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Health Care Services Review Information - Acknowledgment (X216)
  • Specification
  • EDI Inspector
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X12 278 Health Care Services Review Information - Acknowledgment (X216)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.

Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI sample
  • Example 1: Acknowledgment
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
Information Source Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
AAA
0300
Notification Validation
Max use 9
Optional
Information Receiver Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Subscriber Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Subscriber Trace Number
Max use 3
Optional
AAA
0300
Subscriber Notification Validation
Max use 9
Optional
REF
0600
Notification Receipt Number
Max use 1
Optional
Dependent Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Dependent Trace Number
Max use 3
Optional
AAA
0300
Dependent Notification Validation
Max use 9
Optional
REF
0600
Notification Receipt Number
Max use 1
Optional
Patient Event Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Patient Event Tracking Number
Max use 3
Optional
AAA
0300
Patient Event Request Validation
Max use 9
Optional
UM
0400
Health Care Services Review Information
Max use 1
Required
HCR
0500
Health Care Services Review
Max use 1
Optional
REF
0600
Administrative Reference Number
Max use 1
Optional
REF
0600
Previous Review Authorization Number
Max use 1
Optional
DTP
0700
Event Date
Max use 1
Optional
DTP
0700
Admission Date
Max use 1
Optional
DTP
0700
Discharge Date
Max use 1
Optional
DTP
0700
Certification Issue Date
Max use 1
Optional
DTP
0700
Certification Expiration Date
Max use 1
Optional
DTP
0700
Certification Effective Date
Max use 1
Optional
HI
0800
Patient Diagnosis
Max use 1
Optional
Patient Event Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Patient Event Tracking Number
Max use 3
Optional
AAA
0300
Patient Event Request Validation
Max use 9
Optional
UM
0400
Health Care Services Review Information
Max use 1
Required
HCR
0500
Health Care Services Review
Max use 1
Optional
REF
0600
Administrative Reference Number
Max use 1
Optional
REF
0600
Previous Review Authorization Number
Max use 1
Optional
DTP
0700
Event Date
Max use 1
Optional
DTP
0700
Admission Date
Max use 1
Optional
DTP
0700
Discharge Date
Max use 1
Optional
DTP
0700
Certification Issue Date
Max use 1
Optional
DTP
0700
Certification Expiration Date
Max use 1
Optional
DTP
0700
Certification Effective Date
Max use 1
Optional
HI
0800
Patient Diagnosis
Max use 1
Optional
SE
2800
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

HI
Health Care Services Review Information (278)
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

005010X216

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

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

Usage notes
  • This segment indicates the start of a health care services review notification acknowledgment response transaction set with all the supporting information. This transaction set is the electronic equivalent of a phone, fax, or paper-based receipt acknowledgment.
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).
278
Health Care Services Review Information
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 Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research. Use the corresponding value in SE02 for this transaction set.
ST-03
1705
Implementation Guide Version Name
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 (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
005010X216
BHT
0200
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

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

0007
Information Source, Information Receiver, Subscriber, Dependent, Event, Services
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

44
Rejection

Use to indicate that this transaction acknowledges a notification that was rejected due to data errors or non-availability of the receiving system.

53
Completion

Use to indicate that this is an acknowledgment of successful receipt of a notification.

BHT-03
127
Submitter 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
  • Return the transaction identifier entered in BHT03 on the 278 notification.
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.
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.
Heading end

Detail

2000A Information Source Level Loop
RequiredMax 1
HL
0100
Detail > Information Source 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.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
AAA
0300
Detail > Information Source Level Loop > AAA

Notification Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the notification cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No

Use this code to indicate that the notification transaction has been rejected as identified by the code in AAA03.

AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

04
Authorized Quantity Exceeded

Use this code to indicate that the functional group exceeds the maximum number of transactions as specified by agreement between the application sender GS02 and application receiver GS03.

41
Authorization/Access Restrictions

Use this code to indicate that the application sender (GS02) and application receiver (GS03) do not have a trading partner agreement for the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02. The 278 transaction set has three different implementations. The transaction set purpose, as identified in BHT02, specifies the implementation.

42
Unable to Respond at Current Time

Use this code to indicate that the entity responsible for forwarding the request to the information receiver (Loop 2010B) is unable to process the transaction at the current time. This indicates a problem in the system forwarding the notification transaction and not in the information receiver's system.

79
Invalid Participant Identification

Use this code to indicate that the identifier used in GS02 or GS03 is invalid or unknown.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
P
Please Resubmit Original Transaction
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2010A Information Source Name Loop
RequiredMax 2
NM1
1700
Detail > Information Source Level Loop > Information Source Name Loop > NM1

Information Source Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This NM1 loop identifies the notification sender. In most cases, the sender is the same entity as the information source. The information source is the entity that determined the outcome of a health services review or the owner of the information.

If the sender is not the same entity as the information source, use the first NM1 loop to identify the information sender and the second NM1 loop to identify the information source.

