Status Information Effective Date
    Required
    CCYYMMDD format

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

    • STC02 is the effective date of the status information.
    STC-03
    306
    Action Code
    Required

    Code indicating type of action

    Usage notes
    • STC03 at this level is intended to convey the electronic transmission status of the ST - SE envelope. The terms "Accept" and "Reject" refer to the electronic transmission status of the 837 transaction not the processing status.
    U
    Reject

    Required when the entire claim transaction (ST-SE) is rejected due to submitter level errors. No subordinate HL information is reported.

    WQ
    Accept

    Required when code value "U" is not used. At least one subordinate HL loop must be reported.

    STC-04
    782
    Total Submitted Charges for Unit Work
    Required
    Min 1Max 15

    Monetary amount

    • STC04 is the amount of original submitted charges.
    Usage notes
    • This will be the sum of all CLM02 values (claim charge) for the claims being acknowledged. In most instances, this will be the sum of charges submitted from ST to SE of a single 837 transaction set.

    In situations where the 837 transaction from the Information Receiver is separated (e.g., due to clearinghouse involvement), this amount will be the sum of the CLM02 values for the claims being acknowledged.

    STC-10
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    STC-11
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    QTY
    1210

    Total Accepted Quantity

    OptionalMax use 1

    To specify quantity information

    Usage notes
    • Required when at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.
    • The purpose of this segment is to report the total number of claims accepted by the Information Source. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
    Example
    Variants (all may be used)
    QTYTotal Rejected Quantity
    QTY-01
    673
    Quantity Qualifier
    Required

    Code specifying the type of quantity

    90
    Acknowledged Quantity
    QTY-02
    380
    Total Accepted Quantity
    Required
    Min 1Max 15

    Numeric value of quantity

    QTY
    1210

    Total Rejected Quantity

    OptionalMax use 1

    To specify quantity information

    Usage notes
    • Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.
    • The purpose of this segment is to report the total number of claims rejected for this Information Receiver (e.g., not accepted) by the Information Source.
    Example
    Variants (all may be used)
    QTYTotal Accepted Quantity
    QTY-01
    673
    Quantity Qualifier
    Required

    Code specifying the type of quantity

    AA
    Unacknowledged Quantity
    QTY-02
    380
    Total Rejected Quantity
    Required
    Min 1Max 15

    Numeric value of quantity

    AMT
    1220

    Total Accepted Amount

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.
    • The purpose of this segment is to report the total of the claim charge amount (Sum of Loop ID 2300 CLM02) of claims accepted by the Information Source. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
    Example
    Variants (all may be used)
    AMTTotal Rejected Amount
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    YU
    In Process
    AMT-02
    782
    Total Accepted Amount
    Required
    Min 1Max 15

    Monetary amount

    AMT
    1220

    Total Rejected Amount

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.
    • The purpose of this segment is to report the total of the claim charge amount (Sum of Loop ID 2300 CLM02) of claims rejected by the Information Source.
    Example
    Variants (all may be used)
    AMTTotal Accepted Amount
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    YY
    Returned
    AMT-02
    782
    Total Rejected Amount
    Required
    Min 1Max 15

    Monetary amount

    2000C Billing/Service Provider Hierarchical Level Loop
    OptionalMax >1
    HL
    0100

    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
    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
    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

    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.
    19
    Provider of Service
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    2100C Billing/Service Provider Name Loop
    RequiredMax 1
    NM1
    0500

    Billing/Service Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This segment contains information which can be found in Loop 2010AA of the 837 implementation guides.
    Example
    If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    85
    Billing Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-04
    1036
    Provider First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Provider Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Provider Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    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
    Billing Provider Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    2200C Billing/Service Provider Trace Identifier Loop
    OptionalMax 1
    TRN
    0900

    Billing/Service Provider Trace Identifier

    RequiredMax use 1

    To uniquely identify a transaction to an application

    Usage notes
    • Because the TRN segment is syntactically required in order to use Loop 2200C, TRN02 can either be a sender assigned value or a default value of zero (0).
    • Required when a secondary provider identifier needs to be reported in the Loop ID 2200C REF Billing/Service Provider Secondary Identifier segment, or to provide the status of a specific billing/service provider's group of claims in the Loop ID 2200C STC Billing/Service Provider Status Information. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers
    TRN-02
    127
    Provider of Service Information Trace Identifier
    Required
    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.
    STC
    1000

    Billing/Service Provider Status Information

    OptionalMax use >1

    To report the status, required action, and paid information of a claim or service line

    Usage notes
    • See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
    • Required when needed to provide the status of a specific Billing/Service Provider's group of claims. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
    Example
    STC-01
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    85
    Billing Provider
    STC-03
    306
    Action Code
    Required

    Code indicating type of action

    U
    Reject

    Use this code to indicate that the provider's group of claims has been rejected. If any portion of the provider's group of claims is accepted then the code "WQ" - Accept must be used.

