X12 HIPAA
/
Health Care Claim: Institutional (X223A3)
  • Specification
  • EDI Inspector
Import guide into your account
Stedi maintains this guide based on public documentation from X12 HIPAA. Contact X12 HIPAA for official EDI specifications. To report any errors in this guide, please contact us.
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X12 837 Health Care Claim: Institutional (X223A3)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.

For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
—
  • Example 1a: Institutional Claim
  • Example 1b: Two Claims for the Same Provider
  • Example 1c: PPO Repriced Claim
  • Example 1d: Out of Network Repriced Claim
  • Example 2a: Automobile Accident
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0050
Transaction Set Header
Max use 1
Required
BHT
0100
Beginning of Hierarchical Transaction
Max use 1
Required
Submitter Name Loop
NM1
0200
Submitter Name
Max use 1
Required
PER
0450
Submitter EDI Contact Information
Max use 2
Required
Receiver Name Loop
NM1
0200
Receiver Name
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
PER
0400
Billing Provider Contact Information
Max use 2
Optional
Pay-to Address Name Loop
NM1
0150
Pay-to Address Name
Max use 1
Required
N3
0250
Pay-to Address - ADDRESS
Max use 1
Required
N4
0300
Pay-To Address City, State, ZIP Code
Max use 1
Required
Pay-To Plan Name Loop
NM1
0150
Pay-To Plan Name
Max use 1
Required
N3
0250
Pay-to Plan Address
Max use 1
Required
N4
0300
Pay-To Plan City, State, ZIP Code
Max use 1
Required
REF
0350
Pay-to Plan Secondary Identification
Max use 1
Optional
REF
0350
Pay-To Plan Tax Identification Number
Max use 1
Required
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
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
Payer Name Loop
NM1
0150
Payer Name
Max use 1
Required
N3
0250
Payer Address
Max use 1
Optional
N4
0300
Payer City, State, ZIP Code
Max use 1
Optional
REF
0350
Billing Provider Secondary Identification
Max use 1
Optional
REF
0350
Payer Secondary Identification
Max use 3
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Admission Date/Hour
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
DTP
1350
Discharge Hour
Max use 1
Optional
DTP
1350
Statement Dates
Max use 1
Required
CL1
1400
Institutional Claim Code
Max use 1
Required
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Estimated Amount Due
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Auto Accident State
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 5
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Peer Review Organization (PRO) Approval 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
Billing Note
Max use 1
Optional
NTE
1900
Claim Note
Max use 10
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
HI
2310
Admitting Diagnosis
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HI
2310
Diagnosis Related Group (DRG) Information
Max use 1
Optional
HI
2310
External Cause of Injury
Max use 1
Optional
HI
2310
Occurrence Information
Max use 2
Optional
HI
2310
Occurrence Span Information
Max use 2
Optional
HI
2310
Other Diagnosis Information
Max use 2
Optional
HI
2310
Other Procedure Information
Max use 2
Optional
HI
2310
Patient's Reason For Visit
Max use 1
Optional
HI
2310
Principal Diagnosis
Max use 1
Required
HI
2310
Principal Procedure Information
Max use 1
Optional
HI
2310
Treatment Code Information
Max use 2
Optional
HI
2310
Value Information
Max use 2
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Attending Provider Name Loop
NM1
2500
Attending Provider Name
Max use 1
Required
PRV
2550
Attending Provider Specialty Information
Max use 1
Optional
REF
2710
Attending Provider Secondary Identification
Max use 4
Optional
Operating Physician Name Loop
NM1
2500
Operating Physician Name
Max use 1
Required
REF
2710
Operating Physician Secondary Identification
Max use 4
Optional
Other Operating Physician Name Loop
NM1
2500
Other Operating Physician Name
Max use 1
Required
REF
2710
Other Operating Physician Secondary Identification
Max use 4
Optional
Rendering Provider Name Loop
NM1
2500
Rendering Provider Name
Max use 1
Required
REF
2710
Rendering Provider Secondary Identification
Max use 4
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
Referring Provider Name Loop
NM1
2500
Referring Provider Name
Max use 1
Required
REF
2710
Referring Provider Secondary Identification
Max use 3
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
MIA
3150
Inpatient Adjudication Information
Max use 1
Optional
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Subscriber Name Loop
NM1
3250
Other Subscriber Name
Max use 1
Required
N3
3320
Other Subscriber Address
Max use 1
Optional
N4
3400
Other Subscriber City, State, ZIP Code
Max use 1
Optional
REF
3550
Other Subscriber Secondary Identification
Max use 2
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
3500
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
Other Payer Attending Provider Loop
NM1
3250
Other Payer Attending Provider
Max use 1
Required
REF
3550
Other Payer Attending Provider Secondary Identification
Max use 4
Required
Other Payer Operating Physician Loop
NM1
3250
Other Payer Operating Physician
Max use 1
Required
REF
3550
Other Payer Operating Physician Secondary Identification
Max use 4
Required
Other Payer Other Operating Physician Loop
NM1
3250
Other Payer Other Operating Physician
Max use 1
Required
REF
3550
Other Payer Other Operating Physician Secondary Identification
Max use 4
Required
Other Payer Service Facility Location Loop
NM1
3250
Other Payer Service Facility Location
Max use 1
Required
REF
3550
Other Payer Service Facility Location Secondary Identification
Max use 3
Required
Other Payer Rendering Provider Name Loop
NM1
3250
Other Payer Rendering Provider Name
Max use 1
Required
REF
3550
Other Payer Rendering Provider Secondary Identification
Max use 4
Required
Other Payer Referring Provider Loop
NM1
3250
Other Payer Referring Provider
Max use 1
Required
REF
3550
Other Payer Referring Provider Secondary Identification
Max use 3
Required
Other Payer Billing Provider Loop
NM1
3250
Other Payer Billing Provider
Max use 1
Required
REF
3550
Other Payer Billing Provider Secondary Identification
Max use 2
Required
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV2
3750
Institutional Service Line
Max use 1
Required
PWK
4200
Line Supplemental Information
Max use 10
Optional
DTP
4550
Date - Service Date
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
AMT
4750
Facility Tax Amount
Max use 1
Optional
AMT
4750
Service Tax Amount
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
Drug Identification Loop
LIN
4930
Drug Identification
Max use 1
Required
CTP
4940
Drug Quantity
Max use 1
Required
REF
4950
Prescription or Compound Drug Association Number
Max use 1
Optional
Operating Physician Name Loop
NM1
5000
Operating Physician Name
Max use 1
Required
REF
5250
Operating Physician Secondary Identification
Max use 20
Optional
Other Operating Physician Name Loop
NM1
5000
Other Operating Physician Name
Max use 1
Required
REF
5250
Other Operating Physician Secondary Identification
Max use 20
Optional
Rendering Provider Name Loop
NM1
5000
Rendering Provider Name
Max use 1
Required
REF
5250
Rendering Provider Secondary Identification
Max use 20
Optional
Referring Provider Name Loop
NM1
5000
Referring Provider Name
Max use 1
Required
REF
5250
Referring Provider Secondary Identification
Max use 20
Optional
Line Adjudication Information Loop
SVD
5400
Line Adjudication Information
Max use 1
Required
CAS
5450
Line Adjustment
Max use 5
Optional
DTP
5500
Line Check or Remittance Date
Max use 1
Required
AMT
5505
Remaining Patient Liability
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
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Admission Date/Hour
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
DTP
1350
Discharge Hour
Max use 1
Optional
DTP
1350
Statement Dates
Max use 1
Required
CL1
1400
Institutional Claim Code
Max use 1
Required
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Estimated Amount Due
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Auto Accident State
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 5
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Peer Review Organization (PRO) Approval 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
Billing Note
Max use 1
Optional
NTE
1900
Claim Note
Max use 10
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
HI
2310
Admitting Diagnosis
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HI
2310
Diagnosis Related Group (DRG) Information
Max use 1
Optional
HI
2310
External Cause of Injury
Max use 1
Optional
HI
2310
Occurrence Information
Max use 2
Optional
HI
2310
Occurrence Span Information
Max use 2
Optional
HI
2310
Other Diagnosis Information
Max use 2
Optional
HI
2310
Other Procedure Information
Max use 2
Optional
HI
2310
Patient's Reason For Visit
Max use 1
Optional
HI
2310
Principal Diagnosis
Max use 1
Required
HI
2310
Principal Procedure Information
Max use 1
Optional
HI
2310
Treatment Code Information
Max use 2
Optional
HI
2310
Value Information
Max use 2
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Attending Provider Name Loop
NM1
2500
Attending Provider Name
Max use 1
Required
PRV
2550
Attending Provider Specialty Information
Max use 1
Optional
REF
2710
Attending Provider Secondary Identification
Max use 4
Optional
Operating Physician Name Loop
NM1
2500
Operating Physician Name
Max use 1
Required
REF
2710
Operating Physician Secondary Identification
Max use 4
Optional
Other Operating Physician Name Loop
NM1
2500
Other Operating Physician Name
Max use 1
Required
REF
2710
Other Operating Physician Secondary Identification
Max use 4
Optional
Rendering Provider Name Loop
NM1
2500
Rendering Provider Name
Max use 1
Required
REF
2710
Rendering Provider Secondary Identification
Max use 4
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
Referring Provider Name Loop
NM1
2500
Referring Provider Name
Max use 1
Required
REF
2710
Referring Provider Secondary Identification
Max use 3
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
MIA
3150
Inpatient Adjudication Information
Max use 1
Optional
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Subscriber Name Loop
NM1
3250
Other Subscriber Name
Max use 1
Required
N3
3320
Other Subscriber Address
Max use 1
Optional
N4
3400
Other Subscriber City, State, ZIP Code
Max use 1
Optional
REF
3550
Other Subscriber Secondary Identification
Max use 2
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
3500
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
Other Payer Attending Provider Loop
NM1
3250
Other Payer Attending Provider
Max use 1
Required
REF
3550
Other Payer Attending Provider Secondary Identification
Max use 4
Required
Other Payer Operating Physician Loop
NM1
3250
Other Payer Operating Physician
Max use 1
Required
REF
3550
Other Payer Operating Physician Secondary Identification
Max use 4
Required
Other Payer Other Operating Physician Loop
NM1
3250
Other Payer Other Operating Physician
Max use 1
Required
REF
3550
Other Payer Other Operating Physician Secondary Identification
Max use 4
Required
Other Payer Service Facility Location Loop
NM1
3250
Other Payer Service Facility Location
Max use 1
Required
REF
3550
Other Payer Service Facility Location Secondary Identification
Max use 3
Required
Other Payer Rendering Provider Name Loop
NM1
3250
Other Payer Rendering Provider Name
Max use 1
Required
REF
3550
Other Payer Rendering Provider Secondary Identification
Max use 4
Required
Other Payer Referring Provider Loop
NM1
3250
Other Payer Referring Provider
Max use 1
Required
REF
3550
Other Payer Referring Provider Secondary Identification
Max use 3
Required
Other Payer Billing Provider Loop
NM1
3250
Other Payer Billing Provider
Max use 1
Required
REF
3550
Other Payer Billing Provider Secondary Identification
Max use 2
Required
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV2
3750
Institutional Service Line
Max use 1
Required
PWK
4200
Line Supplemental Information
Max use 10
Optional
DTP
4550
Date - Service Date
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
AMT
4750
Facility Tax Amount
Max use 1
Optional
AMT
4750
Service Tax Amount
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
Drug Identification Loop
LIN
4930
Drug Identification
Max use 1
Required
CTP
4940
Drug Quantity
Max use 1
Required
REF
4950
Prescription or Compound Drug Association Number
Max use 1
Optional
Operating Physician Name Loop
NM1
5000
Operating Physician Name
Max use 1
Required
REF
5250
Operating Physician Secondary Identification
Max use 20
Optional
Other Operating Physician Name Loop
NM1
5000
Other Operating Physician Name
Max use 1
Required
REF
5250
Other Operating Physician Secondary Identification
Max use 20
Optional
Rendering Provider Name Loop
NM1
5000
Rendering Provider Name
Max use 1
Required
REF
5250
Rendering Provider Secondary Identification
Max use 20
Optional
Referring Provider Name Loop
NM1
5000
Referring Provider Name
Max use 1
Required
REF
5250
Referring Provider Secondary Identification
Max use 20
Optional
Line Adjudication Information Loop
SVD
5400
Line Adjudication Information
Max use 1
Required
CAS
5450
Line Adjustment
Max use 5
Optional
DTP
5500
Line Check or Remittance Date
Max use 1
Required
AMT
5505
Remaining Patient Liability
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