  • The second NM1 loop is required when the sender is not the same entity as the information source. If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

1P
Provider
2B
Third-Party Administrator
FA
Facility
PR
Payer
X3
Utilization Management Organization
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
Information Source Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Information Source Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Information Source 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)

24
Employer's Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
PI
Payor Identification

Use until the National PlanID is mandated if the information source is a payer.

XV
Centers for Medicare and Medicaid Services PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Information Source Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > Information Source Level Loop > Information Source Name Loop > REF

Information Source Supplemental Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • Required when valued on the notification and used by the receiver to identify the information source or sender. 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

1G
Provider UPIN Number
1J
Facility ID Number
EI
Employer's Identification Number

Not used if NM108 = 24.

G5
Provider Site Number
N5
Provider Plan Network Identification Number
N7
Facility Network Identification Number
SY
Social Security Number

The social security number may not be used for Medicare. Not used if NM108 = 34.

ZH
Carrier Assigned Reference Number

Use if the sender or information source is a provider to indicate the identifier assigned to the provider by the receiver identified in Loop 2000B.

REF-02
127
Information Source 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

AAA
2300
Detail > Information Source Level Loop > Information Source Name Loop > AAA

Information Source Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Use this segment to convey rejection information regarding the entity;that initiated a notification or information copy transaction.
  • Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

35
Out of Network
41
Authorization/Access Restrictions
43
Invalid/Missing Provider Identification
44
Invalid/Missing Provider Name
45
Invalid/Missing Provider Specialty
46
Invalid/Missing Provider Phone Number
47
Invalid/Missing Provider State
49
Provider is Not Primary Care Physician
50
Provider Ineligible for Inquiries

Use if the provider is not authorized for notifications.

51
Provider Not on File
79
Invalid Participant Identification

Use for invalid/missing information source supplemental identifier.

97
Invalid or Missing Provider Address
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
R
Resubmission Allowed
PRV
2400
Detail > Information Source Level Loop > Information Source Name Loop > PRV

Information Source Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when used by the information receiver to identify the information source. 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

AD
Admitting
AS
Assistant Surgeon
AT
Attending
CO
Consulting
CV
Covering
OP
Operating
OR
Ordering
OT
Other Physician
PC
Primary Care Physician
PE
Performing
RF
Referring
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

2010A Information Source Name Loop end
2000B Information Receiver Level Loop
OptionalMax 1
HL
0100
Detail > Information Source Level Loop > Information Receiver 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.
21
Information Receiver
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.
2010B Information Receiver Name Loop
RequiredMax 1
NM1
1700
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

Information Receiver Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This NM1 loop identifies the notification receiver.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

1P
Provider
2B
Third-Party Administrator
FA
Facility
PR
Payer
X3
Utilization Management Organization
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
Information Receiver Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Information Receiver Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Information Receiver 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)

24
Employer's Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
PI
Payor Identification

Use until the National PlanID is mandated if the information receiver is a payer.

XV
Centers for Medicare and Medicaid Services PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Information Receiver Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
2200
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > PER

Information Receiver Contact Information

OptionalMax use 1

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 should 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 (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
  • Required when the information source must direct requests for follow-up to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-03) or Information Receiver Contact Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Information Receiver Contact Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Information Receiver Contact 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
Information Receiver Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

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

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Information Receiver Contact Communication Number
Optional
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

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
PER-06
364
Information Receiver Contact 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

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
PER-08
364
Information Receiver Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

AAA
2300
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > AAA

Information Receiver Notification Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Use this AAA segment to report the reasons why the information receiver cannot receive the notification at a system or application level based on the information source identified in Loop 2010A.
  • Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

04
Authorized Quantity Exceeded

Use this code to indicate that the transaction exceeds the maximum number of patient events for this information receiver. This implementation guide limits each transaction to a single patient event.

41
Authorization/Access Restrictions

Use this reason code to indicate that the sender, as identified in ISA06 or GS02 is not authorized to send the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02 to the information receiver identified in Loop 2010B. The 278 transaction set has three different implementations. The transaction set purpose as identified in BHT02 specifies the implementation.

42
Unable to Respond at Current Time

Use this code to indicate that the information receiver identified in Loop 2010B is unable to process the transaction at the current time. This indicates that there is a problem within the receiver's system.

79
Invalid Participant Identification

Use this code to indicate that the code used in Loop 2010B of the notification to identify the information receiver is invalid.

80
No Response received - Transaction Terminated

Use this code to indicate that the trading partner/application system responsible for sending the notification to the information receiver has not received a response in the expected timeframe and therefore has terminated the notification.

T4
Payer Name or Identifier Missing

Use this code to indicate that either the name or identifier for the information receiver identified in Loop 2010B is missing.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

N
Resubmission Not Allowed
P
Please Resubmit Original Transaction
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2010B Information Receiver Name Loop end
2000C Subscriber Level Loop
OptionalMax 1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber 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.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > TRN

Subscriber Trace Number

OptionalMax use 3

To uniquely identify a transaction to an application

Usage notes
  • Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.
  • If the 278 notification transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:

If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.

  • If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number.
  • Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information receiver).

2
Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.

