X12 HIPAA
/
Health Care Claim: Professional (X222A1)
  • Specification
  • EDI Inspector
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X12 837 Health Care Claim: Professional (X222A1)

X12 Release 5010
—
Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
—
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
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
REF
0350
Billing Provider UPIN/License Information
Max use 2
Optional
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
PAT
0070
Patient Information
Max use 1
Optional
Subscriber Name Loop
NM1
0150
Subscriber Name
Max use 1
Required
N3
0250
Subscriber Address
Max use 1
Optional
N4
0300
Subscriber City, State, ZIP Code
Max use 1
Optional
DMG
0320
Subscriber Demographic Information
Max use 1
Optional
REF
0350
Subscriber Secondary Identification
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
PER
0400
Property and Casualty Subscriber Contact Information
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
Payer Secondary Identification
Max use 3
Optional
REF
0350
Billing Provider Secondary Identification
Max use 2
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Acute Manifestation
Max use 1
Optional
DTP
1350
Date - Admission
Max use 1
Optional
DTP
1350
Date - Assumed and Relinquished Care Dates
Max use 2
Optional
DTP
1350
Date - Authorized Return to Work
Max use 1
Optional
DTP
1350
Date - Disability Dates
Max use 1
Optional
DTP
1350
Date - Discharge
Max use 1
Optional
DTP
1350
Date - Hearing and Vision Prescription Date
Max use 1
Optional
DTP
1350
Date - Last Menstrual Period
Max use 1
Optional
DTP
1350
Date - Onset of Current Illness or Symptom
Max use 1
Optional
DTP
1350
Date - Initial Treatment Date
Max use 1
Optional
DTP
1350
Date - Last Seen Date
Max use 1
Optional
DTP
1350
Date - Last Worked
Max use 1
Optional
DTP
1350
Date - Last X-ray Date
Max use 1
Optional
DTP
1350
Date - Property and Casualty Date of First Contact
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Care Plan Oversight
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Mammography Certification Number
Max use 1
Optional
REF
1800
Mandatory Medicare (Section 4081) Crossover Indicator
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 1
Optional
CR1
1950
Ambulance Transport Information
Max use 1
Optional
CR2
2000
Spinal Manipulation Service Information
Max use 1
Optional
CRC
2200
Ambulance Certification
Max use 3
Optional
CRC
2200
Patient Condition Information: Vision
Max use 3
Optional
CRC
2200
Homebound Indicator
Max use 1
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Required
HI
2310
Anesthesia Related Procedure
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Referring Provider Name Loop
NM1
2500
Referring Provider Name
Max use 1
Required
REF
2710
Referring Provider Secondary Identification
Max use 3
Optional
Rendering Provider Name Loop
NM1
2500
Rendering Provider Name
Max use 1
Required
PRV
2550
Rendering Provider Specialty Information
Max use 1
Optional
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
PER
2750
Service Facility Contact Information
Max use 1
Optional
Supervising Provider Name Loop
NM1
2500
Supervising Provider Name
Max use 1
Required
REF
2710
Supervising Provider Secondary Identification
Max use 4
Optional
Ambulance Pick-up Location Loop
NM1
2500
Ambulance Pick-up Location
Max use 1
Required
N3
2650
Ambulance Pick-up Location Address
Max use 1
Required
N4
2700
Ambulance Pick-up Location City, State, ZIP Code
Max use 1
Required
Ambulance Drop-off Location Loop
NM1
2500
Ambulance Drop-off Location
Max use 1
Required
N3
2650
Ambulance Drop-off Location Address
Max use 1
Required
N4
2700
Ambulance Drop-off Location City, State, ZIP Code
Max use 1
Required
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Optional
AMT
3000
Coordination of Benefits (COB) Total Non-Covered Amount
Max use 1
Optional
AMT
3000
Remaining Patient Liability
Max use 1
Optional
OI
3100
Other Insurance Coverage Information
Max use 1
Required
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other 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 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
N3
3320
Other Payer Address
Max use 1
Optional
N4
3400
Other Payer City, State, ZIP Code
Max use 1
Optional
DTP
3450
Claim Check or Remittance Date
Max use 1
Optional
REF
3550
Other Payer Secondary Identifier
Max use 2
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 Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
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 Rendering Provider Loop
NM1
3250
Other Payer Rendering Provider
Max use 1