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

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

Code identifying the type of information in the Authorization Information

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

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

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

Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

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

Date of the interchange

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

Time of the interchange

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

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

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

Code specifying the version number of the interchange control segments

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

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

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

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

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

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

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

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

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

Code identifying a group of application related transaction sets

HC
Health Care Claim (837)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

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

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

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

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

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

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

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

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

Assigned number originated and maintained by the sender

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

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

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

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

005010X223A3

Heading

ST
0050
Heading > ST

Transaction Set Header

RequiredMax use 1

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

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

Code uniquely identifying a Transaction Set

  • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
837
Health Care Claim
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

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

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
ST-03
1705
Version, Release, or Industry Identifier
Required
String (AN)

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 element must be populated with the guide identifier named in Section 1.2.
  • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
005010X223A3
BHT
0100
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

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

Usage notes
  • The second example denotes the case where the entire transaction set contains ENCOUNTERS.
Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)

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

0019
Information Source, Subscriber, Dependent
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

Usage notes
  • BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status.
00
Original

Original transmissions are transmissions which have never been sent to the receiver.

18
Reissue

If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent.

BHT-03
127
Originator Application Transaction Identifier
Required
String (AN)
Min 1Max 50

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

  • BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
Usage notes
  • The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
  • This field is limited to 30 characters.
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

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

  • BHT04 is the date the transaction was created within the business application system.
Usage notes
  • This is the date that the original submitter created the claim file from their business application system.
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

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

  • BHT05 is the time the transaction was created within the business application system.
Usage notes
  • This is the time that the original submitter created the claim file from their business application system.
BHT-06
640
Claim Identifier
Required
Identifier (ID)

Code specifying the type of transaction

31
Subrogation Demand

The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners.
NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction.

CH
Chargeable

Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.

RP
Reporting

Use RP when the entire ST-SE envelope contains only capitated encounters.
Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes.

1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name Loop
NM1
0200
Heading > Submitter Name Loop > NM1

Submitter Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • The submitter is the entity responsible for the creation and formatting of this transaction.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

41
Submitter
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

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

46
Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

NM1-09
67
Submitter Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
0450
Heading > Submitter Name Loop > PER

Submitter EDI Contact Information

RequiredMax use 2

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

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
  • The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
  • There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
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
PER-01
366
Contact Function Code
Required
Identifier (ID)

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

IC
Information Contact
PER-02
93
Submitter Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

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

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

1000A Submitter Name Loop end
1000B Receiver Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Name Loop
NM1
0200
Heading > Receiver Name Loop > NM1

Receiver Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

40
Receiver
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

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

Code identifying a party or other code

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV

Billing Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

BI
Billing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

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

CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR

Foreign Currency Information

OptionalMax use 1

To specify the currency (dollars, pounds, francs, etc.) used in a transaction

Usage notes
  • Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.
  • It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.
Example
CUR-01
98
Entity Identifier Code
Required
Identifier (ID)

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

85
Billing Provider
CUR-02
100
Currency Code
Required
Identifier (ID)
Min 3Max 3

Code (Standard ISO) for country in whose currency the charges are specified

Usage notes
  • The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.
2010AA Billing Provider Name Loop
RequiredMax 1
Variants (all may be used)
Pay-to Address Name LoopPay-To Plan Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1

Billing Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
  • Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
  • The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
  • When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
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
Identifier (ID)

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

85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

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

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3

Billing Provider Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
Example
N3-01
166
Billing Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Billing Provider Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4

Billing Provider City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider Tax Identification

RequiredMax use 1

To specify identifying information

Usage notes
  • This is the tax identification number (TIN) of the entity to be paid for the submitted services.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

REF-02
127
Billing Provider Tax Identification Number
Required
String (AN)
Min 1Max 50

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

PER
0400
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER

Billing Provider Contact Information

OptionalMax use 2

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

Usage notes
  • Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
  • There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
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
PER-01
366
Contact Function Code
Required
Identifier (ID)

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

IC
Information Contact
PER-02
93
Billing Provider Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

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

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

2010AA Billing Provider Name Loop end
2010AB Pay-to Address Name Loop
OptionalMax 1
Variants (all may be used)
Billing Provider Name LoopPay-To Plan Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1

Pay-to Address Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
  • The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

87
Pay-to Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3

Pay-to Address - ADDRESS

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Pay-To Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Pay-To Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4

Pay-To Address City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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
N4-01
19
Pay-to Address City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2010AB Pay-to Address Name Loop end
2010AC Pay-To Plan Name Loop
OptionalMax 1
Variants (all may be used)
Billing Provider Name LoopPay-to Address Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > NM1

Pay-To Plan Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when willing trading partners agree to use this implementation for their subrogation payment requests.
  • This loop may only be used when BHT06 = 31.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

PE
Payee

PE is used to indicate the subrogated payee.

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

Usage notes
  • Use code value "PI" when reporting Payor Identification.
    Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:

  1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
    OR
  2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Pay-To Plan Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3

Pay-to Plan Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Pay-To Plan Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Pay-To Plan Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4

Pay-To Plan City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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
N4-01
19
Pay-To Plan City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-to Plan Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFPay-To Plan Tax Identification Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number

This code is only allowed when the qualifier XV is reported in NM108 of this loop.

FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Pay-to Plan Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-To Plan Tax Identification Number

RequiredMax use 1

To specify identifying information

Example
Variants (all may be used)
REFPay-to Plan Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

REF-02
127
Pay-To Plan Tax Identification Number
Required
String (AN)
Min 1Max 50

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

2010AC 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

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR

Subscriber Information

RequiredMax use 1

To record information specific to the primary insured and the insurance carrier for that insured

Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Usage notes
  • Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
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

This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

SBR-02
1069
Individual Relationship Code
Optional
Identifier (ID)

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
18
Self
SBR-03
127
Subscriber Group or Policy Number
Optional
String (AN)
Min 1Max 50

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

  • SBR03 is policy or group number.
Usage notes
  • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
SBR-04
93
Subscriber Group Name
Optional
String (AN)
Min 1Max 60

Free-form name

  • SBR04 is plan name.
SBR-09
1032
Claim Filing Indicator Code
Required
Identifier (ID)

Code identifying type of claim

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

Use code OF when submitting Medicare Part D claims.

TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined

Use Code ZZ when Type of Insurance is not known.

2010BA Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Payer Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

Usage notes
  • Examples: I, II, III, IV, Jr, Sr
    This data element is used only to indicate generation or patronymic.
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

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

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

NM1-09
67
Subscriber Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
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
N4-01
19
Subscriber City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Property and Casualty Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
  • This segment is not a HIPAA requirement as of this writing.
  • Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFSubscriber Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50

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

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Subscriber Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50

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

2010BA Subscriber Name Loop end
2010BB Payer Name Loop
RequiredMax 1
Variants (all may be used)
Subscriber Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1

Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This is the destination payer.
  • For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

Usage notes
  • Use code value "PI" when reporting Payor Identification.
    Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:

  1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
    OR
  2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Payer Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3

Payer Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
N3-01
166
Payer Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4

Payer City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
Only one of Payer 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
N4-01
19
Payer City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Billing Provider Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFPayer Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Payer Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFBilling Provider Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number

This code is only allowed when the qualifier XV is reported in NM108 of this loop.

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Payer Additional Identifier
Required
String (AN)
Min 1Max 50

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

2010BB 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

To specify basic data about the claim

Usage notes
  • The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
  • For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38

Identifier used to track a claim from creation by the health care provider through payment

Usage notes
  • The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
  • When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
  • The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CLM02 is the total amount of all submitted charges of service segments for this claim.
Usage notes
  • The Total Claim Charge Amount must be greater than or equal to zero.
  • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim.
CLM-05
C023
Health Care Service Location Information
Required
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Facility Type Code
Required
String (AN)
Min 1Max 2

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

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

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
A
Uniform Billing Claim Form Bill Type
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)

Code indicating whether the provider accepts assignment

Usage notes
  • Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
A
Assigned

Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans.

