X12 278 Health Care Services Review Information - Notification (X216)
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.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
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)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
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)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
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
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
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
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
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HI
- Health Care Services Review Information (278)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
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)
Assigned number originated and maintained by the sender
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
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
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
- Use this segment to indicate the start of a health care services review notification or information copy transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based notification or information copy.
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
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- 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.
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.
- 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
Beginning of Hierarchical Transaction
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
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
Code identifying purpose of transaction set
- 14
- Advance Notification
Use for administrative notification (provider to payer) of admissions, referrals, pre-certifications of future events. For example, use for notification of authorization to admit a patient, notification of authorization to refer a patient, notification of authorization for pre-certification of services.
- 22
- Information Copy
Use for courtesy copy of notification. For example, use to send copies of health care service review decision outcomes from a delegated entity, PCP, or UMO to the service provider.
- CN
- Completion Notification
Use CN for administrative notification (provider to payer) of admissions, referrals, pre-certifications associated with completed events. For example, use for Notice of Admission and Notice of Discharge.
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.
- If the receiver returns a 278 acknowledgment response, this identifier must be returned in the 278 acknowledgment transaction's BHT03.
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.
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.
Code specifying the type of transaction
- If BHT06 is not valued, the information receiver shall assume that a 278 acknowledgment response is not required or desired.
- NO
- Notice
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Source Name
To supply the full name of an individual or organizational entity
- The first occurrence of the NM1 loop is required and 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.
- The second NM1 loop may be used when the sender is not the same entity as the information source, or if there is a need to identify another requesting entity that was neither the sender or the information source.
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
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
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 UMO is a payer.
- XV
- Centers for Medicare and Medicaid Services PlanID
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI;
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI;
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it;If not required by this implementation guide, do not send.
Code identifying a party or other code
Information Source Supplemental Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the UMO to identify the provider;
OR
Required after the mandated NPI implementation date, when the entity is a non-health care provider, and an identifier is necessary for the UMO to identify the entity.
If not required by this implementation guide, do not send. - Use the NM1 segment for the primary identifier.
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
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Information Source Address
To specify the location of the named party
- Required when necessary to identify the information source by location. If not required, by this implementation guide, do not send.
- Used to identify a specific location when the information source has multiple locations and his authority varies based on location.
Information Source City, State, ZIP Code
To specify the geographic place of the named party
- Required when necessary to identify the information source by location. If not required, by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Information Source Contact Information
To identify a person or office to whom administrative communications should be directed
- 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 telephone 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 receiver 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.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Information Source Provider Information
To specify the identifying characteristics of a provider
- PRV02 qualifies PRV03.
- Required when the information source is a provider and the provider's role in the care of the patient or the provider's specialty is needed to further identify the provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
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
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Receiver Name
To supply the full name of an individual or organizational entity
- This segment identifies the receiver of information.
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
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
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
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 submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.If not required by this implementation guide, do not send.
Code identifying a party or other code
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
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.
Subscriber Name
To supply the full name of an individual or organizational entity
- This segment conveys the name and identification number of the subscriber (who may also be the patient).
- The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02) - Refer to Section 1.11.2.1, Identifying the Subscriber/Patient.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
- 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.
Code identifying a party or other code
Subscriber Supplemental Identification
To specify identifying information
- Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.
The primary identifier is the Member Identification Number in the NM1 segment.
- 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.
- If the information source values this segment with the Patient Account Number (REF01="EJ") on the notification, the notification receiver must return the same value in this segment on the acknowledgment response if one is returned.
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
Use this code only if the subscriber is the patient.
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 is also a need to pass the subscriber'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 was not used by the payer as its primary method of identifying the subscriber. The social security number may not be used for Medicare.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Subscriber Address
To specify the location of the named party
- Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Demographic Information
To supply demographic information
- Required when birth date is needed to identify the patient or when gender information was used to render a medical decision. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Subscriber Relationship
To provide benefit information on insured entities
- Required when the subscriber's role in the military was used to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
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
Code indicating the relationship between two individuals or entities
- 18
- Self
Code showing the general employment status of an employee/claimant
- 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
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Dependent Name
To supply the full name of an individual or organizational entity
- This segment conveys the name of the dependent who is the patient.
- The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
Dependent Last Name (NM103)
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02)
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Dependent Supplemental Identification
To specify identifying information
- Required when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.
- Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
- If the information source values this segment with the Patient Account Number (REF01="EJ") on the notification, the notification receiver must return the same value in this segment on the acknowledgment response if one is returned.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Dependent Address
To specify the location of the named party
- Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Dependent City, State, ZIP Code
To specify the geographic place of the named party
- Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Dependent Demographic Information
To supply demographic information
- Required when birth date is needed to identify the patient or when gender information was used to render a medical decision. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Dependent Relationship
To provide benefit information on insured entities
- Required when patient relationship to insured or birth sequence was used to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
- This segment may be used to further identify the patient. Examples include identifying a patient in a multiple birth or differentiating dependents with the same name.
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
Code indicating the relationship between two individuals or entities
- 01
- Spouse
- 19
- Child
- G8
- Other Relationship
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.).
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
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.
Patient Event Tracking Number
To uniquely identify a transaction to an application
- Required when the information source needs to assign a unique trace number at the patient event level. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
- This enables the requester to
- uniquely identify this patient event request
- trace the request
- match the response to the request
- reference this request in any associated attachments containing additional patient information related to this patient event request.
- If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
- Each trace number provided in the TRN segment at this level on the request must be returned by the information receiver in the TRN segment at the corresponding level of the response.
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 notification transaction (the information source).
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid the information source and clearinghouses in identifying their TRN in the 278 acknowledgment.
- 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.
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.
Patient Event Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request. If not required, may be provided at the sender's discretion.
- Required when this is a notification of a health care services review that was rejected due to invalid or missing patient event information. If not required by this implementation guide, do not send.
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
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 request 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.
- 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.
Health Care Services Review Information
To specify health care services review information
- Required to identify the type of health care services in this notification.
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.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value to identify appeals of review decisions where the service required was emergency or urgent.
- 2
- Appeal - Standard
Use this value to identify appeals of review decisions where the service required was not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Use this value to identify 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 this value to identify a revision of a certification for which services have not been rendered. For example, the information source may be identifying additional procedures or other procedures for the same patient event.
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
Required when UM04 is not valued at 2000F. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
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
Code specifying the level of service rendered
- 03
- Emergency
- E
- Elective
- U
- Urgent
Health Care Services Review
To specify the outcome of a health care services review
- The HCR segment at the 2000E event level contains information relevant to the original decision holder for the event. Certification Action, Review Identification, Review Decision Reason Code and Second Surgical Opinion Indicator data from the original decision maker is made available in the HCR segment to the information receiver.
- Required when health care services review information applies to the event level. If not required by this implementation guide, do not send.
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.
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.
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
- The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.
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
Previous Review Authorization Number
To specify identifying information
- This is the authorization number assigned by the UMO to the original review outcome associated with this event. This is not the trace number assigned by the requester.
- Required when the certification number assigned by the UMO to the original event review outcome was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Administrative Reference Number
To specify identifying information
- This is the administrative number assigned by the Information receiver in an acknowledgment from a prior notification. This is not the trace number assigned by the Information receiver.
- Required when this notification is related to an acknowledgment received from the information receiver in a prior acknowledgment transaction. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Accident Date
To specify any or all of a date, a time, or a time period
- Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 439
- Accident
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
Expression of a date, a time, or range of dates, times or dates and times
Last Menstrual Period Date
To specify any or all of a date, a time, or a time period
- Required when the notification is pregnancy related. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 484
- Last Menstrual Period
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
Expression of a date, a time, or range of dates, times or dates and times
Estimated Date of Birth
To specify any or all of a date, a time, or a time period
- Required when the notification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- ABC
- Estimated Date of Birth
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
Expression of a date, a time, or range of dates, times or dates and times
Onset of Current Symptoms or Illness Date
To specify any or all of a date, a time, or a time period
- Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 431
- Onset of Current Symptoms or Illness
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
Expression of a date, a time, or range of dates, times or dates and times
Event Date
To specify any or all of a date, a time, or a time period
- Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.
- If UM01 = AR use Admit Date.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- AAH
- Event
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
Expression of a date, a time, or range of dates, times or dates and times
Admission Date
To specify any or all of a date, a time, or a time period
- Required when identifying an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 435
- Admission
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. Use the HSD segment for the length of stay.;
Expression of a date, a time, or range of dates, times or dates and times
Discharge Date
To specify any or all of a date, a time, or a time period
- Required when identifying an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 096
- Discharge
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Required when certification issue date is different than the certification effective date. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Required when the certification has an expiration date that indicates the date on which the certification will expire. If not required by the implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Required when the certification is limited by effective dates to indicate the date or date range when the certification is effective. If not required by the implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Expression of a date, a time, or range of dates, times or dates and times
Patient Diagnosis
To supply information related to the delivery of health care
- Required when identifying the diagnosis code at the event level. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Health Care Services Delivery
To specify the delivery pattern of health care services
Required when HSD02 is valued to qualify the type of service count for this patient event. If not required by this implementation guide, do not send.