Required
REF
3550
Other Payer Rendering Provider Secondary Identification
Max use 3
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 Supervising Provider Loop
NM1
3250
Other Payer Supervising Provider
Max use 1
Required
REF
3550
Other Payer Supervising 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
SV1
3700
Professional Service
Max use 1
Required
SV5
4000
Durable Medical Equipment Service
Max use 1
Optional
PWK
4200
Line Supplemental Information
Max use 10
Optional
PWK
4200
Durable Medical Equipment Certificate of Medical Necessity Indicator
Max use 1
Optional
CR1
4250
Ambulance Transport Information
Max use 1
Optional
CR3
4350
Durable Medical Equipment Certification
Max use 1
Optional
CRC
4500
Ambulance Certification
Max use 3
Optional
CRC
4500
Hospice Employee Indicator
Max use 1
Optional
CRC
4500
Condition Indicator/Durable Medical Equipment
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Required
DTP
4550
Date - Prescription Date
Max use 1
Optional
DTP
4550
DATE - Certification Revision/Recertification Date
Max use 1
Optional
DTP
4550
Date - Begin Therapy Date
Max use 1
Optional
DTP
4550
Date - Initial Treatment Date
Max use 1
Optional
DTP
4550
Date - Last Certification Date
Max use 1
Optional
DTP
4550
Date - Last Seen Date
Max use 1
Optional
DTP
4550
Date - Last X-ray Date
Max use 1
Optional
DTP
4550
Date - Shipped Date
Max use 1
Optional
DTP
4550
Date - Test Date
Max use 2
Optional
QTY
4600
Ambulance Patient Count
Max use 1
Optional
QTY
4600
Obstetric Anesthesia Additional Units
Max use 1
Optional
MEA
4620
Test Result
Max use 5
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
4700
Immunization Batch Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Mammography Certification Number
Max use 1
Optional
REF
4700
Referral Number
Max use 5
Optional
REF
4700
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
AMT
4750
Postage Claimed Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
NTE
4850
Line Note
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
PS1
4880
Purchased Service Information
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
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
Rendering Provider Name Loop
NM1
5000
Rendering Provider Name
Max use 1
Required
PRV
5050
Rendering Provider Specialty Information
Max use 1
Optional
REF
5250
Rendering Provider Secondary Identification
Max use 20
Optional
Purchased Service Provider Name Loop
NM1
5000
Purchased Service Provider Name
Max use 1
Required
REF
5250
Purchased Service Provider Secondary Identification
Max use 20
Optional
Service Facility Location Name Loop
NM1
5000
Service Facility Location Name
Max use 1
Required
N3
5140
Service Facility Location Address
Max use 1
Required
N4
5200
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
5250
Service Facility Location Secondary Identification
Max use 3
Optional
Supervising Provider Name Loop
NM1
5000
Supervising Provider Name
Max use 1
Required
REF
5250
Supervising Provider Secondary Identification
Max use 20
Optional
Ordering Provider Name Loop
NM1
5000
Ordering Provider Name
Max use 1
Required
N3
5140
Ordering Provider Address
Max use 1
Optional
N4
5200
Ordering Provider City, State, ZIP Code
Max use 1
Optional
REF
5250
Ordering Provider Secondary Identification
Max use 20
Optional
PER
5300
Ordering Provider Contact Information
Max use 1
Optional
Referring Provider Name Loop
NM1
5000
Referring Provider Name
Max use 1
Required
REF
5250
Referring Provider Secondary Identification
Max use 20
Optional
Ambulance Pick-up Location Loop
NM1
5000
Ambulance Pick-up Location
Max use 1
Required
N3
5140
Ambulance Pick-up Location Address
Max use 1
Required
N4
5200
Ambulance Pick-up Location City, State, ZIP Code
Max use 1
Required
Ambulance Drop-off Location Loop
NM1
5000
Ambulance Drop-off Location
Max use 1
Required
N3
5140
Ambulance Drop-off Location Address
Max use 1
Required
N4
5200
Ambulance Drop-off Location City, State, ZIP Code
Max use 1
Required
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
Form Identification Code Loop
LQ
5510
Form Identification Code
Max use 1
Required
FRM
5520
Supporting Documentation
Max use 99
Required
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Patient Name Loop
NM1
0150
Patient Name
Max use 1
Required
N3
0250
Patient Address
Max use 1
Required
N4
0300
Patient City, State, ZIP Code
Max use 1
Required
DMG
0320
Patient Demographic Information
Max use 1
Required
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
REF
0350
Property and Casualty Patient Identifier
Max use 1
Optional
PER
0400
Property and Casualty Patient Contact Information