    WQ
    Accept
    STC-04
    782
    Total Submitted Charges for Unit Work
    Required
    Min 1Max 15

    Monetary amount

    • STC04 is the amount of original submitted charges.
    Usage notes
    • Sum of the Billing/Service Provider claims within the 837 transaction being acknowledged.
    STC-10
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    STC-11
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    REF
    1100

    Billing/Service Provider Secondary Identifier

    OptionalMax use 5

    To specify identifying information

    Usage notes
    • Required when no billing/service provider identifier is sent in NM109 of this loop

    OR

    when an identification number in addition to that provided in NM109 of this loop is necessary for the processor to identify the entity.

    If not required by this implementation guide, do not send.

    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1J
    Facility ID Number
    G2
    Provider Commercial Number
    LU
    Location Number
    TJ
    Federal Taxpayer's Identification Number
    REF-02
    127
    Billing Provider Additional Identifier
    Required
    Min 1Max 50

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

    QTY
    1210

    Total Accepted Quantity

    OptionalMax use 1

    To specify quantity information

    Usage notes
    • The purpose of this segment is to report the total number of claims accepted by the Information Source for the Billing/Service Provider. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
    • Required when reporting status for a specific billing/service provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    QTYTotal Rejected Quantity
    QTY-01
    673
    Quantity Qualifier
    Required

    Code specifying the type of quantity

    QA
    Quantity Approved
    QTY-02
    380
    Total Accepted Quantity
    Required
    Min 1Max 15

    Numeric value of quantity

    QTY
    1210

    Total Rejected Quantity

    OptionalMax use 1

    To specify quantity information

    Usage notes
    • The purpose of this segment is to report the total number of claims rejected by the Information Source for the Billing/Service Provider.
    • Required when reporting status for a specific billing/service provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    QTYTotal Accepted Quantity
    QTY-01
    673
    Quantity Qualifier
    Required

    Code specifying the type of quantity

    QC
    Quantity Disapproved
    QTY-02
    380
    Total Rejected Quantity
    Required
    Min 1Max 15

    Numeric value of quantity

    AMT
    1220

    Total Accepted Amount

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) accepted by the Information Source for the Billing/Service Provider in this acknowledgment. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
    • Required when reporting status for a specific billing/service provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    AMTTotal Rejected Amount
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    YU
    In Process
    AMT-02
    782
    Total Accepted Amount
    Required
    Min 1Max 15

    Monetary amount

    AMT
    1220

    Total Rejected Amount

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) rejected by the Information Source for the Billing/Service Provider in this acknowledgment.
    • Required when reporting status for a specific billing/service provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    AMTTotal Accepted Amount
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    YY
    Returned
    AMT-02
    782
    Total Rejected Amount
    Required
    Min 1Max 15

    Monetary amount

    2000D Patient Level Loop
    OptionalMax >1
    HL
    0100

    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
    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
    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

    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.
    PT
    Patient
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    2100D Patient Name Loop
    RequiredMax 1
    NM1
    0500

    Patient Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    QC
    Patient
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    NM1-03
    1035
    Patient Last Name
    Required
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Patient First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Patient Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Patient Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    II
    Standard Unique Health Identifier for each Individual in the United States

    Use when the HIPAA Individual Patient Identifier is mandated for use.

    MI
    Member Identification Number
    NM1-09
    67
    Patient Identification Number
    Required
    Min 2Max 80

    Code identifying a party or other code

    Usage notes
    • This is the patient identifier. This data element is the value from Loop 2010CA NM109 of the submitted claim. If there is no value is in the Loop 2010CA NM109, then use the value from the Loop 2010BA NM109 of the submitted claim.
    2200D Claim Status Tracking Number Loop
    RequiredMax >1
    TRN
    0900