- Required when identifying services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
- Report delivery patterns for specific services in the Service Level (Loop 2000F).
- An explanation of the uses of this segment follows.
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".
Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".
Code specifying the type of quantity
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- MO
- Months
- WK
- Week
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
Code defining periods
- 6
- Hour
- 7
- Day
- 21
- Years
- 26
- Episode
- 27
- Visit
- 34
- Month
- 35
- Week
Code which specifies the routine shipments, deliveries, or calendar pattern
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SA
- Sunday, Monday, Thursday, Friday, Saturday
- SB
- Tuesday through Saturday
- SC
- Sunday, Wednesday, Thursday, Friday, Saturday
- SD
- Monday, Wednesday, Thursday, Friday, Saturday
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- WE
- Weekend
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Code which specifies the time for routine shipments or deliveries
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Institutional Claim Code
To supply information specific to hospital claims
Required when admission type code information is used between the information sender and information receiver. If not required by this implementation guide, do not send.
- Required when identifying certifications for admissions (UM01 = AR) to a facility. If not required by this implementation guide, do not send.
Code indicating the priority of this admission
Code indicating the source of this admission
Code indicating patient status as of the "statement covers through date"
Ambulance Transport Information
To supply information related to the ambulance service rendered to a patient
- Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.
- When the CR1 segment is used, then Loop 2010EB is required.
Code indicating the type of ambulance transport
- I
- Initial Trip
- R
- Return Trip
- T
- Transfer Trip
- X
- Round Trip
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DH
- Miles
- DK
- Kilometers
Numeric value of quantity
- CR106 is the distance traveled during transport.
Spinal Manipulation Service Information
To supply information related to the chiropractic service rendered to a patient
Required when identifying certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.
- Required when identifying certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.
Occurrence counter
- CR201 is the number this treatment is in the series.
Numeric value of quantity
- CR202 is the total number of treatments in the series.
Code identifying the specific level of subluxation
- When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Code identifying the specific level of subluxation
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Home Oxygen Therapy Information
To supply information regarding certification of medical necessity for home oxygen therapy
- Required when identifying initial, extended, or revised certification of home oxygen therapy. If not required by this implementation guide, do not send.
- Use the UM segment data element UM02 instead of CR501 to specify the Certification Type Code.
- Use the HSD segment instead of CR502 to specify the treatment period.
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Numeric value of quantity
- CR506 is the oxygen flow rate in liters per minute.
Numeric value of quantity
- CR507 is the number of times per day the patient must use oxygen.
Numeric value of quantity
- CR508 is the number of hours per period of oxygen use.
A free-form description to clarify the related data elements and their content
- CR509 is the special orders for the respiratory therapist.
Numeric value of quantity
- CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
Code to indicate if a particular form of delivery was prescribed
- A
- Nasal Cannula
- B
- Oxygen Conserving Device
- C
- Oxygen Conserving Device with Oxygen Pulse System
- D
- Oxygen Conserving Device with Reservoir System
- E
- Transtracheal Catheter
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
Home Health Care Information
To supply information related to the certification of a home health care patient
- Required when identifying certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.
- Requests for home health care must include a principal diagnosis (HI01 = BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.
Code indicating physician's prognosis for the patient
- 1
- Poor
- 2
- Guarded
- 3
- Fair
- 4
- Good
- 5
- Very Good
- 6
- Excellent
- 7
- Less than 6 Months to Live
- 8
- Terminal
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR602 is the date covered home health services began.
Code indicating the date format, time format, or date and time format
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- CR604 is the certification period covered by this plan of treatment.
Code indicating a Yes or No condition or response
- CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.
- W
- Not Applicable
Code indicating the type of certification
- This element must have the same value as UM02.
- 1
- Appeal - Immediate
Use this value only for appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
- 5
- Notification
- 6
- Verification
This code is used to request the UMO to reconsider a previously denied referral or certification request.