B
Assignment Accepted on Clinical Lab Services Only

Required when the provider accepts assignment for Clinical Lab Services only.

C
Not Assigned

Required when neither codes A' nor B' apply.

CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)

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

Usage notes
  • The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)

Code indicating the reason why a request was delayed

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

Admission Date/Hour

OptionalMax use 1

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

Usage notes
  • Required on inpatient claims.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - Repricer Received DateDTPDischarge HourDTPStatement Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

435
Admission
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
Usage notes
  • Selection of the appropriate qualifier is designated by the NUBC Billing Manual.
D8
Date Expressed in Format CCYYMMDD
DT
Date and Time Expressed in Format CCYYMMDDHHMM
DTP-03
1251
Admission Date and Hour
Required
String (AN)
Min 1Max 35

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

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Repricer Received Date

OptionalMax use 1

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

Usage notes
  • Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPAdmission Date/HourDTPDischarge HourDTPStatement Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Discharge Hour

OptionalMax use 1

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

Usage notes
  • Required on all final inpatient claims. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPAdmission Date/HourDTPDate - Repricer Received DateDTPStatement Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

096
Discharge
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Statement Dates

RequiredMax use 1

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

Example
Variants (all may be used)
DTPAdmission Date/HourDTPDate - Repricer Received DateDTPDischarge Hour
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

434
Statement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same.

DTP-03
1251
Statement From and To Date
Required
String (AN)
Min 1Max 35

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

CL1
1400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CL1

Institutional Claim Code

RequiredMax use 1

To supply information specific to hospital claims

Example
CL1-01
1315
Admission Type Code
Required
Identifier (ID)
Min 1Max 1

Code indicating the priority of this admission

CL1-02
1314
Admission Source Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating the source of this admission

CL1-03
1352
Patient Status Code
Required
Identifier (ID)
Min 1Max 2

Code indicating patient status as of the "statement covers through date"

PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK

Claim Supplemental Information

OptionalMax use 10

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • Required when there is a paper attachment following this claim.
    OR
    Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
    OR
    Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
    If not required by this implementation guide, do not send.
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

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
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

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

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1

To specify basic data about the contract or contract line item

Usage notes
  • Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
  • The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)

Code identifying a contract type

01
Diagnosis Related Group (DRG)
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CN102 is the contract amount.
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

  • CN103 is the allowance or charge percent.
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50

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

  • CN104 is the contract code.
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

  • CN106 is an additional identifying number for the contract.
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT

Patient Estimated Amount Due

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the Patient Responsibility Amount is applicable to this claim.
    If not required by this implementation guide, do not send.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

F3
Patient Responsibility - Estimated
AMT-02
782
Patient Responsibility Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
Example
Variants (all may be used)
REFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Auto Accident State

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code named in code source 22. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

LU
Location Number
REF-02
127
Auto Accident State or Province Code
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Values in this field must be valid codes found in code source 22.
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Claim Identifier For Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
  • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes
  • Number assigned by clearinghouse, van, etc.
D9
Claim Number
REF-02
127
Value Added Network Trace Number
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The value carried in this element is limited to a maximum of 20 positions.
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Demonstration Project Identifier

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

P4
Project Code
REF-02
127
Demonstration Project Identifier
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Investigational Device Exemption Number

OptionalMax use 5

To specify identifying information

Usage notes
  • Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

LX
Qualified Products List
REF-02
127
Investigational Device Exemption Identifier
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Medical Record Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EA
Medical Record Identification Number
REF-02
127
Medical Record Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Peer Review Organization (PRO) Approval Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G4
Peer Review Organization (PRO) Approval Number
REF-02
127
Peer Review Authorization Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Prior Authorization

OptionalMax use 1

To specify identifying information

Usage notes
  • Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • Required when an authorization number is assigned by the payer or UMO
    AND
    the services on this claim were preauthorized.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Prior Authorization Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
    AND
    a referral is involved.
    If not required by this implementation guide, do not send.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Service Authorization Exception Code

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Allowable values for this element are:
    1 Immediate/Urgent Care
    2 Services Rendered in a Retroactive Period
    3 Emergency Care
    4 Client has Temporary Medicaid
    5 Request from County for Second Opinion to Determine
    if Recipient Can Work
    6 Request for Override Pending
    7 Special Handling
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10

To transmit a fixed-format record or matrix contents

Usage notes
  • Required when ALL of the following conditions are met:
  • A regulatory agency concludes it must use the K3 to meet an emergency
    legislative requirement;
  • The administering regulatory agency or other state organization has
    completed each one of the following steps:
    contacted the X12N workgroup,
    requested a review of the K3 data requirement to ensure there is not
    an existing method within the implementation guide to meet this
    requirement
  • X12N determines that there is no method to meet the requirement.
    If not required by this implementation guide, do not send.
  • At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
    Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE

Billing Note

OptionalMax use 1

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
NTEClaim Note
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

ADD
Additional Information
NTE-02
352
Billing Note Text
Required
String (AN)
Min 1Max 80

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

NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE

Claim Note

OptionalMax use 10

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
    OR
    Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services.
    If not required by this implementation guide, do not send.
  • The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Example
Variants (all may be used)
NTEBilling Note
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

ALG
Allergies
DCP
Goals, Rehabilitation Potential, or Discharge Plans
DGN
Diagnosis Description
DME
Durable Medical Equipment (DME) and Supplies
MED
Medications
NTR
Nutritional Requirements
ODT
Orders for Disciplines and Treatments
RHB
Functional Limitations, Reason Homebound, or Both
RLH
Reasons Patient Leaves Home
RNH
Times and Reasons Patient Not at Home
SET
Unusual Home, Social Environment, or Both
SFM
Safety Measures
SPT
Supplementary Plan of Treatment
UPI
Updated Information
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80

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

CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC

EPSDT Referral

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Qualifier
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
ZZ
Mutually Defined

EPSDT Screening referral information.

CRC-02
1073
Certification Condition Code Applies Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Usage notes
  • The response answers the question: Was an EPSDT referral given to the patient?
N
No

If no, then choose "NU" in CRC03 indicating no referral given.

Y
Yes
CRC-03
1321
Condition Indicator
Required
Identifier (ID)

Code indicating a condition

Usage notes
  • The codes for CRC03 also can be used for CRC04 through CRC05.
AV
Available - Not Used

Patient refused referral.

NU
Not Used

This conditioner indicator must be used when the submitter answers "N" in CRC02.

S2
Under Treatment

Patient is currently under treatment for referred diagnostic or corrective health problem.

ST
New Services Requested

Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
OR
Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).;

CRC-04
1321
Condition Indicator
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-05
1321
Condition Indicator
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Admitting Diagnosis

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when claim involves an inpatient admission.
    If not required by this implementation guide, do not send.;
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
C022-02
1271
Admitting Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Condition Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Diagnosis Related Group (DRG) Information

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
DR
Diagnosis Related Group (DRG)
C022-02
1271
Diagnosis Related Group (DRG) Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

External Cause of Injury

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
  • In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Occurrence Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Occurrence Span Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Other Diagnosis Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
  • Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Other Procedure Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Patient's Reason For Visit

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when claim involves outpatient visits. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Patient Reason For Visit
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Patient Reason For Visit
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Patient Reason For Visit
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Principal Diagnosis

RequiredMax use 1

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Principal Procedure Information

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBR
International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BR
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes
CAH
Advanced Billing Concepts (ABC) Codes
C022-02
1271
Principal Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Principal Procedure Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Treatment Code Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Value Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP

Claim Pricing/Repricing Information

OptionalMax use 1

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Example
If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

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

  • HCP04 is the repricing organization identification number.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-06
127
Repriced Approved DRG Code
Optional
String (AN)
Min 1Max 50

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

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-07
782
Repriced Approved Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP07 is the approved DRG amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-08
234
Repriced Approved Revenue Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP08 is the approved revenue code.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

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

DA
Days
UN
Unit
HCP-12
380
Repriced Approved Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • HCP12 is the approved service units or inpatient days.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)

Code specifying policy compliance

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2310A Attending Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > NM1

Attending Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send.
  • The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim.
Example
If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

71
Attending Physician

When used, the term physician is any type of provider filling this role.

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Attending Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Attending Provider Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV

Attending Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AT
Attending
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

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

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF

Attending Provider Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Attending Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310A Attending Provider Name Loop end
2310B Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOther Operating Physician Name LoopRendering Provider Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1

Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send.
  • The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s).
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

72
Operating Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Operating Physician Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > REF

Operating Physician Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Operating Physician Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310B Operating Physician Name Loop end
2310C Other Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopRendering Provider Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > NM1

Other Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when another Operating Physician is involved. If not required by the implementation guide, do not send.
  • The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician.
  • This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

ZZ
Mutually Defined

ZZ is used to indicate Other Operating Physician.

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Other Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Other Operating Physician Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > REF

Other Operating Physician Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Other Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310C Other Operating Physician Name Loop end
2310D Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopOther Operating Physician Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim.
    AND
    When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.)
    If not required by this implementation guide, do not send.
  • The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310D Rendering Provider Name Loop end
2310E Service Facility Location Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
    If not required by this implementation guide, do not send.
  • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of Laboratory or Facility 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
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310E Service Facility Location Name Loop end
2310F Referring Provider Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name LoopService Facility Location Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send.
  • The Referring Provider is provider who sends the patient to another provider for services.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310F Referring Provider Name Loop end
2320 Other Subscriber Information Loop
OptionalMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1

To record information specific to the primary insured and the insurance carrier for that insured

Usage notes
  • Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
  • All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Usage notes
  • Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
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

This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

SBR-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
01
Spouse
18
Self
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
SBR-03
127
Insured Group or Policy Number
Optional
String (AN)
Min 1Max 50

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

  • SBR03 is policy or group number.
Usage notes
  • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
SBR-04
93
Other Insured Group Name
Optional
String (AN)
Min 1Max 60

Free-form name

  • SBR04 is plan name.
SBR-09
1032
Claim Filing Indicator Code
Required
Identifier (ID)

Code identifying type of claim

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

Use code OF when submitting Medicare Part D claims.

TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined

Use Code ZZ when Type of Insurance is not known.

CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS

Claim Level Adjustments

OptionalMax use 5

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
  • Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
  • Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
  • Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)

Code identifying the general category of payment adjustment

CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Payer Paid Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
    OR
    Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
    If not required by this implementation guide, do not send.;
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Total Non-Covered AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

D
Payor Amount Paid
AMT-02
782
Payer Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • It is acceptable to show "0" as the amount paid.
  • When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Total Non-Covered Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
  • When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

A8
Noncovered Charges - Actual
AMT-02
782
Non-Covered Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
    OR
    Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
    If not required by this implementation guide, do not send.
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
  • This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTCoordination of Benefits (COB) Total Non-Covered Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

OI
3100
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI

Other Insurance Coverage Information

RequiredMax use 1

To specify information associated with other health insurance coverage

Usage notes
  • All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Example
OI-03
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This is a crosswalk from CLM08 when doing COB.
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
OI-06
1363
Release of Information Code
Required
Identifier (ID)

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

Usage notes
  • This is a crosswalk from CLM09 when doing COB.
  • The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

MIA
3150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA

Inpatient Adjudication Information

OptionalMax use 1

To provide claim-level data related to the adjudication of Medicare inpatient claims

Usage notes
  • Required when inpatient adjudication information is reported in the remittance advice.
    OR
    Required when it is necessary to report remark codes.
    If not required by this implementation guide, do not send.
Example
MIA-01
380
Covered Days or Visits Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • MIA01 is the covered days.
MIA-03
380
Lifetime Psychiatric Days Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • MIA03 is the lifetime psychiatric days.
MIA-04
782
Claim DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA04 is the Diagnosis Related Group (DRG) amount.
MIA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA05 is the Claim Payment Remark Code. See Code Source 411.
MIA-06
782
Claim Disproportionate Share Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA06 is the disproportionate share amount.
MIA-07
782
Claim MSP Pass-through Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.
MIA-08
782
Claim PPS Capital Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA08 is the total Prospective Payment System (PPS) capital amount.
MIA-09
782
PPS-Capital FSP DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount.
MIA-10
782
PPS-Capital HSP DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount.
MIA-11
782
PPS-Capital DSH DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount.
MIA-12
782
Old Capital Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA12 is the old capital amount.
MIA-13
782
PPS-Capital IME amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.
MIA-14
782
PPS-Operating Hospital Specific DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.
MIA-15
380
Cost Report Day Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • MIA15 is the cost report days.
MIA-16
782
PPS-Operating Federal Specific DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA16 is the federal specific Diagnosis Related Group (DRG) amount.
MIA-17
782
Claim PPS Capital Outlier Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.
MIA-18
782
Claim Indirect Teaching Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA18 is the indirect teaching amount.
MIA-19
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA19 is the professional component amount billed but not payable.
MIA-20
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA20 is the Claim Payment Remark Code. See Code Source 411.
MIA-21
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA21 is the Claim Payment Remark Code. See Code Source 411.
MIA-22
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA22 is the Claim Payment Remark Code. See Code Source 411.
MIA-23
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA23 is the Claim Payment Remark Code. See Code Source 411.
MIA-24
782
PPS-Capital Exception Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA24 is the capital exception amount.
MOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA

Outpatient Adjudication Information

OptionalMax use 1

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Usage notes
  • Required when outpatient adjudication information is reported in the remittance advice
    OR
    Required when it is necessary to report remark codes.
    If not required by this implementation guide, do not send.
Example
MOA-01
954
Reimbursement Rate
Optional
Decimal number (R)
Min 1Max 10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

  • MOA01 is the reimbursement rate.
MOA-02
782
HCPCS Payable Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
MOA-03
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA-04
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA04 is the Claim Payment Remark Code. See Code Source 411.
MOA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA05 is the Claim Payment Remark Code. See Code Source 411.
MOA-06
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA06 is the Claim Payment Remark Code. See Code Source 411.
MOA-07
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA-08
782
End Stage Renal Disease Payment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA08 is the End Stage Renal Disease (ESRD) payment amount.
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA09 is the professional component amount billed but not payable.
2330A Other Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Other Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1

Other Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
  • If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

NM1-09
67
Other Insured Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3

Other Subscriber Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
Example
N3-01
166
Other Insured Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Insured Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4

Other Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
Example
Only one of Other Insured 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
N4-01
19
Other Insured City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF

Other Subscriber Secondary Identification

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Other Insured Additional Identifier
Required
String (AN)
Min 1Max 50

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

2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1

Other Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

Usage notes
  • Use code value "PI" when reporting Payor Identification.
    Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:

  1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
    OR
  2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3

Other Payer Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
N3-01
166
Other Payer Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Payer Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4

Other Payer City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
Only one of Other Payer 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
N4-01
19
Other Payer City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DTP
3500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP

Claim Check or Remittance Date

OptionalMax use 1

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

Usage notes
  • Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Adjustment Indicator

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the claim is being sent in the payer-to-payer COB model,
    AND
    the destination payer is secondary to the payer identified in this Loop ID-2330B,
    AND
    the payer identified in this Loop ID-2330B has re-adjudicated the claim.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

T4
Signal Code
REF-02
127
Other Payer Claim Adjustment Indicator
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Only allowed value is "Y".
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
    OR
    Required when the Other Payer's Claim Control Number is available.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F8
Original Reference Number

This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.

REF-02
127
Other Payer's Claim Control Number
Required
String (AN)
Min 1Max 50

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Prior Authorization Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a prior authorization number to this claim.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Other Payer Prior Authorization Number
Required
String (AN)
Min 1Max 50

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a referral number to this claim.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Other Payer Prior Authorization or Referral Number
Required
String (AN)
Min 1Max 50

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Secondary Identifier

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Referral Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number

This code is only allowed when the qualifier XV is reported in NM108 of this loop.

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Other Payer Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330B Other Payer Name Loop end
2330C Other Payer Attending Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > NM1

Other Payer Attending Provider

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

71
Attending Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > REF

Other Payer Attending Provider Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Attending Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330C Other Payer Attending Provider Loop end
2330D Other Payer Operating Physician Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > NM1

Other Payer Operating Physician

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

72
Operating Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > REF

Other Payer Operating Physician Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Operating Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330D Other Payer Operating Physician Loop end
2330E Other Payer Other Operating Physician Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > NM1

Other Payer Other Operating Physician

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

ZZ
Mutually Defined

ZZ is used to indicate Other Operating Physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > REF

Other Payer Other Operating Physician Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Other Operating Physician Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330E Other Payer Other Operating Physician Loop end
2330F Other Payer Service Facility Location Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1

Other Payer Service Facility Location

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF

Other Payer Service Facility Location Secondary Identification

RequiredMax use 3

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Service Facility Location Identifier
Required
String (AN)
Min 1Max 50

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

2330F Other Payer Service Facility Location Loop end
2330G Other Payer Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > NM1

Other Payer Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > REF

Other Payer Rendering Provider Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330G Other Payer Rendering Provider Name Loop end
2330H Other Payer Referring Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1

Other Payer Referring Provider

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF

Other Payer Referring Provider Secondary Identification

RequiredMax use 3

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

REF-02
127
Other Payer Referring Provider Identifier
Required
String (AN)
Min 1Max 50

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

2330H Other Payer Referring Provider Loop end
2330I Other Payer Billing Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1

Other Payer Billing Provider

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF

Other Payer Billing Provider Secondary Identification

RequiredMax use 2

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Billing Provider Identifier
Required
String (AN)
Min 1Max 50

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

2330I Other Payer Billing Provider Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 999
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX

Service Line Number

RequiredMax use 1

To reference a line number in a transaction set

Usage notes
  • The LX functions as a line counter.
  • The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
  • LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

SV2
3750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV2

Institutional Service Line

RequiredMax use 1

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

Example
SV2-01
234
Service Line Revenue Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • SV201 is the revenue code.
Usage notes
  • See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
SV2-02
C003
Composite Medical Procedure Identifier
Optional
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes

Required for outpatient claims when an appropriate procedure code exists for this service line item.
OR
Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics only) or HIPPS code exists for this service line item.
If not required by this implementation guide, do not send.;

C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

  • C003-01 qualifies C003-02 and C003-08.
ER
Jurisdiction Specific Procedure and Supply Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

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

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.;

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

C003-02
234
Procedure Code
Required
String (AN)
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.
C003-03
1339
Procedure Modifier
Optional
String (AN)
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
String (AN)
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
String (AN)
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
String (AN)
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.
C003-07
352
Description
Optional
String (AN)
Min 1Max 80

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

  • C003-07 is the description of the procedure identified in C003-02.
SV2-03
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV203 is the submitted service line item amount.
Usage notes
  • This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
  • Zero "0" is an acceptable value for this element.
SV2-04
355
Unit or Basis for Measurement Code
Required
Identifier (ID)

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

DA
Days
UN
Unit
SV2-05
380
Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SV2-07
782
Line Item Denied Charge or Non-Covered Charge Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV207 is a non-covered service amount.
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK

Line Supplemental Information

OptionalMax use 10

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • Required when there is a paper attachment following this claim.
    OR
    Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
    OR
    Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
    If not required by this implementation guide, do not send.
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

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
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

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

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Service Date

OptionalMax use 1

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

Usage notes
  • Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day.
    OR
    Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written.
    If not required by this implementation guide, do not send.
  • In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.
  • In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written).
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
Usage notes
  • RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35

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

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Adjusted Repriced Line Item Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFLine Item Control NumberREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9D
Adjusted Repriced Line Item Reference Number
REF-02
127
Adjusted Repriced Line Item Reference Number
Required
String (AN)
Min 1Max 50

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

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Line Item Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
  • The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
  • Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

Usage notes
  • The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Repriced Line Item Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFLine Item Control Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9B
Repriced Line Item Reference Number
REF-02
127
Repriced Line Item Reference Number
Required
String (AN)
Min 1Max 50

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

AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Facility Tax Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
  • When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount.
Example
Variants (all may be used)
AMTService Tax Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

N8
Miscellaneous Taxes
AMT-02
782
Facility Tax Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Service Tax Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
  • When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount.
Example
Variants (all may be used)
AMTFacility Tax Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

GT
Goods and Services Tax
AMT-02
782
Service Tax Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

NTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE

Third Party Organization Notes

OptionalMax use 1

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

TPO
Third Party Organization Notes
NTE-02
352
Line Note Text
Required
String (AN)
Min 1Max 80

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

HCP
4920
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP

Line Pricing/Repricing Information

OptionalMax use 1

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Example
If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required
If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Monetary Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Monetary Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-04
127
Reference Identification
Optional
String (AN)
Min 1Max 50