TRN-02
127
Patient Event Tracking Number
Required
String (AN)
Min 1Max 50

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

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction. If TRN01 is "1", use this information to identify the information receiver organization that assigned this trace number.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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

  • TRN04 identifies a further subdivision within the organization.
AAA
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > AAA

Subscriber Notification Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Use this AAA segment to identify the reasons why the notification could not be received based on the contents of the HI Subscriber Diagnosis segment or the DTP date segments in Loop 2000C of the notification.
  • Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use for missing diagnosis codes and dates.

33
Input Errors

Use for invalid diagnosis codes and dates.

56
Inappropriate Date

Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
REF
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > REF

Notification Receipt Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the information receiver returns a receipt number to indicate receipt of the notification. 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

BAF
Receipt Number
REF-02
127
Notification Receipt Number
Required
String (AN)
Min 1Max 50

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

2010C Subscriber Name Loop
RequiredMax 1
NM1
1700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

Subscriber 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

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Subscriber Last Name
Optional
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

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

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

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

ZZ
Mutually Defined

The value "ZZ", when used in this data element, shall be defined as "HIPAA Individual Identifier" once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.

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

Code identifying a party or other code

REF
1800
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

Subscriber Supplemental Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
  • Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. 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

1L
Group or Policy Number

Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

6P
Group Number
EJ
Patient Account Number

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

F6
Health Insurance Claim (HIC) Number

Use the NM1 (Subscriber Name) segment if the subscriber's HIC number is the primary identifier for his or her coverage. Use this code only in a REF segment when the payer has a different member number, and there also is a need to pass the dependent's HIC number. This might occur in a Medicare HMO situation.

HJ
Identity Card Number

Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.

IG
Insurance Policy Number
N6
Plan Network Identification Number
NQ
Medicaid Recipient Identification Number
SY
Social Security Number

Use this code only if the Social Security Number is not the primary;identifier for the subscriber. The social security number may not be;used for Medicare.

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

AAA
2300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > AAA

Subscriber Notification Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use when data is missing that is not covered by another Reject Reason Code. Use to indicate that there is not enough data to identify the subscriber.

58
Invalid/Missing Date-of-Birth
64
Invalid/Missing Patient ID
65
Invalid/Missing Patient Name
66
Invalid/Missing Patient Gender Code
67
Patient Not Found
68
Duplicate Patient ID Number
71
Patient Birth Date Does Not Match That for the Patient on the Database
72
Invalid/Missing Subscriber/Insured ID
73
Invalid/Missing Subscriber/Insured Name
74
Invalid/Missing Subscriber/Insured Gender Code
75
Subscriber/Insured Not Found
76
Duplicate Subscriber/Insured ID Number
77
Subscriber Found, Patient Not Found
78
Subscriber/Insured Not in Group/Plan Identified
79
Invalid Participant Identification

Use for invalid/missing subscriber supplemental identifier.

95
Patient Not Eligible
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
DMG
2500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify 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
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
INS
2600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

Subscriber Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when the subscriber's role in the military is used by the information receiver to identify the subscriber. If not required by this implementation guide, do not send.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
Y
Yes
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

18
Self
INS-08
584
Employment Status Code
Required
Identifier (ID)

Code showing the general employment status of an employee/claimant

Usage notes
  • Use to qualify the patient's relationship to the military.
AO
Active Military - Overseas
AU
Active Military - USA
DI
Deceased
PV
Previous
RU
Retired Military - USA
2010C Subscriber Name Loop end
2000D Dependent Level Loop
OptionalMax 1
Variants (all may be used)
Patient Event Level Loop
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent 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.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > TRN

Dependent Trace Number

OptionalMax use 3

To uniquely identify a transaction to an application

Usage notes
  • Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.
  • If the 278 notification transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:

If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment.

If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 notification in the 278 acknowledgment response transaction.

  • Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
  • If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information receiver).

2
Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.

TRN-02
127
Patient Event Tracking Number
Required
String (AN)
Min 1Max 50

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

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction. If TRN01 is "1", use this information to identify the information receiver organization that assigned this trace number.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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

  • TRN04 identifies a further subdivision within the organization.
AAA
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > AAA

Dependent Notification Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Use this AAA segment to identify the reasons why the notification could not be processed based on the contents of the HI Dependent Diagnosis Segment or the DTP date segments in Loop 2000D of the notification.
  • Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use for missing diagnosis codes and dates.

33
Input Errors

Use for invalid diagnosis codes and dates.

56
Inappropriate Date

Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
REF
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > REF

Notification Receipt Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the information receiver returns a receipt number to indicate receipt of the notification. 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

BAF
Receipt Number
REF-02
127
Notification Receipt Number
Required
String (AN)
Min 1Max 50

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

2010D Dependent Name Loop
RequiredMax 1
NM1
1700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

Dependent Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment conveys the name of the dependent who is the patient.
  • NM108 and NM109 are situational on the acknowledgment but Not Used on the notification. This enables the information receiver (UMO for example) to return a unique member ID for the dependent that was not known to the information source at the time of the review. Normally, if the dependent has a unique member ID, Loop 2000D is not used.
Example
If either Identification Code Qualifier (NM1-08) or Dependent 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

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
Dependent Last Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Dependent Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Dependent 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)

MI
Member Identification Number

Use this code for the payer-assigned identifier for the dependent, even if the payer calls its number a policy number, recipient number, HIC number, or some other synonym.