- I
- Initial
- R
- Renewal
- S
- Revised
Additional Patient Information
To identify the type or transmission or both of paperwork or supporting information
- This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number inPWK06 would be referenced in the electronic attachment.
- Required when needed to identify missing teeth for dental services, or to identify additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
- The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
Expected outcomes of rehabilitative services.
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- 48
- Social Security Benefit Letter
- 55
- Rental Agreement
Use for medical or dental equipment rental.
- 59
- Benefit Letter
- 77
- Support Data for Verification
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
Information to support necessity of ambulance trip.
- AS
- Admission Summary
A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.
- AT
- Purchase Order Attachment
Use for purchase of medical or dental equipment.
- B2
- Prescription
- B3
- Physician Order
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
- CK
- Consent Form(s)
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- FM
- Family Medical History Document
- HC
- Health Certificate
- HP
- History and Physical
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- P4
- Pathology Report
- P5
- Patient Medical History Document
- P6
- Periodontal Charts
- P7
- Periodontal Reports
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- QC
- Cause and Corrective Action Report
- QR
- Quality Report
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- T7
- Therapy Notes
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- BM
- By Mail
- EL
- Electronically Only
Use to indicate that the attachment is being transmitted in a separate X12 functional group.
- EM
- FX
- By Fax
- VO
- Voice
Use this for voicemail or phone communication.
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
A free-form description to clarify the related data elements and their content
- PWK07 may be used to indicate special information to be shown on the specified report.
- To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2) bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the second byte with a space.
Message Text
To provide a free-form format that allows the transmission of text information
- Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.
- Free form text or description fields are not recommended because they require human interpretation.
- Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
Patient Event Provider Name
To supply the full name of an individual or organizational entity
- Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued of if loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.
- If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
- If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.
Code identifying an organizational entity, a physical location, property or an individual
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- AAJ
- Admitting Services
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DN
- Referring Provider
- FA
- Facility
- G3
- Clinic
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- QV
- Group Practice
- SJ
- Service Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
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 submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.If not required by this implementation guide, do not send.
Code identifying a party or other code
Patient Event Provider Supplemental Identification
To specify identifying information
- Use the NM1 segment for the primary identifier.
- Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
If not required by this implementation guide, do not send.
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 when the requestor has not been assigned an NPI, or NPI is not mandated for use and the UMO identified in loop 2010A has assigned its own identifier for this provider.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Patient Event Provider Address
To specify the location of the named party
- Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.
Patient Event Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Patient Event Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Patient Event Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.
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
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
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 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.
- 97
- Invalid or Missing Provider Address
- IP
- Inappropriate Provider Role
Patient Event Provider Information
To specify the identifying characteristics of a provider
- Required when the notification is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Additional Patient Information Contact Name
To supply the full name of an individual or organizational entity
- Required when additional information is sent by an information contact that is different from the information source identified in loop 2010A. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- L5
- Contact
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Use this name only if the destination is an individual, such as an individual primary care physician.
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
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 destination is a payer.
- XV
- Centers for Medicare and Medicaid Services PlanID
Use if the destination is a payer.
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Use if the destination is a provider.
Code identifying a party or other code
Additional Patient Information Contact Address
To specify the location of the named party
- Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.
Additional Patient Information City, State, ZIP Code
To specify the geographic place of the named party
- Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Additional Patient Information Contact Information
To identify a person or office to whom administrative communications should be directed
- 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 telephone 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.
- By definition of the standard, if PER03 is used, PER04 is required.
- Required when the request for additional patient information must be routed to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Patient Event Transport Information
To supply the full name of an individual or organizational entity
- Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.
- At least two iterations of this loop are necessary to indicate the pick;up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
- When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop
Code identifying an organizational entity, a physical location, property or an individual
- 45
- Drop-off Location
- FS
- Final Scheduled Destination
- ND
- Next Destination
- PW
- Pickup Address
- R3
- Next Scheduled Destination
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Patient Event Transport Location Address
To specify the location of the named party
Address information
- Use this element for the first line of the transport location address.
Address information
Patient Event Transport Location City/State/ZIP Code
To specify the geographic place of the named party
Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Patient Event Transport Information Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.
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
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 transport information.
- 33
- Input Errors
Use for input errors not covered by another reject reason code.
- 47
- Invalid/Missing Provider State
Use to code to indicate that the transport location state is invalid or missing.