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

  • HCP04 is the repricing organization identification number.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-05
118
Rate
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-06
127
Reference Identification
Optional
String (AN)
Min 1Max 50

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

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-07
782
Monetary Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP07 is the approved DRG amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-08
234
Product or Service ID
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP08 is the approved revenue code.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-09
235
Product or Service ID Qualifier
Optional
Identifier (ID)

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

ER
Jurisdiction Specific Procedure and Supply Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

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

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.;

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

HCP-10
234
Repriced Approved HCPCS Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP10 is the approved procedure code.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

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

DA
Days
UN
Unit
HCP-12
380
Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • HCP12 is the approved service units or inpatient days.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)

Code specifying policy compliance

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2410 Drug Identification Loop
OptionalMax 1
LIN
4930
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN

Drug Identification

RequiredMax use 1

To specify basic item identification data

Usage notes
  • Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400.
  • Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers.
    OR
    Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.
    If not required by this implementation guide, do not send.
Example
LIN-02
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

  • LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU.
N4
National Drug Code in 5-4-2 Format
LIN-03
234
National Drug Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

CTP
4940
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP

Drug Quantity

RequiredMax use 1

To specify pricing information

Example
CTP-04
380
National Drug Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

CTP-05
C001
Composite Unit of Measure
Required
To identify a composite unit of measure (See Figures Appendix for examples of use)
C001-01
355
Code Qualifier
Required
Identifier (ID)

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

F2
International Unit
GR
Gram
ME
Milligram
ML
Milliliter
UN
Unit
REF
4950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF

Prescription or Compound Drug Association Number

OptionalMax use 1

To specify identifying information

Usage notes
  • In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
  • Required when dispensing of the drug has been done with an assigned prescription number.
    OR
    Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number.
    If not required by this implementation guide, do not send.
  • For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

VY
Link Sequence Number
XZ
Pharmacy Prescription Number
REF-02
127
Prescription Number
Required
String (AN)
Min 1Max 50

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

2410 Drug Identification Loop end
2420A Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Other Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > NM1

Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when a surgical procedure code is listed on this claim.
    AND
    The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level).
    If not required by this implementation guide, do not send.
  • The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s).
Example
If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

72
Operating Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Operating Physician Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF

Operating Physician Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Operating Physician Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420A Operating Physician Name Loop end
2420B Other Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > NM1

Other Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when another Operating Physician is involved,
    AND
    The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level).
    If not required by this implementation guide, do not send.;
Example
If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

ZZ
Mutually Defined

ZZ is used to indicate Other Operating Physician.

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Other Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Other Operating Physician Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > REF

Other Operating Physician Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Other Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420B Other Operating Physician Name Loop end
2420C Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopReferring Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim.
    AND
    State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.)
    AND
    The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level).
    If not required by this implementation guide, do not send.
  • The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure.
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420C Rendering Provider Name Loop end
2420D Referring Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required on an outpatient claim when the Referring Provider is different than the Attending Provider.
    AND
    The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level).
    If not required by this implementation guide, do not send.
  • The Referring Provider is provider who sends the patient to another provider for services.
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420D Referring Provider Name Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD

Line Adjudication Information

RequiredMax use 1

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

Usage notes
  • Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
  • To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Example
SVD-01
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • SVD01 is the payer identification code.
Usage notes
  • This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
SVD-02
782
Service Line Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVD02 is the amount paid for this service line.
Usage notes
  • Zero "0" is an acceptable value for this element.
SVD-03
C003
Composite Medical Procedure Identifier
Optional
To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
Usage notes

Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01).
If not required by this implementation guide, do not send.

C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

  • C003-01 qualifies C003-02 and C003-08.
ER
Jurisdiction Specific Procedure and Supply Codes
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.;

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

C003-02
234
Procedure Code
Required
String (AN)
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.
C003-03
1339
Procedure Modifier
Optional
String (AN)
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
String (AN)
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
String (AN)
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
String (AN)
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.
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

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

  • C003-07 is the description of the procedure identified in C003-02.
SVD-04
234
Service Line Revenue Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • SVD04 is the revenue code.
SVD-05
380
Paid Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SVD05 is the paid units of service.
Usage notes
  • This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SVD-06
554
Bundled Line Number
Optional
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

  • SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS

Line Adjustment

OptionalMax use 5

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)

Code identifying the general category of payment adjustment

CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP

Line Check or Remittance Date

RequiredMax use 1

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

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

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

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
  • Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
  • This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000C Patient Hierarchical Level Loop
OptionalMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT

Patient Information

RequiredMax use 1

To supply patient information

Example
PAT-01
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

Usage notes
  • Specifies the patient's relationship to the person insured.
01
Spouse
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
2010CA Patient Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1

Patient Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N3

Patient Address

RequiredMax use 1

To specify the location of the named party

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

Address information

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

Address information

N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N4

Patient City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG

Patient Demographic Information

RequiredMax use 1

To supply demographic information

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

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

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

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

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

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF

Property and Casualty Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
  • This segment is not a HIPAA requirement as of this writing.
  • Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFProperty and Casualty Patient Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50

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

REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF

Property and Casualty Patient Identifier

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1W
Member Identification Number

This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim.

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Property and Casualty Patient Identifier
Required
String (AN)
Min 1Max 50

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

2010CA Patient Name Loop end
2300 Claim Information Loop
RequiredMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CLM

Claim Information

RequiredMax use 1

To specify basic data about the claim

Usage notes
  • The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
  • For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38

Identifier used to track a claim from creation by the health care provider through payment

Usage notes
  • The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
  • When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
  • The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CLM02 is the total amount of all submitted charges of service segments for this claim.
Usage notes
  • The Total Claim Charge Amount must be greater than or equal to zero.
  • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim.
CLM-05
C023
Health Care Service Location Information
Required
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Facility Type Code
Required
String (AN)
Min 1Max 2

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

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

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
A
Uniform Billing Claim Form Bill Type
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)

Code indicating whether the provider accepts assignment

Usage notes
  • Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
A
Assigned

Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans.

B
Assignment Accepted on Clinical Lab Services Only

Required when the provider accepts assignment for Clinical Lab Services only.

C
Not Assigned

Required when neither codes A' nor B' apply.

CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)

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

Usage notes
  • The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)

Code indicating the reason why a request was delayed

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 > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Admission Date/Hour

OptionalMax use 1

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

Usage notes
  • Required on inpatient claims.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - Repricer Received DateDTPDischarge HourDTPStatement Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

435
Admission
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
Usage notes
  • Selection of the appropriate qualifier is designated by the NUBC Billing Manual.
D8
Date Expressed in Format CCYYMMDD
DT
Date and Time Expressed in Format CCYYMMDDHHMM
DTP-03
1251
Admission Date and Hour
Required
String (AN)
Min 1Max 35

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

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Date - Repricer Received Date

OptionalMax use 1

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

Usage notes
  • Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPAdmission Date/HourDTPDischarge HourDTPStatement Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Discharge Hour

OptionalMax use 1

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

Usage notes
  • Required on all final inpatient claims. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPAdmission Date/HourDTPDate - Repricer Received DateDTPStatement Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

096
Discharge
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Statement Dates

RequiredMax use 1

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

Example
Variants (all may be used)
DTPAdmission Date/HourDTPDate - Repricer Received DateDTPDischarge Hour
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

434
Statement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same.

DTP-03
1251
Statement From and To Date
Required
String (AN)
Min 1Max 35

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

CL1
1400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CL1

Institutional Claim Code

RequiredMax use 1

To supply information specific to hospital claims

Example
CL1-01
1315
Admission Type Code
Required
Identifier (ID)
Min 1Max 1

Code indicating the priority of this admission

CL1-02
1314
Admission Source Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating the source of this admission

CL1-03
1352
Patient Status Code
Required
Identifier (ID)
Min 1Max 2

Code indicating patient status as of the "statement covers through date"

PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > PWK

Claim Supplemental Information

OptionalMax use 10

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • Required when there is a paper attachment following this claim.
    OR
    Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
    OR
    Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
    If not required by this implementation guide, do not send.
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

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
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

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

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1

To specify basic data about the contract or contract line item

Usage notes
  • Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
  • The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)

Code identifying a contract type

01
Diagnosis Related Group (DRG)
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CN102 is the contract amount.
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6

Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)

  • CN103 is the allowance or charge percent.
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50

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

  • CN104 is the contract code.
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

  • CN106 is an additional identifying number for the contract.
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > AMT

Patient Estimated Amount Due

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the Patient Responsibility Amount is applicable to this claim.
    If not required by this implementation guide, do not send.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

F3
Patient Responsibility - Estimated
AMT-02
782
Patient Responsibility Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
Example
Variants (all may be used)
REFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Auto Accident State

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code named in code source 22. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

LU
Location Number
REF-02
127
Auto Accident State or Province Code
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Values in this field must be valid codes found in code source 22.
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Claim Identifier For Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
  • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes
  • Number assigned by clearinghouse, van, etc.
D9
Claim Number
REF-02
127
Value Added Network Trace Number
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The value carried in this element is limited to a maximum of 20 positions.
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Demonstration Project Identifier

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

P4
Project Code
REF-02
127
Demonstration Project Identifier
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Investigational Device Exemption Number

OptionalMax use 5

To specify identifying information

Usage notes
  • Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

LX
Qualified Products List
REF-02
127
Investigational Device Exemption Identifier
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Medical Record Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EA
Medical Record Identification Number
REF-02
127
Medical Record Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Peer Review Organization (PRO) Approval Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G4
Peer Review Organization (PRO) Approval Number
REF-02
127
Peer Review Authorization Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Prior Authorization

OptionalMax use 1

To specify identifying information

Usage notes
  • Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • Required when an authorization number is assigned by the payer or UMO
    AND
    the services on this claim were preauthorized.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Prior Authorization Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
    AND
    a referral is involved.
    If not required by this implementation guide, do not send.
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

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

REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Service Authorization Exception Code

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Allowable values for this element are:
    1 Immediate/Urgent Care
    2 Services Rendered in a Retroactive Period
    3 Emergency Care
    4 Client has Temporary Medicaid
    5 Request from County for Second Opinion to Determine
    if Recipient Can Work
    6 Request for Override Pending
    7 Special Handling
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10

To transmit a fixed-format record or matrix contents

Usage notes
  • Required when ALL of the following conditions are met:
  • A regulatory agency concludes it must use the K3 to meet an emergency
    legislative requirement;
  • The administering regulatory agency or other state organization has
    completed each one of the following steps:
    contacted the X12N workgroup,
    requested a review of the K3 data requirement to ensure there is not
    an existing method within the implementation guide to meet this
    requirement
  • X12N determines that there is no method to meet the requirement.
    If not required by this implementation guide, do not send.
  • At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
    Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE

Billing Note

OptionalMax use 1

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
NTEClaim Note
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

ADD
Additional Information
NTE-02
352
Billing Note Text
Required
String (AN)
Min 1Max 80

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

NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE

Claim Note

OptionalMax use 10

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
    OR
    Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services.
    If not required by this implementation guide, do not send.
  • The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Example
Variants (all may be used)
NTEBilling Note
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

ALG
Allergies
DCP
Goals, Rehabilitation Potential, or Discharge Plans
DGN
Diagnosis Description
DME
Durable Medical Equipment (DME) and Supplies
MED
Medications
NTR
Nutritional Requirements
ODT
Orders for Disciplines and Treatments
RHB
Functional Limitations, Reason Homebound, or Both
RLH
Reasons Patient Leaves Home
RNH
Times and Reasons Patient Not at Home
SET
Unusual Home, Social Environment, or Both
SFM
Safety Measures
SPT
Supplementary Plan of Treatment
UPI
Updated Information
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80

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

CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC

EPSDT Referral

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.
Example
CRC-01
1136
Code Qualifier
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
ZZ
Mutually Defined

EPSDT Screening referral information.