ZZ
Mutually Defined

The value "ZZ", when used in this data element, shall be defined as "HIPAA Individual Identifier" once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.

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

Code identifying a party or other code

REF
1800
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

Dependent Supplemental Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. 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

EJ
Patient Account Number

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

SY
Social Security Number

The social security number may not be used for Medicare.

REF-02
127
Dependent 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

AAA
2300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > AAA

Dependent Notification Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use this code to indicate missing dependent relationship information.

33
Input Errors

Use this code to indicate invalid dependent relationship information.

58
Invalid/Missing Date-of-Birth
64
Invalid/Missing Patient ID
65
Invalid/Missing Patient Name
66
Invalid/Missing Patient Gender Code
67
Patient Not Found
68
Duplicate Patient ID Number
71
Patient Birth Date Does Not Match That for the Patient on the Database
77
Subscriber Found, Patient Not Found
95
Patient Not Eligible
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
DMG
2500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

Dependent Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify the patient. 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
Dependent 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
Dependent Gender Code
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
INS
2600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

Dependent Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when valued on the notification and used by the information receiver to identify the patient. If not required by this implementation guide, do not send.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
N
No
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

01
Spouse
04
Grandfather or Grandmother
05
Grandson or Granddaughter
07
Nephew or Niece
09
Adopted Child
10
Foster Child
15
Ward
17
Stepson or Stepdaughter
19
Child
20
Employee
21
Unknown
22
Handicapped Dependent
23
Sponsored Dependent
24
Dependent of a Minor Dependent
29
Significant Other
32
Mother
33
Father
34
Other Adult
39
Organ Donor
40
Cadaver Donor
41
Injured Plaintiff
43
Child Where Insured Has No Financial Responsibility
53
Life Partner
G8
Other Relationship
INS-17
1470
Birth Sequence Number
Optional
Numeric (N0)
Min 1Max 9

A generic number

  • INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
2010D Dependent Name Loop end
2000E Patient Event Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event 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.
EV
Event
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.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > TRN

Patient Event Tracking Number

OptionalMax use 3

To uniquely identify a transaction to an application

Usage notes
  • Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the information source or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
  • Any trace numbers provided at this level on the notification must be returned by the information sender at this level of the 278 notification.
  • If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
  • If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information source).

2
Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.

TRN-02
127
Patient Event 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

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • Use this element to identify the entity that assigned this trace number. If TRN01 is "1", use this value to identify the information source of this acknowledgment transaction that assigned the trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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

  • TRN04 identifies a further subdivision within the organization.
AAA
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > AAA

Patient Event Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the notification is not valid at this level. If not required by this implementation guide do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
Y
Yes
AAA-03
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.

33
Input Errors

Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid diagnosis codes and diagnosis dates.

52
Service Dates Not Within Provider Plan Enrollment

Use for Event Date(s).

56
Inappropriate Date

Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the notification is inconsistent with the patient condition or services requested.

57
Invalid/Missing Date(s) of Service

Use for invalid/missing event date.

60
Date of Birth Follows Date(s) of Service

Use for Date(s) of Event.

61
Date of Death Precedes Date(s) of Service

Use for Date(s) of Event.

62
Date of Service Not Within Allowable Inquiry Period

Use for Date of Event.

84
Certification Not Required for this Service
90
Requested Information Not Received
AF
Invalid/Missing Diagnosis Code(s)
AH
Invalid/Missing Onset of Current Condition or Illness Date
AI
Invalid/Missing Accident Date
AJ
Invalid/Missing Last Menstrual Period Date
AK
Invalid/Missing Expected Date of Birth
AM
Invalid/Missing Admission Date
AN
Invalid/Missing Discharge Date
T5
Certification Information Missing

Use to indicate missing previous certification number information.

AAA-04
889
Follow-up Action Code
Optional
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
UM
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > UM

Health Care Services Review Information

RequiredMax use 1

To specify health care services review information

Usage notes
  • Required to identify the type of health care services review notification to which this acknowledgment pertains.
Example
UM-01
1525
Request Category Code
Required
Identifier (ID)

Code indicating a type of request

AR
Admission Review

Use this value to identify admission to a facility.

HS
Health Services Review

Use this value to identify services related to an episode of care.

SC
Specialty Care Review

Use this value to identify a referral to a specialty provider.

UM-02
1322
Certification Type Code
Required
Identifier (ID)

Code indicating the type of certification

1
Appeal - Immediate

Use this value to identify appeals of review decisions where the level of service required is emergency or urgent. If UM02 = 1 then UM06 must be valued.

2
Appeal - Standard

Use this value for appeals of review decisions where the level of service required is not emergency or urgent.

3
Cancel
4
Extension

Use this value to identify an extension request to a prior approved service.

5
Notification
6
Verification
I
Initial
R
Renewal

Use this value to identify the various services, such as physical therapy, spinal manipulation, and allergy treatment, that have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

S
Revised

Use if the Information Source is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.