Max use 1
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Acute Manifestation
Max use 1
Optional
DTP
1350
Date - Admission
Max use 1
Optional
DTP
1350
Date - Assumed and Relinquished Care Dates
Max use 2
Optional
DTP
1350
Date - Authorized Return to Work
Max use 1
Optional
DTP
1350
Date - Disability Dates
Max use 1
Optional
DTP
1350
Date - Discharge
Max use 1
Optional
DTP
1350
Date - Hearing and Vision Prescription Date
Max use 1
Optional
DTP
1350
Date - Last Menstrual Period
Max use 1
Optional
DTP
1350
Date - Onset of Current Illness or Symptom
Max use 1
Optional
DTP
1350
Date - Initial Treatment Date
Max use 1
Optional
DTP
1350
Date - Last Seen Date
Max use 1
Optional
DTP
1350
Date - Last Worked
Max use 1
Optional
DTP
1350
Date - Last X-ray Date
Max use 1
Optional
DTP
1350
Date - Property and Casualty Date of First Contact
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Care Plan Oversight
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Mammography Certification Number
Max use 1
Optional
REF
1800
Mandatory Medicare (Section 4081) Crossover Indicator
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 1
Optional
CR1
1950
Ambulance Transport Information
Max use 1
Optional
CR2
2000
Spinal Manipulation Service Information
Max use 1
Optional
CRC
2200
Ambulance Certification
Max use 3
Optional
CRC
2200
Patient Condition Information: Vision
Max use 3
Optional
CRC
2200
Homebound Indicator
Max use 1
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Required
HI
2310
Anesthesia Related Procedure
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Referring Provider Name Loop
NM1
2500
Referring Provider Name
Max use 1
Required
REF
2710
Referring Provider Secondary Identification
Max use 3
Optional
Rendering Provider Name Loop
NM1
2500
Rendering Provider Name
Max use 1
Required
PRV
2550
Rendering Provider Specialty Information
Max use 1
Optional
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
PER
2750
Service Facility Contact Information
Max use 1
Optional
Supervising Provider Name Loop
NM1
2500
Supervising Provider Name
Max use 1
Required
REF
2710
Supervising Provider Secondary Identification
Max use 4
Optional
Ambulance Pick-up Location Loop
NM1
2500
Ambulance Pick-up Location
Max use 1
Required
N3
2650
Ambulance Pick-up Location Address
Max use 1
Required
N4
2700
Ambulance Pick-up Location City, State, ZIP Code
Max use 1
Required
Ambulance Drop-off Location Loop
NM1
2500
Ambulance Drop-off Location
Max use 1
Required
N3
2650
Ambulance Drop-off Location Address
Max use 1
Required
N4
2700
Ambulance Drop-off Location City, State, ZIP Code
Max use 1
Required
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Optional
AMT
3000
Coordination of Benefits (COB) Total Non-Covered Amount
Max use 1
Optional
AMT
3000
Remaining Patient Liability
Max use 1
Optional
OI
3100
Other Insurance Coverage Information
Max use 1
Required
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other 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 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
N3
3320
Other Payer Address
Max use 1
Optional
N4
3400
Other Payer City, State, ZIP Code
Max use 1
Optional
DTP
3450
Claim Check or Remittance Date
Max use 1
Optional
REF
3550
Other Payer Secondary Identifier
Max use 2
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 Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
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 Rendering Provider Loop
NM1
3250
Other Payer Rendering Provider
Max use 1
Required
REF
3550
Other Payer Rendering Provider Secondary Identification
Max use 3
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 Supervising Provider Loop
NM1
3250
Other Payer Supervising Provider
Max use 1
Required
REF
3550
Other Payer Supervising 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
SV1
3700
Professional Service
Max use 1
Required
SV5
4000
Durable Medical Equipment Service
Max use 1
Optional
PWK
4200
Line Supplemental Information
Max use 10
Optional
PWK
4200
Durable Medical Equipment Certificate of Medical Necessity Indicator
Max use 1
Optional
CR1
4250
Ambulance Transport Information
Max use 1
Optional
CR3
4350
Durable Medical Equipment Certification
Max use 1
Optional
CRC
4500
Ambulance Certification
Max use 3
Optional
CRC
4500
Hospice Employee Indicator
Max use 1
Optional
CRC
4500
Condition Indicator/Durable Medical Equipment
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Required
DTP
4550
Date - Prescription Date
Max use 1
Optional
DTP
4550
DATE - Certification Revision/Recertification Date
Max use 1
Optional
DTP
4550
Date - Begin Therapy Date