- 97
- Invalid or Missing Provider Address
Use this code to indicate that the transport location address is invalid or missing.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Patient Event Other UMO Name
To supply the full name of an individual or organizational entity
- Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 00
- Alternate Insurer
Use this code to indate that the other UMO is commerical insurance.
- CA
- Carrier
Use this code to indicate that the other UMO is Medicare Part B.
- GG
- Intermediary
Use this code to indicate that the other UMO is Medicare Part A.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Other UMO Denial Reason
To specify identifying information
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other UMO Denial Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 598
- Rejected
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
Expression of a date, a time, or range of dates, times or dates and times
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
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.
Service Trace Number
To uniquely identify a transaction to an application
- This enables the requester to
- uniquely identify this service line request
- trace the request
- match the response to the request
- reference this request in any associated attachments containing additional service information related to this service line request.
- Required when the requester needs to assign a unique trace number to the service line request. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
- If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
- Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
- If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.
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 notification 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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- 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 UMO 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.
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.
Service Request Validation
To specify the validity of the request and indicate follow-up action authorized
- If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service information. If not required by this implementation guide, do not send.
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
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
Use for invalid/missing service, admission, surgery, or discharge dates.
- 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
- AG
- Invalid/Missing Procedure Code(s)
- T5
- Certification Information Missing
Use to indicate missing previous certification number information.
Health Care Services Review Information
To specify health care services review information
- Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
Code indicating a type of request
- 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.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value only for appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Use this value for an extension request to a prior approved service.
- 5
- Notification
- I
- Initial
- R
- Renewal
Various services, such as physical therapy, spinal manipulation, and allergy treatment, 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 this value when revising the specifics of a notification for which services have not been rendered. For example, the Information Source may be identifying additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- Values at the Service Level override the values entered at the Patient Event Level for this 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 services.
- 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
Required when different from the UM04 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
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
Health Care Services Review
To specify the outcome of a health care services review
- If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.
- Required when the HCR segment is not used in 2000E, or if HCR01 in 2000E is A2. If not required by this implementation guide, do not send.
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
Use only if certification is not required.
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.
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
- The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.
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
Previous Review Authorization Number
To specify identifying information
- Required when different from the Previous Review Authorization Number specified at the Patient Event Level (2000E). If not required by this implementation guide, do not send.
- This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Administrative Reference Number
To specify identifying information
- This is the administrative number assigned by the Information receiver for the original acknowledgment of the notification associated with this service review. This is not the trace number assigned by the requester.
- Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Date
To specify any or all of a date, a time, or a time period
- Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.
- Use this segment for the valid date(s) during which the service can be performed.
Code specifying type of date or time, or both date and time
- 472
- Service
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Required when Certification Issue Date is different from the Patient Event Certification Issue Date in Loop 2000E. If not required by this implementation guide, do not send.
- Use this segment for the date when the certification was issued.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Required when Certification Expiration Date is different from the Patient Event Certification Expiration Date in Loop 2000E. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Required when different from the Certification Effective Date in Loop 2000E. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Expression of a date, a time, or range of dates, times or dates and times
Professional Service
To specify the service line item detail for a health care professional
- Required when identifying a specific Professional Service. If not required by this implementation guide, do not send.
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
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.
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.
- Use this data element for the first procedure code modifier.
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.
- Use this data element for the second procedure code modifier.
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.
- Use this data element for the third procedure code modifier.
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.
- Use this data element for the fourth procedure code modifier.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- Use SV101-2 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.
Monetary amount
- SV102 is the submitted service line item amount.
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
Required when this procedure relates to a specific diagnosis reported in HI Loop 2000E to point to the specific diagnosis. If not required by this implementation guide, do not send.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
- Use this pointer for the second diagnosis code pointer.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
- Use this pointer for the third diagnosis code pointer.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
- Use this pointer for the fourth diagnosis code pointer.
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
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
Institutional Service Line
To specify the service line item detail for a health care institution
Required when the service review decision was determined using a revenue code. If not required by this implementation guide, do not send.
- Required when identifying a specific Institutional Service, or a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.
Identifying number for a product or service
- SV201 is the revenue code.
- See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
Required when identifying a specific procedure code. If not required by this implementation guide, do not send.
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
- 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. - 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
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.
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.
- Use this data element for the first procedure code modifier.
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.
- Use this data element for the second procedure code modifier.
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.
- Use this data element for the third procedure code modifier.
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.
- Use this data element for the fourth procedure code modifier.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- Use SV202-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.