UM-03
1365
Service Type Code
Optional
Identifier (ID)

Code identifying the classification of service

1
Medical Care
2
Surgical
3
Consultation
4
Diagnostic X-Ray
5
Diagnostic Lab
6
Radiation Therapy
7
Anesthesia
8
Surgical Assistance
11
Used Durable Medical Equipment
12
Durable Medical Equipment Purchase
14
Renal Supplies in the Home
15
Alternate Method Dialysis
16
Chronic Renal Disease (CRD) Equipment
17
Pre-Admission Testing
18
Durable Medical Equipment Rental
20
Second Surgical Opinion
21
Third Surgical Opinion
23
Diagnostic Dental
24
Periodontics
25
Restorative

Use for restorative dental.

26
Endodontics
27
Maxillofacial Prosthetics
28
Adjunctive Dental Services
33
Chiropractic
35
Dental Care
36
Dental Crowns
37
Dental Accident
38
Orthodontics
39
Prosthodontics
40
Oral Surgery
42
Home Health Care
44
Home Health Visits
45
Hospice
46
Respite Care
54
Long Term Care
56
Medically Related Transportation
61
In-vitro Fertilization
62
MRI/CAT Scan
63
Donor Procedures
64
Acupuncture
65
Newborn Care
66
Pathology
67
Smoking Cessation
68
Well Baby Care
69
Maternity
70
Transplants
71
Audiology Exam
72
Inhalation Therapy
73
Diagnostic Medical
74
Private Duty Nursing
75
Prosthetic Device
76
Dialysis
77
Otological Exam
78
Chemotherapy
79
Allergy Testing
80
Immunizations
82
Family Planning
83
Infertility
84
Abortion
85
AIDS
86
Emergency Services
88
Pharmacy
93
Podiatry
A4
Psychiatric
A6
Psychotherapy
A9
Rehabilitation
AD
Occupational Therapy
AE
Physical Medicine
AF
Speech Therapy
AG
Skilled Nursing Care
AI
Substance Abuse
AJ
Alcoholism
AK
Drug Addiction
AL
Vision (Optometry)
AR
Experimental Drug Therapy
B1
Burn Care
BB
Partial Hospitalization (Psychiatric)
BC
Day Care (Psychiatric)
BD
Cognitive Therapy
BE
Massage Therapy
BF
Pulmonary Rehabilitation
BG
Cardiac Rehabilitation
BL
Cardiac
BN
Gastrointestinal
BP
Endocrine
BQ
Neurology
BS
Invasive Procedures
BY
Physician Visit - Office: Sick
BZ
Physician Visit - Office: Well
C1
Coronary Care
CQ
Case Management
GY
Allergy
IC
Intensive Care
MH
Mental Health
NI
Neonatal Intensive Care
ON
Oncology
PT
Physical Therapy
PU
Pulmonary
RN
Renal
RT
Residential Psychiatric Treatment
TC
Transitional Care
TN
Transitional Nursery Care
UM-04
C023
Health Care Service Location Information
OptionalMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
Usage notes

Required when UM04 is not valued at 2000F. If not required by this implementation guide, do not send.

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.

Usage notes
  • Use to indicate a facility code value from the code source referenced in UM04-2.
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
B
Place of Service Codes for Professional or Dental Services
UM-06
1338
Level of Service Code
Optional
Identifier (ID)

Code specifying the level of service rendered

03
Emergency
E
Elective
U
Urgent
HCR
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HCR

Health Care Services Review

OptionalMax use 1

To specify the outcome of a health care services review

Usage notes
  • Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.
  • If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.
  • If the acknowledgment contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.
Example
HCR-01
306
Action Code
Required
Identifier (ID)

Code indicating type of action

A1
Certified in total
A2
Certified - partial

Use to identify that the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

A3
Not Certified
A4
Pended
A6
Modified
C
Cancelled
CT
Contact Payer
NA
No Action Required

Use only if certification is not required.

HCR-02
127
Review Identification Number
Optional
String (AN)
Min 1Max 50

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

  • HCR02 is the number assigned by the information source to this review outcome.
HCR-03
1271
Review Decision Reason Code
Optional
String (AN)
Max use 5
Min 1Max 30

Code indicating a code from a specific industry code list

  • HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
HCR-04
1073
Second Surgical Opinion Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
N
No
Y
Yes
REF
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Administrative Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the information source of the acknowledgment transaction assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.
  • This is the administrative number assigned by the Information Sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the Information Receiver.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

NT
Administrator's Reference Number
REF-02
127
Administrative 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
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when valued on the notification at the Event Level or if the acknowledgment information sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdministrative Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BB
Authorization Number
REF-02
127
Previous 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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Event Date

OptionalMax use 1

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

Usage notes
  • Use this segment for the valid date(s) during which this event can occur. If not required, do not send.
  • Required when valued on the notification and the notification is not valid at this level. 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

AAH
Event
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
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Proposed or Actual Event Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Admission Date

OptionalMax use 1

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

Usage notes
  • Use this segment for the proposed or actual date of admission.
  • Required when valued on the notification and the notification is not valid at this level. 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

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.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use this for the range of dates when admission can occur.