Max use 1
Optional
DTP
4550
Date - Initial Treatment Date
Max use 1
Optional
DTP
4550
Date - Last Certification Date
Max use 1
Optional
DTP
4550
Date - Last Seen Date
Max use 1
Optional
DTP
4550
Date - Last X-ray Date
Max use 1
Optional
DTP
4550
Date - Shipped Date
Max use 1
Optional
DTP
4550
Date - Test Date
Max use 2
Optional
QTY
4600
Ambulance Patient Count
Max use 1
Optional
QTY
4600
Obstetric Anesthesia Additional Units
Max use 1
Optional
MEA
4620
Test Result
Max use 5
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
4700
Immunization Batch Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Mammography Certification Number
Max use 1
Optional
REF
4700
Referral Number
Max use 5
Optional
REF
4700
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
AMT
4750
Postage Claimed Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
NTE
4850
Line Note
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
PS1
4880
Purchased Service Information
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
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
Rendering Provider Name Loop
NM1
5000
Rendering Provider Name
Max use 1
Required
PRV
5050
Rendering Provider Specialty Information
Max use 1
Optional
REF
5250
Rendering Provider Secondary Identification
Max use 20
Optional
Purchased Service Provider Name Loop
NM1
5000
Purchased Service Provider Name
Max use 1
Required
REF
5250
Purchased Service Provider Secondary Identification
Max use 20
Optional
Service Facility Location Name Loop
NM1
5000
Service Facility Location Name
Max use 1
Required
N3
5140
Service Facility Location Address
Max use 1
Required
N4
5200
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
5250
Service Facility Location Secondary Identification
Max use 3
Optional
Supervising Provider Name Loop
NM1
5000
Supervising Provider Name
Max use 1
Required
REF
5250
Supervising Provider Secondary Identification
Max use 20
Optional
Ordering Provider Name Loop
NM1
5000
Ordering Provider Name
Max use 1
Required
N3
5140
Ordering Provider Address
Max use 1
Optional
N4
5200
Ordering Provider City, State, ZIP Code
Max use 1
Optional
REF
5250
Ordering Provider Secondary Identification
Max use 20
Optional
PER
5300
Ordering Provider Contact Information
Max use 1
Optional
Referring Provider Name Loop
NM1
5000
Referring Provider Name
Max use 1
Required
REF
5250
Referring Provider Secondary Identification
Max use 20
Optional
Ambulance Pick-up Location Loop
NM1
5000
Ambulance Pick-up Location
Max use 1
Required
N3
5140
Ambulance Pick-up Location Address
Max use 1
Required
N4
5200
Ambulance Pick-up Location City, State, ZIP Code
Max use 1
Required
Ambulance Drop-off Location Loop
NM1
5000
Ambulance Drop-off Location
Max use 1
Required
N3
5140
Ambulance Drop-off Location Address
Max use 1
Required
N4
5200
Ambulance Drop-off Location City, State, ZIP Code
Max use 1
Required
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
Form Identification Code Loop
LQ
5510
Form Identification Code
Max use 1
Required
FRM
5520
Supporting Documentation
Max use 99
Required
SE
5550
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1
—
Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)
—
00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10
—
ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)
—
00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10
—
ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
—
Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 15
—
ISA-07
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
—
Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 15
—
ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format
—
ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format
—
ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1
—
^
Repetition Separator
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)
—
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
—
ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
Min 1Max 1
—
0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1
—
I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1
—
>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1
—
Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)
—
HC
Health Care Claim (837)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15
—
GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15
—
GS-04
373
Date
Required
Date (DT)
CCYYMMDD format
—
GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9
—
GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 2
—
T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)
—
005010X222A1