    Claim Status Tracking Number

    RequiredMax use 1

    To uniquely identify a transaction to an application

    Usage notes
    • This segment is the patient control number submitted in the CLM01 of the 837.
    • This number must be returned exactly as submitted in the 837 up to the 20 character limit as defined in the 837 guide.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    2
    Referenced Transaction Trace Numbers
    TRN-02
    127
    Patient Control Number
    Required
    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.
    STC
    1000

    Claim Level Status Information

    RequiredMax use >1

    To report the status, required action, and paid information of a claim or service line

    Usage notes
    • See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
    Example
    STC-01
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    40
    Receiver
    41
    Submitter
    45
    Drop-off Location
    71
    Attending Physician
    72
    Operating Physician
    73
    Other Physician
    77
    Service Location
    82
    Rendering Provider
    85
    Billing Provider
    DK
    Ordering Physician
    DN
    Referring Provider
    DQ
    Supervising Physician
    IL
    Insured or Subscriber
    P3
    Primary Care Provider
    PR
    Payer
    PRP
    Primary Payer
    PW
    Pickup Address
    QB
    Purchase Service Provider
    QC
    Patient
    SEP
    Secondary Payer
    SJ
    Service Provider
    TTP
    Tertiary Payer
    ZD
    Party to Receive Reports
    ZZ
    Mutually Defined

    Use when indicating the Entity is an Other Operating Physician.

    STC-02
    373
    Status Information Effective Date
    Required
    CCYYMMDD format

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

    • STC02 is the effective date of the status information.
    STC-03
    306
    Status Information Action Code
    Required

    Code indicating type of action

    EZ
    Exception Occurred

    Use when the Health Care Claim Status Code(s) reported in this segment and/or a line level STC segment serves as a warning to the submitter an error has been detected, but is not significant enough to reject the claim.

    U
    Reject

    Use when there is a claim level reject reason OR any of the Loop ID 2220D claim service lines have been assigned an STC03 Action Code of `U' (Reject). Claim splitting of accepted vs rejected lines is not supported in this implementation.

    WQ
    Accept
    STC-04
    782
    Total Claim Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    • STC04 is the amount of original submitted charges.
    Usage notes
    • Zero is an acceptable amount.
    • This is the Loop ID 2300 CLM02 Total Claim Charge Amount from the submitted 837.
    STC-10
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    STC-11
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    STC-12
    933
    Free Form Message Text
    Optional
    Min 1Max 264

    Free-form message text

    • STC12 allows additional free-form status information.
    Usage notes
    • When an Information Source deems there is a need to use the Free Form Message Text enabled by this element, the Information Source is expected to request a new Health Care Claim Status Category and/or Health Care Claim Status code(s) to enable codification of the message thereby eliminating the need to use this field for that given purpose.
    REF
    1100

    Data Receiver Claim Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the Data Receiving Entity of the 837 assigns a specific number to the claim for processing and the number is available at the time of this acknowledgment. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    F8
    Original Reference Number
    REF-02
    127
    Data Receiver Claim Control Number
    Required
    Min 1Max 50

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

    REF
    1100

    Payer Claim Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when acknowledging a Post Adjudicated Claim Data Reporting (PACDR) 837 and Loop ID 2320 SBR06 = `6'. If not required by this implementation guide, do not send.
    • This is the Other Payer Claim Control Number from Loop 2330B (REF*F8) when SBR06 = `6' in Loop 2320.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    1K
    Payor's Claim Number
    REF-02
    127
    Payer Claim Control Number
    Required
    Min 1Max 50

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

    REF
    1100

    Claim Identifier For Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This number must be returned as received in the 837.
    • Required when the Claim Identifier Number For Transmission Intermediary was sent in the 837. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    D9
    Claim Number
    REF-02
    127
    Clearinghouse Trace Number
    Required
    Min 1Max 50

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

    DTP
    1200

    Claim Level Service Date

    RequiredMax use 1

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

    Usage notes
    • For Institutional and Data Reporting claims, this is the statement period submitted in Loop ID 2300 (DTP01 = 434).

    For Professional claims this information is derived from the earliest service level dates in Loop ID 2400 (DTP01 = 472) to the latest service level date.

    For Dental claims this is the service date submitted in Loop ID 2300 (DTP01 = 472). If there is no service date in Loop ID 2300 (DTP01=472), then this is:

    the service date in Loop ID 2400 (DTP01=472),
    OR
    it is the treatment start in Loop ID ID 2400 (DTP01=196),
    OR
    the treatment end in Loop ID 2400 (DTP01=198),
    OR
    both the treatment start and treatment end dates in Loop ID 2400 listing the date range as from treatment start date to the treatment end date.