CRC-02
1073
Certification Condition Code Applies Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Usage notes
  • The response answers the question: Was an EPSDT referral given to the patient?
N
No

If no, then choose "NU" in CRC03 indicating no referral given.

Y
Yes
CRC-03
1321
Condition Indicator
Required
Identifier (ID)

Code indicating a condition

Usage notes
  • The codes for CRC03 also can be used for CRC04 through CRC05.
AV
Available - Not Used

Patient refused referral.

NU
Not Used

This conditioner indicator must be used when the submitter answers "N" in CRC02.

S2
Under Treatment

Patient is currently under treatment for referred diagnostic or corrective health problem.

ST
New Services Requested

Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
OR
Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).;

CRC-04
1321
Condition Indicator
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-05
1321
Condition Indicator
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Admitting Diagnosis

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when claim involves an inpatient admission.
    If not required by this implementation guide, do not send.;
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
C022-02
1271
Admitting Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Condition Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Diagnosis Related Group (DRG) Information

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
DR
Diagnosis Related Group (DRG)
C022-02
1271
Diagnosis Related Group (DRG) Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

External Cause of Injury

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
  • In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABN
International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BN
International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
C022-02
1271
External Cause of Injury Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Occurrence Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BH
Occurrence
C022-02
1271
Occurrence Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Occurrence Code Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Occurrence Span Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BI
Occurrence Span
C022-02
1271
Occurrence Span Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
C022-04
1251
Occurrence Span Code Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Other Diagnosis Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
  • Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Other Diagnosis
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Other Procedure Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBQ
International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BQ
International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
C022-02
1271
Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Procedure Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Patient's Reason For Visit

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when claim involves outpatient visits. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Patient Reason For Visit
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Patient Reason For Visit
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Patient Reason For Visit
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Principal Diagnosis

RequiredMax use 1

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal Procedure InformationHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-09
1073
Present on Admission Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
  • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
N
No
U
Unknown
W
Not Applicable
Y
Yes
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Principal Procedure Information

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send.
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHITreatment Code InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BBR
International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-PCS as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

BR
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes
CAH
Advanced Billing Concepts (ABC) Codes
C022-02
1271
Principal Procedure Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Principal Procedure Date
Required
String (AN)
Min 1Max 35

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

HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Treatment Code Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHIValue Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
TC
Treatment Codes
C022-02
1271
Treatment Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Value Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-02
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-03
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-04
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-08
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BE
Value
C022-02
1271
Value Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-05
782
Value Code Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP

Claim Pricing/Repricing Information

OptionalMax use 1

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Example
If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

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

  • HCP04 is the repricing organization identification number.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-06
127
Repriced Approved DRG Code
Optional
String (AN)
Min 1Max 50

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

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-07
782
Repriced Approved Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP07 is the approved DRG amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-08
234
Repriced Approved Revenue Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP08 is the approved revenue code.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

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

DA
Days
UN
Unit
HCP-12
380
Repriced Approved Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • HCP12 is the approved service units or inpatient days.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)

Code specifying policy compliance

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2310A Attending Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > NM1

Attending Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send.
  • The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim.
Example
If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

71
Attending Physician

When used, the term physician is any type of provider filling this role.

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Attending Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Attending Provider Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV

Attending Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AT
Attending
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

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

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF

Attending Provider Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Attending Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310A Attending Provider Name Loop end
2310B Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOther Operating Physician Name LoopRendering Provider Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1

Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send.
  • The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s).
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

72
Operating Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Operating Physician Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > REF

Operating Physician Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Operating Physician Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310B Operating Physician Name Loop end
2310C Other Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopRendering Provider Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > NM1

Other Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when another Operating Physician is involved. If not required by the implementation guide, do not send.
  • The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician.
  • This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

ZZ
Mutually Defined

ZZ is used to indicate Other Operating Physician.

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Other Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Other Operating Physician Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > REF

Other Operating Physician Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Other Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310C Other Operating Physician Name Loop end
2310D Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopOther Operating Physician Name LoopService Facility Location Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim.
    AND
    When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.)
    If not required by this implementation guide, do not send.
  • The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310D Rendering Provider Name Loop end
2310E Service Facility Location Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
    If not required by this implementation guide, do not send.
  • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of Laboratory or Facility 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
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310E Service Facility Location Name Loop end
2310F Referring Provider Name Loop
OptionalMax 1
Variants (all may be used)
Attending Provider Name LoopOperating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name LoopService Facility Location Name Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send.
  • The Referring Provider is provider who sends the patient to another provider for services.
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310F Referring Provider Name Loop end
2320 Other Subscriber Information Loop
OptionalMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1

To record information specific to the primary insured and the insurance carrier for that insured

Usage notes
  • Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
  • All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)

Code identifying the insurance carrier's level of responsibility for a payment of a claim

Usage notes
  • Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
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

This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

SBR-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
01
Spouse
18
Self
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
SBR-03
127
Insured Group or Policy Number
Optional
String (AN)
Min 1Max 50

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

  • SBR03 is policy or group number.
Usage notes
  • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
SBR-04
93
Other Insured Group Name
Optional
String (AN)
Min 1Max 60

Free-form name

  • SBR04 is plan name.
SBR-09
1032
Claim Filing Indicator Code
Required
Identifier (ID)

Code identifying type of claim

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

Use code OF when submitting Medicare Part D claims.

TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined

Use Code ZZ when Type of Insurance is not known.

CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS

Claim Level Adjustments

OptionalMax use 5

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
  • Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
  • Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
  • Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)

Code identifying the general category of payment adjustment

CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Payer Paid Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
    OR
    Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
    If not required by this implementation guide, do not send.;
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Total Non-Covered AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

D
Payor Amount Paid
AMT-02
782
Payer Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • It is acceptable to show "0" as the amount paid.
  • When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Total Non-Covered Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
  • When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

A8
Noncovered Charges - Actual
AMT-02
782
Non-Covered Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
    OR
    Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
    If not required by this implementation guide, do not send.
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
  • This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTCoordination of Benefits (COB) Total Non-Covered Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

OI
3100
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI

Other Insurance Coverage Information

RequiredMax use 1

To specify information associated with other health insurance coverage

Usage notes
  • All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Example
OI-03
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Usage notes
  • This is a crosswalk from CLM08 when doing COB.
  • This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
N
No
W
Not Applicable

Use code `W' when the patient refuses to assign benefits.

Y
Yes
OI-06
1363
Release of Information Code
Required
Identifier (ID)

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

Usage notes
  • This is a crosswalk from CLM09 when doing COB.
  • The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.

MIA
3150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA

Inpatient Adjudication Information

OptionalMax use 1

To provide claim-level data related to the adjudication of Medicare inpatient claims

Usage notes
  • Required when inpatient adjudication information is reported in the remittance advice.
    OR
    Required when it is necessary to report remark codes.
    If not required by this implementation guide, do not send.
Example
MIA-01
380
Covered Days or Visits Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • MIA01 is the covered days.
MIA-03
380
Lifetime Psychiatric Days Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • MIA03 is the lifetime psychiatric days.
MIA-04
782
Claim DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA04 is the Diagnosis Related Group (DRG) amount.
MIA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA05 is the Claim Payment Remark Code. See Code Source 411.
MIA-06
782
Claim Disproportionate Share Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA06 is the disproportionate share amount.
MIA-07
782
Claim MSP Pass-through Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.
MIA-08
782
Claim PPS Capital Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA08 is the total Prospective Payment System (PPS) capital amount.
MIA-09
782
PPS-Capital FSP DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount.
MIA-10
782
PPS-Capital HSP DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount.
MIA-11
782
PPS-Capital DSH DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount.
MIA-12
782
Old Capital Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA12 is the old capital amount.
MIA-13
782
PPS-Capital IME amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.
MIA-14
782
PPS-Operating Hospital Specific DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.
MIA-15
380
Cost Report Day Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • MIA15 is the cost report days.
MIA-16
782
PPS-Operating Federal Specific DRG Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA16 is the federal specific Diagnosis Related Group (DRG) amount.
MIA-17
782
Claim PPS Capital Outlier Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.
MIA-18
782
Claim Indirect Teaching Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA18 is the indirect teaching amount.
MIA-19
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA19 is the professional component amount billed but not payable.
MIA-20
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA20 is the Claim Payment Remark Code. See Code Source 411.
MIA-21
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA21 is the Claim Payment Remark Code. See Code Source 411.
MIA-22
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA22 is the Claim Payment Remark Code. See Code Source 411.
MIA-23
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MIA23 is the Claim Payment Remark Code. See Code Source 411.
MIA-24
782
PPS-Capital Exception Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MIA24 is the capital exception amount.
MOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA

Outpatient Adjudication Information

OptionalMax use 1

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Usage notes
  • Required when outpatient adjudication information is reported in the remittance advice
    OR
    Required when it is necessary to report remark codes.
    If not required by this implementation guide, do not send.
Example
MOA-01
954
Reimbursement Rate
Optional
Decimal number (R)
Min 1Max 10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