Heading

ST
0050
Heading > ST

Transaction Set Header

RequiredMax use 1
—
Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)
—
837
Health Care Claim
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9
—
Usage notes
—
ST-03
1705
Implementation Guide Version Name
Required
String (AN)
—
Usage notes
—
005010X222A1
BHT
0100
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1
—
Usage notes
—
Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)
—
0019
Information Source, Subscriber, Dependent
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)
—
Usage notes
—
00
Original
—
18
Reissue
—
BHT-03
127
Originator Application Transaction Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format
—
Usage notes
—
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
Usage notes
—
BHT-06
640
Claim or Encounter Identifier
Required
Identifier (ID)
—
31
Subrogation Demand
—
CH
Chargeable
—
RP
Reporting
—
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
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
41
Submitter
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Submitter Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Submitter First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Submitter Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
46
Electronic Transmitter Identification Number (ETIN)
—
NM1-09
67
Submitter Identifier
Required
String (AN)
Min 2Max 80
—
PER
0450
Heading > Submitter Name Loop > PER

Submitter EDI Contact Information

RequiredMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
IC
Information Contact
PER-02
93
Submitter Contact Name
Optional
String (AN)
Min 1Max 60
—
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
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
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
40
Receiver
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Receiver Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
46
Electronic Transmitter Identification Number (ETIN)
NM1-09
67
Receiver Primary Identifier
Required
String (AN)
Min 2Max 80
—
1000B Receiver Name Loop end
Heading end

Detail

2000A Billing Provider Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1
—
Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12
—
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)
—
20
Information Source
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)
—
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
—
Usage notes
—
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
—
BI
Billing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
—
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
—
CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR

Foreign Currency Information

OptionalMax use 1
—
Usage notes
—
Example
CUR-01
98
Entity Identifier Code
Required
Identifier (ID)
—
85
Billing Provider
CUR-02
100
Currency Code
Required
Identifier (ID)
Min 3Max 3
—
Usage notes
—
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
—
Usage notes
—
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)
—
85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Billing Provider Last or Organizational Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Billing Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Billing Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Billing Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Billing Provider Identifier
Optional
String (AN)
Min 2Max 80
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3

Billing Provider Address

RequiredMax use 1
—
Usage notes
—
Example
N3-01
166
Billing Provider Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Billing Provider Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4

Billing Provider City, State, ZIP Code

RequiredMax use 1
—
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
—
N4-02
156
Billing Provider State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Billing Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider Tax Identification

RequiredMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider UPIN/License Information
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
EI
Employer's Identification Number
—
SY
Social Security Number
—
REF-02
127
Billing Provider Tax Identification Number
Required
String (AN)
Min 1Max 50
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider UPIN/License Information

OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Tax Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0B
State License Number
1G
Provider UPIN Number
—
REF-02
127
Billing Provider License and/or UPIN Information
Required
String (AN)
Min 1Max 50
—
PER
0400
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER

Billing Provider Contact Information

OptionalMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
IC
Information Contact
PER-02
93
Billing Provider Contact Name
Optional
String (AN)
Min 1Max 60
—
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
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
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
87
Pay-to Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
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
—
Example
N3-01
166
Pay-To Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Pay-To Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4

Pay-To Address City, State, ZIP Code

RequiredMax use 1
—
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
—
N4-02
156
Pay-to Address State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Pay-to Address Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
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
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
PE
Payee
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Pay-To Plan Organizational Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
Usage notes
—
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
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3

Pay-to Plan Address

RequiredMax use 1
—
Example
N3-01
166
Pay-To Plan Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Pay-To Plan Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4

Pay-To Plan City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Pay-To Plan City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Pay-To Plan State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Pay-To Plan Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-to Plan Secondary Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFPay-To Plan Tax Identification Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
—
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
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-To Plan Tax Identification Number