Monetary amount
- SV203 is the submitted service line item amount.
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
The rate per unit of associate revenue for hospital accommodation
Code specifying the status of a nursing home resident at the time of service
- 1
- Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
- 2
- Newly Admitted
- 3
- Newly Eligible
- 4
- No Longer Eligible
- 5
- Still a Resident
- 6
- Temporary Absence - Hospital
- 7
- Temporary Absence - Other
- 8
- Transferred to Intermediate Care Facility - Level II (ICF II)
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
Dental Service
To specify the service line item detail for dental work
- Required when identifying a specific Dental Service. If not required by this implementation guide, do not send.
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
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.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the first procedure code modifier.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the second procedure code modifier.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the third procedure code modifier.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the fourth procedure code modifier.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- Use SV301-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.
Monetary amount
- SV302 is the submitted service line item amount.
Required when necessary to report areas of the mouth that are being treated. If not required by this implementation guide, do not send.
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code specifying the placement status for the dental work
- I
- Initial Placement
- R
- Replacement
Numeric value of quantity
- SV306 is the number of procedures.
- Number of procedures.
A free-form description to clarify the related data elements and their content
- SV307 is the reason for replacement.
Tooth Information
To identify a tooth by number and, if applicable, one or more tooth surfaces
- Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- JP
- Universal National Tooth Designation System
Code indicating a code from a specific industry code list
Required when reporting tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.
Code identifying the area of the tooth that was treated
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Health Care Services Delivery
To specify the delivery pattern of health care services
Required when needed to indicate the type of service count quantified in HSD02. If not required by this implementation guide, do not send.
- An explanation of the uses of this segment follows.
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".
Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".
- Required when identifying services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.
Code specifying the type of quantity
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- If HSD02 is not valued, do not use.
- DA
- Days
- MO
- Months
- WK
- Week
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
Code defining periods
- 6
- Hour
- 7
- Day
- 21
- Years
- 26
- Episode
- 27
- Visit
- 34
- Month
- 35
- Week
Code which specifies the routine shipments, deliveries, or calendar pattern
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SA
- Sunday, Monday, Thursday, Friday, Saturday
- SB
- Tuesday through Saturday
- SC
- Sunday, Wednesday, Thursday, Friday, Saturday
- SD
- Monday, Wednesday, Thursday, Friday, Saturday
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Code which specifies the time for routine shipments or deliveries
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Additional Service Information
To identify the type or transmission or both of paperwork or supporting information
- Required when the information source has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) in this Service loop, and the 278 Notification, or Information Copy (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
- Additional information requested at the Service level should apply to a specific service and/or all the services requested in this service loop.
- This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
- The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
Expected outcomes of rehabilitative services.
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- 48
- Social Security Benefit Letter
- 55
- Rental Agreement
Use for medical or dental equipment rental.
- 59
- Benefit Letter
- 77
- Support Data for Verification
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
Information to support necessity of ambulance trip.
- AS
- Admission Summary
A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.
- AT
- Purchase Order Attachment
Use for purchase of medical or dental equipment.
- B2
- Prescription
- B3
- Physician Order
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
- CK
- Consent Form(s)
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- FM
- Family Medical History Document
- HC
- Health Certificate
- HP
- History and Physical
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- P4
- Pathology Report
- P5
- Patient Medical History Document
- P6
- Periodontal Charts
- P7
- Periodontal Reports
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- QC
- Cause and Corrective Action Report
- QR
- Quality Report
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- T7
- Therapy Notes
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- AA
- Available on Request at Provider Site
This means that the paperwork is not being sent with the notification at this time. Instead, it is available to the Information Receiver upon request.
- BM
- By Mail
- EL
- Electronically Only
Use to indicate that the attachment is being transmitted in a separate X12 functional group.
- EM
- FX
- By Fax
- VO
- Voice
Use this for voicemail or phone communication.
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- The Information Source can use when PWK02 equals "AA" if the Inforamtion Source wants to send a document control number for an attachment remaining at the Provider's office.
A free-form description to clarify the related data elements and their content
- PWK07 may be used to indicate special information to be shown on the specified report.
Message Text
To provide a free-form format that allows the transmission of text information
- Free form text or description fields are not recommended because they require human interpretation.
- Required when needed to transmit a message to the Information Receiver about the service. If not required by this implementation guide, do not send.
- Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
Service Provider Name
To supply the full name of an individual or organizational entity
- Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
- If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event.