    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    472
    Service
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
    DTP-03
    1251
    Claim Service Period
    Required
    Min 1Max 35

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

    2220D Service Line Information Loop
    OptionalMax >1
    SVC
    1800

    Service Line Information

    RequiredMax use 1

    To supply payment and control information to a provider for a particular service

    Usage notes
    • For Institutional claims, when both an NUBC revenue code and HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
    • Required when a Reject Action Code (Loop ID 2220D STC03 = U') is being assigned to a service line. OR Required when an Exception Occurred Action Code (Loop ID 2220D STC03 = EZ') is being assigned to a service line.

    If not required by this implementation guide, do not send.

    Example
    SVC-01
    C003
    Composite Medical Procedure Identifier
    To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
    C003-01
    235
    Procedure Code
    Required

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

    • C003-01 qualifies C003-02 and C003-08.
    AD
    American Dental Association Codes
    ER
    Jurisdiction Specific Procedure and Supply Codes
    HC
    Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
    HP
    Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
    NU
    National Uniform Billing Committee (NUBC) UB92 Codes
    WK
    Advanced Billing Concepts (ABC) Codes
    C003-02
    234
    Procedure Code
    Required
    Min 1Max 48

    Identifying number for a product or service

    • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
    Usage notes
    • If the value in SVC01-1 is "NU", then this element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-2, then SVC04 is not used.
    • Value submitted on the original claim.
    C003-03
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-03 modifies the value in C003-02 and C003-08.
    C003-04
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-04 modifies the value in C003-02 and C003-08.
    C003-05
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-05 modifies the value in C003-02 and C003-08.
    C003-06
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-06 modifies the value in C003-02 and C003-08.
    SVC-02
    782
    Line Item Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    • SVC02 is the submitted service charge.
    Usage notes
    • Zero is an acceptable amount.
    SVC-04
    234
    Revenue Code
    Optional
    Min 1Max 48

    Identifying number for a product or service

    • SVC04 is the National Uniform Billing Committee Revenue Code.
    SVC-07
    380
    Original Units of Service Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • SVC07 is the original submitted units of service.
    STC
    1900

    Service Line Level Status Information

    RequiredMax use >1

    To report the status, required action, and paid information of a claim or service line

    Usage notes
    • See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
    Example
    STC-01
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    45
    Drop-off Location
    72
    Operating Physician
    77
    Service Location
    82
    Rendering Provider
    DD
    Assistant Surgeon
    DK
    Ordering Physician
    DN
    Referring Provider
    DQ
    Supervising Physician
    P3
    Primary Care Provider
    PW
    Pickup Address
    QB
    Purchase Service Provider
    ZZ
    Mutually Defined

    Use when indicating the Entity is an Other Operating Physician.

    STC-03
    306
    Action Code
    Required

    Code indicating type of action

    EZ
    Exception Occurred

    Use when the Health Care Claim Status Code(s) reported in this segment and/or a line level STC segment serves as a warning to the submitter an error has been detected, but is not significant enough to reject the claim.

    U
    Reject
    STC-10
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    STC-11
    C043
    Health Care Claim Status
    Used to convey status of the entire claim or a specific service line
    Usage notes

    Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
    Usage notes
    • See STC01-1 for valid values.
    C043-02
    1271
    Health Care Claim Status Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • C043-02 is used to identify the status of an entire claim or a serviceline.
      Code Source 508 is referenced unless qualified by C043-04.
    Usage notes
    • This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
    C043-03
    98
    Entity Identifier Code
    Optional
    Min 2Max 3

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    STC-12
    933
    Free Form Message Text
    Optional
    Min 1Max 264

    Free-form message text

    • STC12 allows additional free-form status information.
    Usage notes
    • When an Information Source deems there is a need to use the Free Form Message Text enabled by this element, the Information Source is expected to request a new Health Care Claim Status Category and/or Health Care Claim Status code(s) to enable codification of the message thereby eliminating the need to use this field for that given purpose.
    REF
    2000

    Line Item Control Number

    RequiredMax use 1

    To specify identifying information

    Usage notes
    • This is the Line Item Control Number exactly as submitted in the 837 transaction for the original claim in Loop ID 2400, REF02 (REF01 = 6R). If a Line Item Control Number is not submitted, this will be the line sequence number Loop ID 2400 LX01.
    Example
    Variants (all may be used)
    REFPharmacy Prescription Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    6R
    Provider Control Number
    REF-02
    127
    Line Item Control Number
    Required
    Min 1Max 50