  • MOA01 is the reimbursement rate.
MOA-02
782
HCPCS Payable Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
MOA-03
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA-04
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA04 is the Claim Payment Remark Code. See Code Source 411.
MOA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA05 is the Claim Payment Remark Code. See Code Source 411.
MOA-06
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA06 is the Claim Payment Remark Code. See Code Source 411.
MOA-07
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA-08
782
End Stage Renal Disease Payment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA08 is the End Stage Renal Disease (ESRD) payment amount.
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA09 is the professional component amount billed but not payable.
2330A Other Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Other Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1

Other Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
  • If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

NM1-09
67
Other Insured Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3

Other Subscriber Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
Example
N3-01
166
Other Insured Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Insured Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4

Other Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the information is available. If not required by this implementation guide, do not send.
Example
Only one of Other Insured 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
N4-01
19
Other Insured City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF

Other Subscriber Secondary Identification

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

REF-02
127
Other Insured Additional Identifier
Required
String (AN)
Min 1Max 50

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

2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1

Other Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

Usage notes
  • Use code value "PI" when reporting Payor Identification.
    Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:

  1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
    OR
  2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3

Other Payer Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
N3-01
166
Other Payer Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Other Payer Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4

Other Payer City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Example
Only one of Other Payer 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
N4-01
19
Other Payer City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DTP
3500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP

Claim Check or Remittance Date

OptionalMax use 1

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

Usage notes
  • Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Adjustment Indicator

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the claim is being sent in the payer-to-payer COB model,
    AND
    the destination payer is secondary to the payer identified in this Loop ID-2330B,
    AND
    the payer identified in this Loop ID-2330B has re-adjudicated the claim.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

T4
Signal Code
REF-02
127
Other Payer Claim Adjustment Indicator
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Only allowed value is "Y".
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
    OR
    Required when the Other Payer's Claim Control Number is available.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Prior Authorization NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F8
Original Reference Number

This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.

REF-02
127
Other Payer's Claim Control Number
Required
String (AN)
Min 1Max 50

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Prior Authorization Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a prior authorization number to this claim.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Referral NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Other Payer Prior Authorization Number
Required
String (AN)
Min 1Max 50

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the payer identified in this loop has assigned a referral number to this claim.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Secondary Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Other Payer Prior Authorization or Referral Number
Required
String (AN)
Min 1Max 50

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Secondary Identifier

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Prior Authorization NumberREFOther Payer Referral Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number

This code is only allowed when the qualifier XV is reported in NM108 of this loop.

EI
Employer's Identification Number

The Employer's Identification Number must be a string of exactly nine numbers with no separators.

For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.

FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Other Payer Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330B Other Payer Name Loop end
2330C Other Payer Attending Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > NM1

Other Payer Attending Provider

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

71
Attending Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > REF

Other Payer Attending Provider Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Attending Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330C Other Payer Attending Provider Loop end
2330D Other Payer Operating Physician Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > NM1

Other Payer Operating Physician

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

72
Operating Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > REF

Other Payer Operating Physician Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Operating Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330D Other Payer Operating Physician Loop end
2330E Other Payer Other Operating Physician Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > NM1

Other Payer Other Operating Physician

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

ZZ
Mutually Defined

ZZ is used to indicate Other Operating Physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > REF

Other Payer Other Operating Physician Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Other Operating Physician Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330E Other Payer Other Operating Physician Loop end
2330F Other Payer Service Facility Location Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1

Other Payer Service Facility Location

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF

Other Payer Service Facility Location Secondary Identification

RequiredMax use 3

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Service Facility Location Identifier
Required
String (AN)
Min 1Max 50

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

2330F Other Payer Service Facility Location Loop end
2330G Other Payer Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Referring Provider LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > NM1

Other Payer Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > REF

Other Payer Rendering Provider Secondary Identification

RequiredMax use 4

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2330G Other Payer Rendering Provider Name Loop end
2330H Other Payer Referring Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Billing Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1

Other Payer Referring Provider

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF

Other Payer Referring Provider Secondary Identification

RequiredMax use 3

To specify identifying information

Usage notes
  • Non-destination (COB) payer's provider identification number(s).
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

REF-02
127
Other Payer Referring Provider Identifier
Required
String (AN)
Min 1Max 50

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

2330H Other Payer Referring Provider Loop end
2330I Other Payer Billing Provider Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name LoopOther Payer Attending Provider LoopOther Payer Operating Physician LoopOther Payer Other Operating Physician LoopOther Payer Service Facility Location LoopOther Payer Rendering Provider Name LoopOther Payer Referring Provider Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1

Other Payer Billing Provider

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    OR
    Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
    If not required by this implementation guide, do not send.
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF

Other Payer Billing Provider Secondary Identification

RequiredMax use 2

To specify identifying information

Usage notes
  • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number

This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.

LU
Location Number
REF-02
127
Other Payer Billing Provider Identifier
Required
String (AN)
Min 1Max 50

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

2330I Other Payer Billing Provider Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 999
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX

Service Line Number

RequiredMax use 1

To reference a line number in a transaction set

Usage notes
  • The LX functions as a line counter.
  • The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
  • LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

SV2
3750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV2

Institutional Service Line

RequiredMax use 1

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

Example
SV2-01
234
Service Line Revenue Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • SV201 is the revenue code.
Usage notes
  • See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
SV2-02
C003
Composite Medical Procedure Identifier
Optional
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes

Required for outpatient claims when an appropriate procedure code exists for this service line item.
OR
Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics only) or HIPPS code exists for this service line item.
If not required by this implementation guide, do not send.;

C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

  • C003-01 qualifies C003-02 and C003-08.
ER
Jurisdiction Specific Procedure and Supply Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

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

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.;

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

C003-02
234
Procedure Code
Required
String (AN)
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.
C003-03
1339
Procedure Modifier
Optional
String (AN)
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
String (AN)
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
String (AN)
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
String (AN)
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.
C003-07
352
Description
Optional
String (AN)
Min 1Max 80

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

  • C003-07 is the description of the procedure identified in C003-02.
SV2-03
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV203 is the submitted service line item amount.
Usage notes
  • This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
  • Zero "0" is an acceptable value for this element.
SV2-04
355
Unit or Basis for Measurement Code
Required
Identifier (ID)

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

DA
Days
UN
Unit
SV2-05
380
Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SV2-07
782
Line Item Denied Charge or Non-Covered Charge Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV207 is a non-covered service amount.
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK

Line Supplemental Information

OptionalMax use 10

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • Required when there is a paper attachment following this claim.
    OR
    Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
    OR
    Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
    If not required by this implementation guide, do not send.
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

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
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

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

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Service Date

OptionalMax use 1

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

Usage notes
  • Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day.
    OR
    Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written.
    If not required by this implementation guide, do not send.
  • In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.
  • In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written).
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
Usage notes
  • RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35

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

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Adjusted Repriced Line Item Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFLine Item Control NumberREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9D
Adjusted Repriced Line Item Reference Number
REF-02
127
Adjusted Repriced Line Item Reference Number
Required
String (AN)
Min 1Max 50

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

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Line Item Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
  • The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
  • Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

Usage notes
  • The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Repriced Line Item Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFLine Item Control Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9B
Repriced Line Item Reference Number
REF-02
127
Repriced Line Item Reference Number
Required
String (AN)
Min 1Max 50

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

AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Facility Tax Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
  • When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount.
Example
Variants (all may be used)
AMTService Tax Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

N8
Miscellaneous Taxes
AMT-02
782
Facility Tax Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Service Tax Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
  • When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount.
Example
Variants (all may be used)
AMTFacility Tax Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

GT
Goods and Services Tax
AMT-02
782
Service Tax Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

NTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE

Third Party Organization Notes

OptionalMax use 1

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

TPO
Third Party Organization Notes
NTE-02
352
Line Note Text
Required
String (AN)
Min 1Max 80

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

HCP
4920
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP

Line Pricing/Repricing Information

OptionalMax use 1

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Example
If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required
If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Monetary Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Monetary Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-04
127
Reference Identification
Optional
String (AN)
Min 1Max 50

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

  • HCP04 is the repricing organization identification number.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-05
118
Rate
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-06
127
Reference Identification
Optional
String (AN)
Min 1Max 50

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

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-07
782
Monetary Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP07 is the approved DRG amount.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-08
234
Product or Service ID
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP08 is the approved revenue code.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-09
235
Product or Service ID Qualifier
Optional
Identifier (ID)

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

ER
Jurisdiction Specific Procedure and Supply Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

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

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.;

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

HCP-10
234
Repriced Approved HCPCS Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP10 is the approved procedure code.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

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

DA
Days
UN
Unit
HCP-12
380
Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • HCP12 is the approved service units or inpatient days.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)

Code specifying policy compliance

Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
Usage notes
  • This information is specific to the destination payer reported in Loop ID-2010BB.
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2410 Drug Identification Loop
OptionalMax 1
LIN
4930
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN

Drug Identification

RequiredMax use 1

To specify basic item identification data

Usage notes
  • Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400.
  • Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers.
    OR
    Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.
    If not required by this implementation guide, do not send.
Example
LIN-02
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

  • LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU.
N4
National Drug Code in 5-4-2 Format
LIN-03
234
National Drug Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

CTP
4940
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP

Drug Quantity

RequiredMax use 1

To specify pricing information

Example
CTP-04
380
National Drug Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

CTP-05
C001
Composite Unit of Measure
Required
To identify a composite unit of measure (See Figures Appendix for examples of use)
C001-01
355
Code Qualifier
Required
Identifier (ID)

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

F2
International Unit
GR
Gram
ME
Milligram
ML
Milliliter
UN
Unit
REF
4950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF

Prescription or Compound Drug Association Number

OptionalMax use 1

To specify identifying information

Usage notes
  • In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
  • Required when dispensing of the drug has been done with an assigned prescription number.
    OR
    Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number.
    If not required by this implementation guide, do not send.
  • For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

VY
Link Sequence Number
XZ
Pharmacy Prescription Number
REF-02
127
Prescription Number
Required
String (AN)
Min 1Max 50

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

2410 Drug Identification Loop end
2420A Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Other Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > NM1

Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when a surgical procedure code is listed on this claim.
    AND
    The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level).
    If not required by this implementation guide, do not send.
  • The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s).
Example
If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

72
Operating Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Operating Physician Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF

Operating Physician Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Operating Physician Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420A Operating Physician Name Loop end
2420B Other Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > NM1

Other Operating Physician Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when another Operating Physician is involved,
    AND
    The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level).
    If not required by this implementation guide, do not send.;
Example
If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

ZZ
Mutually Defined

ZZ is used to indicate Other Operating Physician.