DTP-03
1251
Proposed or Actual Admission Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Discharge Date

OptionalMax use 1

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

Usage notes
  • Use this segment for the proposed or actual date of discharge from a facility.
  • Required when valued on the notification and the notification is not valid at this level. 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

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.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Proposed or Actual Discharge Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Issue Date

OptionalMax use 1

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

Usage notes
  • Use this segment for the date when the certification was issued.
  • Required when valued on the notification and the notification is not valid at this level. 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

102
Issue
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
Certification Issue Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Expiration Date

OptionalMax use 1

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

Usage notes
  • Required when valued on the notification and the notification is not valid at this level. 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

036
Expiration
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
Certification Expiration Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Effective Date

OptionalMax use 1

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

Usage notes
  • Required when valued on the notification and the notification is not valid at this level. 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

007
Effective
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
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Certification Effective Date
Required
String (AN)
Min 1Max 35

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

HI
0800
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HI

Patient Diagnosis

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
  • This segment is used to hold the event level diagnosis code information that was part of the notification transaction.
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
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
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type 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
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
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.
C022-03
1250
Date Time Period Format Qualifier
Optional
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
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

2010E Patient Event Provider Name Loop
OptionalMax 12
NM1
1700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

Patient Event Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
  • Use this segment to return the name and/or identification number of the service provider (person, group, or facility) specialist, or specialty entity that was in error.
Example
If either Identification Code Qualifier (NM1-08) or Patient Event 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

1T
Physician, Clinic or Group Practice
71
Attending Physician
72
Operating Physician
73
Other Physician
AAJ
Admitting Services
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
FA
Facility
P3
Primary Care Provider
QB
Purchase Service Provider
SJ
Service Provider
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
Patient Event Provider Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Patient Event Provider First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Patient Event Provider Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-06
1038
Patient Event Provider Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

NM1-07
1039
Patient Event 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)

24
Employer's Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
XX
Centers for Medicare and Medicaid Services National Provider Identifier

Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the UMO has the capability to send it.

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

NM1-09
67
Patient Event Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

Patient Event Provider Supplemental Identification

OptionalMax use 7

To specify identifying information

Usage notes
  • Use the NM1 segment for the primary identifier.
  • Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. 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
1J
Facility ID Number
EI
Employer's Identification Number

Not used if NM108 = 24.

N5
Provider Plan Network Identification Number
N7
Facility Network Identification Number
SY
Social Security Number

The social security number may not be used for Medicare. Not used if NM108 = 34.

ZH
Carrier Assigned Reference Number

Use for the provider ID as assigned by the UMO identified in Loop 2000A.

REF-02
127
Patient Event Provider 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

REF-03
352
License Number State Code
Optional
String (AN)
Min 1Max 80

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

AAA
2300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > AAA

Patient Event Provider Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
Y
Yes
AAA-03
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the provider.

33
Input Errors

Use for input errors not covered by another reject reason code.

35
Out of Network
41
Authorization/Access Restrictions
43
Invalid/Missing Provider Identification
44
Invalid/Missing Provider Name
47
Invalid/Missing Provider State
49
Provider is Not Primary Care Physician
51
Provider Not on File
52
Service Dates Not Within Provider Plan Enrollment

Use for patient event dates.

79
Invalid Participant Identification

Use for invalid/missing service provider supplemental identifier.

AAA-04
889
Follow-up Action Code
Optional
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
PRV
2400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

Patient Event Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. 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

AD
Admitting

Use only when NM101 = AAJ.

AS
Assistant Surgeon

Use only when NM101 = DD.

AT
Attending

Use only when NM101 = 71.

OP
Operating

Use only when NM101 = 72.

OR
Ordering

Use only when NM101 = DK.

OT
Other Physician

Use only when NM101 = 73.

PC
Primary Care Physician

Use only when NM101 = P3.

PE
Performing

Use only when NM101 = SJ.

RF
Referring

Use only when NM101 = DN.

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

2010E Patient Event Provider Name Loop end
2000F Service Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service 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.
SS
Services
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.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TRN

Service Trace Number

OptionalMax use 3

To uniquely identify a transaction to an application

Usage notes
  • Required when this service level is returned and any trace numbers were provided at this level on the notification, or if the information receiver or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
  • Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 notification.
  • If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
  • If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information source).

2
Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.

TRN-02
127
Service 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

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
  • Use this element to identify the entity that assigned this trace number. If TRN01 is "1", use this value to identify the information source of this acknowledgment transaction that assigned the trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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

  • TRN04 identifies a further subdivision within the organization.
AAA
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > AAA

Service Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.

33
Input Errors

Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid procedure codes and procedure dates.