- Required when identifying a service provider, specialist, or specialty entity for this service and is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying an organizational entity, a physical location, property or an individual
- 1T
- Physician, Clinic or Group Practice
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DQ
- Supervising Physician
- FA
- Facility
- G3
- Clinic
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- QV
- Group Practice
- SJ
- Service Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- Not Used if identifying a specialty entity.
Individual middle name or initial
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 submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.;If not required by this implementation guide, do not send.
Code identifying a party or other code
Service Provider Supplemental Identification
To specify identifying information
- Use the NM1 segment for the primary identifier.
- Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
If not required by this implementation guide, do not send.
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.
- 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 any Federally administered programs such as Medicare or CHAMPUS. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
- See code source 22: State and Outlying Areas of the US.
Service Provider Address
To specify the location of the named party
- Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.
Service Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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.
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Service Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.
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
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 service 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
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 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
- 79
- Invalid Participant Identification
- 97
- Invalid or Missing Provider Address
Service Provider Information
To specify the identifying characteristics of a provider
- Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
Code identifying the type of provider
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- 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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
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.
Patient Event Tracking Number
To uniquely identify a transaction to an application
- Required when the information source needs to assign a unique trace number at the patient event level. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
- This enables the requester to
- uniquely identify this patient event request
- trace the request
- match the response to the request
- reference this request in any associated attachments containing additional patient information related to this patient event request.
- If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
- Each trace number provided in the TRN segment at this level on the request must be returned by the information receiver in the TRN segment at the corresponding level of the response.
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 notification transaction (the information source).
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid the information source and clearinghouses in identifying their TRN in the 278 acknowledgment.
- 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.
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.
Patient Event Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request. If not required, may be provided at the sender's discretion.
- Required when this is a notification of a health care services review that was rejected due to invalid or missing patient event information. If not required by this implementation guide, do not send.
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
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 request 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.
- 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.
Health Care Services Review Information
To specify health care services review information
- Required to identify the type of health care services in this notification.
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.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value to identify appeals of review decisions where the service required was emergency or urgent.
- 2
- Appeal - Standard
Use this value to identify appeals of review decisions where the service required was not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Use this value to identify 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 this value to identify a revision of a certification for which services have not been rendered. For example, the information source may be identifying additional procedures or other procedures for the same patient event.
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
Required when UM04 is not valued at 2000F. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
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
Code specifying the level of service rendered
- 03
- Emergency
- E
- Elective
- U
- Urgent
Health Care Services Review
To specify the outcome of a health care services review
- The HCR segment at the 2000E event level contains information relevant to the original decision holder for the event. Certification Action, Review Identification, Review Decision Reason Code and Second Surgical Opinion Indicator data from the original decision maker is made available in the HCR segment to the information receiver.
- Required when health care services review information applies to the event level. If not required by this implementation guide, do not send.
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.
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.
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
- The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.
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
Previous Review Authorization Number
To specify identifying information
- This is the authorization number assigned by the UMO to the original review outcome associated with this event. This is not the trace number assigned by the requester.
- Required when the certification number assigned by the UMO to the original event review outcome was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Administrative Reference Number
To specify identifying information
- This is the administrative number assigned by the Information receiver in an acknowledgment from a prior notification. This is not the trace number assigned by the Information receiver.
- Required when this notification is related to an acknowledgment received from the information receiver in a prior acknowledgment transaction. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Accident Date
To specify any or all of a date, a time, or a time period
- Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 439
- Accident
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
Expression of a date, a time, or range of dates, times or dates and times
Last Menstrual Period Date
To specify any or all of a date, a time, or a time period
- Required when the notification is pregnancy related. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 484
- Last Menstrual Period
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
Expression of a date, a time, or range of dates, times or dates and times
Estimated Date of Birth
To specify any or all of a date, a time, or a time period
- Required when the notification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- ABC
- Estimated Date of Birth
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
Expression of a date, a time, or range of dates, times or dates and times
Onset of Current Symptoms or Illness Date
To specify any or all of a date, a time, or a time period
- Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 431
- Onset of Current Symptoms or Illness
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
Expression of a date, a time, or range of dates, times or dates and times
Event Date
To specify any or all of a date, a time, or a time period
- Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.