RequiredMax use 1
—
Example
Variants (all may be used)
REFPay-to Plan Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
EI
Employer's Identification Number
—
REF-02
127
Pay-To Plan Tax Identification Number
Required
String (AN)
Min 1Max 50
—
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
—
Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12
—
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12
—
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)
—
22
Subscriber
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)
—
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR

Subscriber Information

RequiredMax use 1
—
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)
—
Usage notes
—
A
Payer Responsibility Four
B
Payer Responsibility Five
C
Payer Responsibility Six
D
Payer Responsibility Seven
E
Payer Responsibility Eight
F
Payer Responsibility Nine
G
Payer Responsibility Ten
H
Payer Responsibility Eleven
P
Primary
S
Secondary
T
Tertiary
U
Unknown
—
SBR-02
1069
Individual Relationship Code
Optional
Identifier (ID)
—
18
Self
SBR-03
127
Subscriber Group or Policy Number
Optional
String (AN)
Min 1Max 50
—
Usage notes
—
SBR-04
93
Subscriber Group Name
Optional
String (AN)
Min 1Max 60
—
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)
—
12
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13
Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
14
Medicare Secondary, No-fault Insurance including Auto is Primary
15
Medicare Secondary Worker's Compensation
16
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
41
Medicare Secondary Black Lung
42
Medicare Secondary Veteran's Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47
Medicare Secondary, Other Liability Insurance is Primary
SBR-09
1032
Claim Filing Indicator Code
Required
Identifier (ID)
—
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization
AM
Automobile Medical
BL
Blue Cross/Blue Shield
CH
Champus
CI
Commercial Insurance Co.
DS
Disability
FI
Federal Employees Program
HM
Health Maintenance Organization
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
OF
Other Federal Program
—
TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined
—
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > PAT

Patient Information

OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required
If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required
PAT-05
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
PAT-06
1251
Patient Death Date
Optional
String (AN)
Min 1Max 35
—
PAT-07
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)
—
01
Actual Pounds
PAT-08
81
Patient Weight
Optional
Decimal number (R)
Min 1Max 10
—
PAT-09
1073
Pregnancy Indicator
Optional
Identifier (ID)
—
Usage notes
—
Y
Yes
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
—
Usage notes
—
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)
—
IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Subscriber Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Subscriber First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Subscriber Middle Name or Initial
Optional
String (AN)
Min 1Max 25
—
NM1-07
1039
Subscriber Name Suffix
Optional
String (AN)
Min 1Max 10
—
Usage notes
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
II
Standard Unique Health Identifier for each Individual in the United States
—
MI
Member Identification Number
—
NM1-09
67
Subscriber Primary Identifier
Optional
String (AN)
Min 2Max 80
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Subscriber Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Subscriber City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Subscriber State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Subscriber Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1
—
Usage notes
—
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Subscriber Birth Date
Required
String (AN)
Min 1Max 35
—
DMG-03
1068
Subscriber Gender Code
Required
Identifier (ID)
—
F
Female
M
Male
U
Unknown
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Subscriber Secondary Identification

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
SY
Social Security Number
—
REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Property and Casualty Claim Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFSubscriber Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50
—
PER
0400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > PER

Property and Casualty Subscriber Contact Information

OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
IC
Information Contact
PER-02
93
Name
Optional
String (AN)
Min 1Max 60
—
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EX
Telephone Extension
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
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
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Payer Name
Required
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
Usage notes
—
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Payer Identifier
Required
String (AN)
Min 2Max 80
—
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3

Payer Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Payer Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Payer Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4

Payer City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Payer City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Payer State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Payer Secondary Identification

OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
2U
Payer Identification Number
—
EI
Employer's Identification Number
—
FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Payer Secondary Identifier
Required
String (AN)
Min 1Max 50
—
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Billing Provider Secondary Identification

OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFPayer Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
G2
Provider Commercial Number
—
LU
Location Number
REF-02
127
Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
—
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
—
Usage notes
—
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38
—
Usage notes
—
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15
—
Usage notes
—
CLM-05
C023
Health Care Service Location Information
RequiredMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Place of Service Code
Required
String (AN)
Min 1Max 2
—
C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)
—
B
Place of Service Codes for Professional or Dental Services
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1
—
CLM-06
1073
Provider or Supplier Signature Indicator
Required
Identifier (ID)
—
N
No
Y
Yes
CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)
—
Usage notes
—
A
Assigned
—
B
Assignment Accepted on Clinical Lab Services Only
—
C
Not Assigned
—
CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)
—
Usage notes
—
N
No
W
Not Applicable
—
Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)
—
Usage notes
—
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
—
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
—
CLM-10
1351
Patient Signature Source Code
Optional
Identifier (ID)
—
P
Signature generated by provider because the patient was not physically present for services
—
CLM-11
C024
Related Causes Information
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
—
C024-01
1362
Related Causes Code
Required
Identifier (ID)
—
AA
Auto Accident
EM
Employment
OA
Other Accident
C024-02
1362
Related Causes Code
Optional
Identifier (ID)
Min 2Max 3
—
C024-04
156
Auto Accident State or Province Code
Optional
Identifier (ID)
Min 2Max 2
—
C024-05
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
CLM-12
1366
Special Program Indicator
Optional
Identifier (ID)
—
02
Physically Handicapped Children's Program
—
03
Special Federal Funding
—
05
Disability
—
09
Second Opinion or Surgery
—
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)
—
1
Proof of Eligibility Unknown or Unavailable
2
Litigation
3
Authorization Delays
4
Delay in Certifying Provider
5
Delay in Supplying Billing Forms
6
Delay in Delivery of Custom-made Appliances
7
Third Party Processing Delay
8
Delay in Eligibility Determination
9
Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10
Administration Delay in the Prior Approval Process
11
Other
15
Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Accident

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Accident Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Acute Manifestation

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
453
Acute Manifestation of a Chronic Condition
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Acute Manifestation Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Admission

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
435
Admission
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Related Hospitalization Admission Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Assumed and Relinquished Care Dates

OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
090
Report Start
—
091
Report End
—
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Assumed or Relinquished Care Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Authorized Return to Work

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
296
Initial Disability Period Return To Work
—
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Work Return Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Disability Dates

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
314
Disability
—
360
Initial Disability Period Start
—
361
Initial Disability Period End
—
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
—
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
—
DTP-03
1251
Disability From Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Discharge

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
096
Discharge
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Related Hospitalization Discharge Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Hearing and Vision Prescription Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
471
Prescription
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Prescription Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Last Menstrual Period

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
484
Last Menstrual Period
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Last Menstrual Period Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Onset of Current Illness or Symptom

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
431
Onset of Current Symptoms or Illness
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Onset of Current Illness or Injury Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Initial Treatment Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
454
Initial Treatment
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Initial Treatment Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Last Seen Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
304
Latest Visit or Consultation
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Last Seen Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Last Worked

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
297
Initial Disability Period Last Day Worked
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Last Worked Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Last X-ray Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
455
Last X-Ray
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Last X-Ray Date
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Property and Casualty Date of First Contact

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
444
First Visit or Consultation
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Date Time Period
Required
String (AN)
Min 1Max 35
—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Repricer Received Date

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First Contact
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Repricer Received Date
Required
String (AN)
Min 1Max 35
—
PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK

Claim Supplemental Information

OptionalMax use 10
—
Usage notes
—
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)
—
03
Report Justifying Treatment Beyond Utilization Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification
AS
Admission Summary
B2
Prescription
B3
Physician Order
B4
Referral Form
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
CK
Consent Form(s)
CT
Certification
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
EB
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
MT
Models
NN
Nursing Notes
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
OE
Objective Physical Examination (including vital signs) Document
OX
Oxygen Therapy Certification
OZ
Support Data for Claim
P4
Pathology Report
P5
Patient Medical History Document
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician's Report
PZ
Physical Therapy Certification
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)
—
AA
Available on Request at Provider Site
—
BM
By Mail
EL
Electronically Only
—
EM
E-Mail
FT
File Transfer
—
FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)
—
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80
—
Usage notes
—
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1
—
Usage notes
—
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)
—
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
—
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50
—
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6
—
CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30
—
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT

Patient Amount Paid

OptionalMax use 1
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required