52
Service Dates Not Within Provider Plan Enrollment
57
Invalid/Missing Date(s) of Service
60
Date of Birth Follows Date(s) of Service
61
Date of Death Precedes Date(s) of Service
62
Date of Service Not Within Allowable Inquiry Period
84
Certification Not Required for this Service
90
Requested Information Not Received
AG
Invalid/Missing Procedure Code(s)
T5
Certification Information Missing

Use to indicate missing previous certification number information.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
UM
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > UM

Health Care Services Review Information

OptionalMax use 1

To specify health care services review information

Usage notes
  • Required when necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. If not required by this implementation guide, do not send.
Example
UM-01
1525
Request Category Code
Required
Identifier (ID)

Code indicating a type of request

HS
Health Services Review

Required when this is an acknowledgment to a notification of services related to an episode of care.

SC
Specialty Care Review

Required when this is an acknowledgment to a notification for referrals to a specialty provider.

UM-02
1322
Certification Type Code
Optional
Identifier (ID)

Code indicating the type of certification

1
Appeal - Immediate

Use this value to identify appeals of review decisions where the level of service required is emergency or urgent.

2
Appeal - Standard

Use this value to identify appeals of review decisions where the level of service is not emergency or urgent.

3
Cancel
4
Extension

A "UM02 = 4" indicates that this is an extension request to a prior approved service.

5
Notification
I
Initial
N
Reconsideration
R
Renewal

Use this value to identify the various services, such as physical therapy, spinal manipulation, and allergy treatment, that have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

S
Revised

Use if the Information Source is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.

UM-03
1365
Service Type Code
Optional
Identifier (ID)

Code identifying the classification of service

1
Medical Care
2
Surgical
3
Consultation
4
Diagnostic X-Ray
5
Diagnostic Lab
6
Radiation Therapy
7
Anesthesia
8
Surgical Assistance
11
Used Durable Medical Equipment
12
Durable Medical Equipment Purchase
14
Renal Supplies in the Home
15
Alternate Method Dialysis
16
Chronic Renal Disease (CRD) Equipment
17
Pre-Admission Testing
18
Durable Medical Equipment Rental
20
Second Surgical Opinion
21
Third Surgical Opinion
23
Diagnostic Dental
24
Periodontics
25
Restorative
26
Endodontics
27
Maxillofacial Prosthetics
28
Adjunctive Dental Services
33
Chiropractic
35
Dental Care
36
Dental Crowns
37
Dental Accident
38
Orthodontics
39
Prosthodontics
40
Oral Surgery
42
Home Health Care
44
Home Health Visits
45
Hospice
46
Respite Care
54
Long Term Care
56
Medically Related Transportation
61
In-vitro Fertilization
62
MRI/CAT Scan
63
Donor Procedures
64
Acupuncture
65
Newborn Care
66
Pathology
67
Smoking Cessation
68
Well Baby Care
69
Maternity
70
Transplants
71
Audiology Exam
72
Inhalation Therapy
73
Diagnostic Medical
74
Private Duty Nursing
75
Prosthetic Device
76
Dialysis
77
Otological Exam
78
Chemotherapy
79
Allergy Testing
80
Immunizations
82
Family Planning
83
Infertility
84
Abortion
85
AIDS
86
Emergency Services
88
Pharmacy
93
Podiatry
A4
Psychiatric
A6
Psychotherapy
A9
Rehabilitation
AD
Occupational Therapy
AE
Physical Medicine
AF
Speech Therapy
AG
Skilled Nursing Care
AI
Substance Abuse
AJ
Alcoholism
AK
Drug Addiction
AL
Vision (Optometry)
AR
Experimental Drug Therapy
B1
Burn Care
BB
Partial Hospitalization (Psychiatric)
BC
Day Care (Psychiatric)
BD
Cognitive Therapy
BE
Massage Therapy
BF
Pulmonary Rehabilitation
BG
Cardiac Rehabilitation
BL
Cardiac
BN
Gastrointestinal
BP
Endocrine
BQ
Neurology
BS
Invasive Procedures
BY
Physician Visit - Office: Sick
BZ
Physician Visit - Office: Well
C1
Coronary Care
GY
Allergy
IC
Intensive Care
MH
Mental Health
NI
Neonatal Intensive Care
ON
Oncology
PT
Physical Therapy
PU
Pulmonary
RN
Renal
RT
Residential Psychiatric Treatment
TC
Transitional Care
TN
Transitional Nursery Care
UM-04
C023
Health Care Service Location Information
OptionalMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
Usage notes

Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

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.

Usage notes
  • Use to indicate a facility code value from the code source referenced in UM04-2.
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
B
Place of Service Codes for Professional or Dental Services
HCR
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HCR

Health Care Services Review

OptionalMax use 1

To specify the outcome of a health care services review

Usage notes
  • Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.
  • If this segment is used, the values in HCR01 and HCR02 must echo the values contained in the same data elements of the notification.
Example
HCR-01
306
Action Code
Required
Identifier (ID)

Code indicating type of action

A1
Certified in total
A3
Not Certified
A4
Pended
A6
Modified
C
Cancelled
CT
Contact Payer
NA
No Action Required
HCR-02
127
Review Identification Number
Optional
String (AN)
Min 1Max 50

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

  • HCR02 is the number assigned by the information source to this review outcome.
HCR-03
1271
Review Decision Reason Code
Optional
String (AN)
Max use 5
Min 1Max 30