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

    REF
    2000

    Pharmacy Prescription Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when a Pharmacy Prescription Number was sent in the 837 at the Service Line. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFLine Item Control Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    XZ
    Pharmacy Prescription Number
    REF-02
    127
    Pharmacy Prescription Number
    Required
    Min 1Max 50

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

    DTP
    2100

    Service Line Date

    OptionalMax use 1

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

    Usage notes
    • Required when the Date of Service from the original submitted claim for a specific line item is present. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    472
    Service
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
    DTP-03
    1251
    Service Line Date
    Required
    Min 1Max 35

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

    SE
    2700

    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
    Transaction Segment Count
    Required
    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
    Min 4Max 9

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

    Usage notes
    • Data value in SE02 must be identical to ST02.

    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
    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
    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
    Min 1Max 5

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

    IEA-02
    I12
    Interchange Control Number
    Required
    Min 9Max 9

    A control number assigned by the interchange sender

    EDI Samples

    Example 1

    ST*277*0003*005010X364~
    BHT*0085*08*0000221*20190221*1025~
    HL*1**20*1~
    NM1*ACV*2*ALL PAYER CLAIMS DATABASE*****46*APCD01~
    TRN*1*ABC12345~
    DTP*050*D8*20190220~
    DTP*009*D8*20190221~
    HL*2*1*21*1~
    NM1*40*2*YOUR INSURANCE COMPANY*****46*S00003~
    TRN*2*206438976580901~
    STC*DR02>20*20190221*WQ*365.5~
    QTY*90*3~
    QTY*AA*2~
    AMT*YU*200.5~
    AMT*YY*165~
    HL*3*2*19*1~
    NM1*85*1*JONES*HARRY*B**MD*XX*1546326897~
    HL*4*3*PT~
    NM1*QC*1*PATIENT*FEMALE****MI*2222222222~
    TRN*2*PATIENT22222~
    STC*DR02>20>PR*20190221*WQ*100~
    REF*F8*IC847502~
    REF*1K*220216359803X~
    DTP*472*D8*20190214~
    HL*5*3*PT~
    NM1*QC*1*PATIENT*MALE****MI*3333333333~
    TRN*2*PATIENT33333~
    STC*DR06>21*20190221*U*65******DR06>255~
    REF*F8*IC429783~
    REF*1K*220216359954X~
    DTP*472*D8*20190121~
    HL*6*3*PT~
    NM1*QC*1*JONES*LARRY****MI*4444444444~
    TRN*2*JONES44444~
    STC*DR03>26>77*20190221*U*100~
    REF*F8*IC429805~
    REF*1K*220216359964X~
    DTP*472*D8*20190211~
    HL*7*2*19*1~
    NM1*85*1*SMITH*JOHN*C**MD*XX*1546326780~
    TRN*1*0~
    REF*LU*AB142~
    QTY*QA*2~
    AMT*YU*100.5~
    HL*8*7*PT~
    NM1*QC*1*JOHNSON*MARY****MI*5555555555~
    TRN*2*JOHNSON55555~
    STC*DR08>20>PR*20190221*EZ*50.5~
    REF*F8*IC429888~
    REF*1K*220216359806X~
    DTP*472*D8*20190210~
    SVC*HC>G9938*50.5*****1~
    STC*DR08>475**EZ~
    REF*6R*1~
    DTP*472*D8*20190210~
    HL*9*7*PT~
    NM1*QC*1*MILLS*HARRIETT****MI*6666666666~
    TRN*2*MILLS66666~
    STC*DR02>20>PR*20190221*WQ*50~
    REF*F8*IC429956~
    REF*1K*220216359807X~
    DTP*472*D8*20190205~
    SE*63*0003~

    Example 2

    ST*277*0002*005010X364~
    BHT*0085*08*123456789*20190201*0405~
    HL*1**20*1~
    NM1*ACV*2*STATE ENCOUNTER SYSTEM*****46*STATE01~
    TRN*1*20201312005S00002XYZABC~
    DTP*050*D8*20190131~
    DTP*009*D8*20190201~
    HL*2*1*21*0~
    NM1*40*2*ABC PAYER*****46*S00002~
    TRN*2*2020131052389~
    STC*DR03>24>41*20190201*U*800~
    QTY*AA*3~
    AMT*YY*800~
    SE*14*0002~

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