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Other Operating Physician Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Other Operating Physician Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > REF

Other Operating Physician Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Other Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420B Other Operating Physician Name Loop end
2420C Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopReferring Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim.
    AND
    State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.)
    AND
    The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level).
    If not required by this implementation guide, do not send.
  • The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure.
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420C Rendering Provider Name Loop end
2420D Referring Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required on an outpatient claim when the Referring Provider is different than the Attending Provider.
    AND
    The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level).
    If not required by this implementation guide, do not send.
  • The Referring Provider is provider who sends the patient to another provider for services.
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 20

To specify identifying information

Usage notes
  • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
    OR
    Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
    If not required by this implementation guide, do not send.
  • When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number

UPINs must be formatted as either X99999 or XXX999.

G2
Provider Commercial Number

This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

REF-04
C040
Reference Identifier
Optional
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
Usage notes

Required when the identifier reported in REF02 of this segment is for a non-destination payer.

C040-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
C040-02
127
Other Payer Primary Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
2420D Referring Provider Name Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD

Line Adjudication Information

RequiredMax use 1

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

Usage notes
  • Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
  • To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Example
SVD-01
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • SVD01 is the payer identification code.
Usage notes
  • This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
SVD-02
782
Service Line Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVD02 is the amount paid for this service line.
Usage notes
  • Zero "0" is an acceptable value for this element.
SVD-03
C003
Composite Medical Procedure Identifier
Optional
To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
Usage notes

Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01).
If not required by this implementation guide, do not send.

C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

  • C003-01 qualifies C003-02 and C003-08.
ER
Jurisdiction Specific Procedure and Supply Codes
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.;

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

C003-02
234
Procedure Code
Required
String (AN)
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.
C003-03
1339
Procedure Modifier
Optional
String (AN)
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
String (AN)
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
String (AN)
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
String (AN)
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.
C003-07
352
Procedure Code Description
Optional
String (AN)
Min 1Max 80

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

  • C003-07 is the description of the procedure identified in C003-02.
SVD-04
234
Service Line Revenue Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • SVD04 is the revenue code.
SVD-05
380
Paid Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SVD05 is the paid units of service.
Usage notes
  • This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
  • The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
SVD-06
554
Bundled Line Number
Optional
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

  • SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS

Line Adjustment

OptionalMax use 5

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)

Code identifying the general category of payment adjustment

CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP

Line Check or Remittance Date

RequiredMax use 1

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

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

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

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
  • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
  • Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
  • This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000C Patient Hierarchical Level Loop end
2000B Subscriber Hierarchical Level Loop end
2000A Billing Provider Hierarchical Level Loop end
SE
5550
Detail > SE

Transaction Set Trailer

RequiredMax use 1

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

Example
SE-01
96
Transaction Segment Count
Required
Numeric (N0)
Min 1Max 10

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

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

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

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Detail end
GE

Functional Group Trailer

RequiredMax use 1

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

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

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

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

Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

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

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

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

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

A control number assigned by the interchange sender

EDI Samples

Example 1a: Institutional Claim

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231106*1408*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*140822*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*MEDICARE*****46*00120~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
REF*G2*330127~
CLM*756048Q*89.93***14>A>1**A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
HI*BH>A1>D8>19261111*BH>A2>D8>19911101*BH>B1>D8>19261111*BH>B2>D8>19870101~
HI*BE>A2>>>15.31~
HI*BG>09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC>93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*43*987654~
GE*1*000000001~
IEA*1*000000001~

Example 1b: Two Claims for the Same Provider

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231106*1410*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*141054*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*20050630*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*1112223333~
NM1*40*2*TRICARE*****46*99999~
HL*1**20*1~
PRV*BI*PXC*282N00000X~
NM1*85*2*JONES HOSPITAL*****XX*1234567890~
N3*225 MAIN STREET~
N4*ANYWHERE*PA*17111~
REF*EI*123456789~
HL*2*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*DOE*JOHN*T***MI*030005074~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19681111*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756048Q*89.95***13>A>1**C*Y*Y~
DTP*434*RD8*20050315-20050315~
CL1*1**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
NM1*71*1*JONES*JOHN*J***XX*1122334455~
REF*1G*U12345~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*20050315~
LX*2~
SV2*0730*HC>93010*76.56*UN*3~
DTP*472*D8*20050315~
HL*3*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*SMITH*JOE****MI*123405074~
N3*5 MAIN STREET~
N4*ANYWHERE*PA*17111~
DMG*D8*19621210*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756049Q*50***13>A>1**C*Y*Y~
DTP*434*RD8*20050401-20050401~
CL1*1**01~
HI*BK>30000~
NM1*71*1*JONES*JUDY*J***XX*9999999999~
PRV*AT*PXC*363LP0200N~
LX*1~
SV2*0300*HC>85087*50*UN*1~
DTP*472*D8*20050401~
SE*48*987654~
GE*1*000000001~
IEA*1*000000001~

Example 1c: PPO Repriced Claim

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231106*1415*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*141512*000000001*X*005010X223A3~
ST*837*1002*005010X223A3~
BHT*0019*00*1002*20050721*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*LOCAL INSURANCE COMPANY*****46*54334452~
HL*1**20*1~
NM1*85*2*GOOD HEALTH HOSPITAL*****XX*1257234346~
N3*592 NORTH ELM STREET~
N4*EDGEWOOD*AZ*860015590~
REF*EI*344232321~
HL*2*1*22*1~
SBR*P**46522567AW******CI~
NM1*IL*1*JONES*JENNY****MI*345U8423H~
N3*4512 WEST AVENUE~
N4*EVANSVILLE*AZ*863030000~
DMG*D8*19690731*F~
NM1*PR*2*LOCAL INSURANCE COMPANY*****PI*7452723~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*JONES*JOY~
N3*4512 WEST AVENUE~
N4*EVANSVILLE*AZ*863030000~
DMG*D8*19980820*F~
CLM*456DFH43*237.5***13>A>1**A*Y*Y~
DTP*434*RD8*20050706-20050706~
DTP*435*DT*200507060800~
CL1*1*2*01~
AMT*F3*237.5~
REF*9A*09459034092~
REF*D9*04566877634343456~
HI*BK>38181~
HI*BF>38900~
HI*BH>11>D8>20050706~
HCP*03*182.88*54.62*123456789~
NM1*71*1*JOHNSON*SIMON****XX*5544332211~
SBR*S*19**T&T PLUMBING COMPANY*****CI~
OI***Y***Y~
NM1*IL*1*JONES*GEORGE****MI*56454566~
NM1*PR*2*OTHER COVERAGE COMPANY*****PI*534524~
LX*1~
SV2*0471*HC>92557*178*UN*1~
DTP*472*D8*20050706~
HCP*03*137.06*40.94~
LX*2~
SV2*0471*HC>92567*59.5*UN*1~
DTP*472*D8*20050706~
HCP*03*45.82*13.68~
SE*48*1002~
GE*1*000000001~
IEA*1*000000001~

Example 1d: Out of Network Repriced Claim

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231106*1415*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*141557*000000001*X*005010X223A3~
ST*837*1024*005010X223A3~
BHT*0019*00*1024*20050711*1335*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~
HL*1**20*1~
NM1*85*2*LOCAL HOSPITAL*****XX*1122334455~
N3*3423 SMALL STREET~
N4*COLUMBUS*OH*432150000~
REF*EI*111002222~
HL*2*1*22*0~
SBR*P*18*34561W******CI~
NM1*IL*1*SMITH*JAMES*A***MI*34902390F~
N3*934 NORTH STREET~
N4*COLUMBUS*OH*432150000~
DMG*D8*19621015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*0012~
CLM*W392-49141*14.84***13>A>1**A*Y*Y~
DTP*434*RD8*20050617-20050617~
DTP*435*DT*200506170800~
CL1*1*1*01~
AMT*F3*14.84~
REF*9A*459804390823~
REF*D9*32423466233~
HI*BK>53081~
HCP*00*0**333001234*********T1~
NM1*71*1*RIVERS*DAWN****XX*2244224455~
LX*1~
SV2*0301*HC>82270*14.84*UN*1~
DTP*472*D8*20050617~
SE*31*1024~
GE*1*000000001~
IEA*1*000000001~

Example 2a: Automobile Accident

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231106*1416*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*141625*000000001*X*005010X223A3~
ST*837*557766*005010X223A3~
BHT*0019*00*0324*20051111*1800*CH~
NM1*41*2*HALL OF FAME MEMORIAL HOSPITAL*****46*737373737~
PER*IC*KATE CASEY*TE*7152569877~
NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*HALL OF FAME MEMORIAL HOSPITAL*****XX*2365259638~
N3*1 CANTON ROAD~
N4*BROKEN FIELD*CA*99998~
REF*EI*737373737~
HL*2*1*22*1~
SBR*P********AM~
NM1*IL*1*HOWLING*HAL****MI*B999777791G~
NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~
HL*3*2*23*0~
PAT*21~
NM1*QC*1*MEXICO*RON~
N3*32 BUFFALO RUN~
N4*ROCKING HORSE*CA*99666~
DMG*D8*19480601*M~
REF*Y4*32323232~
CLM*67236695521*545***13>A>1**A*Y*Y~
DTP*434*RD8*20051031-20051101~
CL1*3*7*1~
REF*LU*CA~
HI*BK>8842~
HI*PR>8842~
HI*BN>E9750*BN>E9860~
NM1*71*1*LOMBARDO*VINCENT****XX*2533698543~
LX*1~
SV2*0450*HC>98765*150*UN*1~
DTP*472*D8*20051031~
LX*2~
SV2*0360*HC>26591*75*UN*1~
DTP*472*D8*20051031~
LX*3~
SV2*0312*HC>86225*100*UN*2~
DTP*472*D8*20051031~
LX*4~
SV2*0360*HC>99283*220*UN*1~
DTP*472*D8*20051031~
SE*43*557766~
GE*1*000000001~
IEA*1*000000001~

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