Code indicating a code from a specific industry code list

  • HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
HCR-04
1073
Yes No Condition or Response Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating a Yes or No condition or response

  • HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
REF
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when valued on the notification at the Service Level or if the information receiver has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdministrative Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BB
Authorization Number
REF-02
127
Previous 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
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

Administrative Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the information receiver assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.
  • This number can be used by the information Source on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.
  • This is the administrative number assigned by the Information Receiver in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the Information Receiver.
Example
Variants (all may be used)
REFPrevious Review Authorization Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

NT
Administrator's Reference Number
REF-02
127
Administrative 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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Effective Date

OptionalMax use 1

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

Usage notes
  • Use this segment to indicate the certification effective dates that prohibits the information receiver from accepting this notification.
  • Required when valued on the notification and the notification is not valid at this segment. 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

007
Effective
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
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Certification Effective Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Service Date

OptionalMax use 1

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

Usage notes
  • Use this segment to indicate the service dates that prohibits the information receiver from accepting this notification.
  • Required when valued on the notification and the notification is not valid at this segment. 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

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.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Proposed or Actual Service Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Issue Date

OptionalMax use 1

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

Usage notes
  • Use this segment to indicate the certification issue dates that prohibits the information receiver from accepting this notification.
  • Required when valued on the notification and the notification is not valid at this segment. 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

102
Issue
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
Certification Issue Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Certification Expiration Date

OptionalMax use 1

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

Usage notes
  • Use this segment to indicate the certification expiration dates that prohibits the information receiver from accepting this notification.
  • Required when valued on the notification and the notification is not valid at this segment. 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

036
Expiration
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
Certification Expiration Date
Required
String (AN)
Min 1Max 35

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

SV1
0810
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV1

Professional Service

OptionalMax use 1

To specify the service line item detail for a health care professional

Usage notes
  • Use this segment to indicate the professional service data that prohibits the information receiver from accepting this notification.
  • Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Example
If either Unit or Basis for Measurement Code (SV1-03) or Service Unit Count (SV1-04) is present, then the other is required
SV1-01
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
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.
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.

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. Use only in non-HIPAA implementations.

N4
National Drug Code in 5-4-2 Format
WK
Advanced Billing Concepts (ABC) 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 Complimentary, Alternative, or Holistic Procedure 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 service reviews 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.
C003-08
234
Product or Service ID
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • C003-08 represents the ending value in the range in which the code occurs.
SV1-02
782
Service Line Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV102 is the submitted service line item amount.
SV1-03
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

F2
International Unit

International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

MJ
Minutes
UN
Unit
SV1-04
380
Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

SV1-11
1073
EPSDT Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
N
No
Y
Yes
SV1-20
1337
Nursing Home Level of Care
Optional
Identifier (ID)

Code specifying the level of care provided by a nursing home facility

1
Skilled Nursing Facility (SNF)
2
Intermediate Care Facility (ICF)
3
Intermediate Care Facility - Mentally Retarded (ICF-MR)
4
Chronic Disease Hospital (CD)
5
Intermediate Care Facility (ICF) Level II
6
Special Skilled Nursing Facility (SNF)
7
Nursing Facility (NF)
8
Hospice
SV2
0820
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV2

Institutional Service Line

OptionalMax use 1

To specify the service line item detail for a health care institution

Usage notes

Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.

  • Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Example
At least one of Service Line Revenue Code (SV2-01) or Composite Medical Procedure Identifier (SV2-02) is required
If either Unit or Basis for Measurement Code (SV2-04) or Service Unit Count (SV2-05) is present, then the other is required
SV2-01
234
Service Line Revenue Code
Optional
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
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes

Required when returning data that was not valid at this level. 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.
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.

ID
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
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. Use only in non-HIPAA implementations.

N4
National Drug Code in 5-4-2 Format
ZZ
Mutually Defined

Use this code when reporting ICD-10-PCS. This code can only be used if mandated by HIPAA or for services not covered under HIPAA.
CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System

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.
C003-08
234
Product or Service ID
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • C003-08 represents the ending value in the range in which the code occurs.
SV2-03
782
Service Line Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV203 is the submitted service line item amount.
SV2-04
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
F2
International Unit

International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

UN
Unit
SV2-05
380
Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

SV2-06
1371
Service Line Rate
Optional
Decimal number (R)
Min 1Max 10

The rate per unit of associate revenue for hospital accommodation

SV2-10
1337
Nursing Home Level of Care
Optional
Identifier (ID)

Code specifying the level of care provided by a nursing home facility

1
Skilled Nursing Facility (SNF)
2
Intermediate Care Facility (ICF)
3
Intermediate Care Facility - Mentally Retarded (ICF-MR)
4
Chronic Disease Hospital (CD)
5
Intermediate Care Facility (ICF) Level II
6
Special Skilled Nursing Facility (SNF)
7
Nursing Facility (NF)
8
Hospice
SV3
0830
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV3

Dental Service

OptionalMax use 1

To specify the service line item detail for dental work

Usage notes
  • Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Example
SV3-01
C003
Composite Medical Procedure Identifier
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
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.
AD
American Dental Association Codes
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