- If UM01 = AR use Admit Date.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- AAH
- Event
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
Expression of a date, a time, or range of dates, times or dates and times
Admission Date
To specify any or all of a date, a time, or a time period
- Required when identifying an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 435
- Admission
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. Use the HSD segment for the length of stay.;
Expression of a date, a time, or range of dates, times or dates and times
Discharge Date
To specify any or all of a date, a time, or a time period
- Required when identifying an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 096
- Discharge
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Required when certification issue date is different than the certification effective date. If not required by this implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Required when the certification has an expiration date that indicates the date on which the certification will expire. If not required by the implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Required when the certification is limited by effective dates to indicate the date or date range when the certification is effective. If not required by the implementation guide, do not send.
- The total number of DPT segments in the 2000E Loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Expression of a date, a time, or range of dates, times or dates and times
Patient Diagnosis
To supply information related to the delivery of health care
- Required when identifying the diagnosis code at the event level. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
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
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
Expression of a date, a time, or range of dates, times or dates and times
Health Care Services Delivery
To specify the delivery pattern of health care services
Required when HSD02 is valued to qualify the type of service count for this patient event. If not required by this implementation guide, do not send.
- Required when identifying services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
- Report delivery patterns for specific services in the Service Level (Loop 2000F).
- An explanation of the uses of this segment follows.
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".
Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".
Code specifying the type of quantity
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- MO
- Months
- WK
- Week
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
Code defining periods
- 6
- Hour
- 7
- Day
- 21
- Years
- 26
- Episode
- 27
- Visit
- 34
- Month
- 35
- Week
Code which specifies the routine shipments, deliveries, or calendar pattern
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SA
- Sunday, Monday, Thursday, Friday, Saturday
- SB
- Tuesday through Saturday
- SC
- Sunday, Wednesday, Thursday, Friday, Saturday
- SD
- Monday, Wednesday, Thursday, Friday, Saturday
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- WE
- Weekend
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Code which specifies the time for routine shipments or deliveries
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Institutional Claim Code
To supply information specific to hospital claims
Required when admission type code information is used between the information sender and information receiver. If not required by this implementation guide, do not send.
- Required when identifying certifications for admissions (UM01 = AR) to a facility. If not required by this implementation guide, do not send.
Code indicating the priority of this admission
Code indicating the source of this admission
Code indicating patient status as of the "statement covers through date"
Ambulance Transport Information
To supply information related to the ambulance service rendered to a patient
- Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.
- When the CR1 segment is used, then Loop 2010EB is required.
Code indicating the type of ambulance transport
- I
- Initial Trip
- R
- Return Trip
- T
- Transfer Trip
- X
- Round Trip
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DH
- Miles
- DK
- Kilometers
Numeric value of quantity
- CR106 is the distance traveled during transport.
Spinal Manipulation Service Information
To supply information related to the chiropractic service rendered to a patient
Required when identifying certification for a specific treatment number in a series of treatments. If not required by this implementation guide, do not send.
- Required when identifying certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.
Occurrence counter
- CR201 is the number this treatment is in the series.
Numeric value of quantity
- CR202 is the total number of treatments in the series.
Code identifying the specific level of subluxation
- When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Code identifying the specific level of subluxation
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Home Oxygen Therapy Information
To supply information regarding certification of medical necessity for home oxygen therapy
- Required when identifying initial, extended, or revised certification of home oxygen therapy. If not required by this implementation guide, do not send.
- Use the UM segment data element UM02 instead of CR501 to specify the Certification Type Code.
- Use the HSD segment instead of CR502 to specify the treatment period.
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Numeric value of quantity
- CR506 is the oxygen flow rate in liters per minute.
Numeric value of quantity
- CR507 is the number of times per day the patient must use oxygen.
Numeric value of quantity
- CR508 is the number of hours per period of oxygen use.
A free-form description to clarify the related data elements and their content
- CR509 is the special orders for the respiratory therapist.
Numeric value of quantity
- CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
Code to indicate if a particular form of delivery was prescribed
- A
- Nasal Cannula
- B
- Oxygen Conserving Device
- C
- Oxygen Conserving Device with Oxygen Pulse System
- D
- Oxygen Conserving Device with Reservoir System
- E
- Transtracheal Catheter
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
Home Health Care Information
To supply information related to the certification of a home health care patient
- Required when identifying certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.
- Requests for home health care must include a principal diagnosis (HI01 = BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.
Code indicating physician's prognosis for the patient
- 1
- Poor
- 2
- Guarded
- 3
- Fair
- 4
- Good
- 5
- Very Good
- 6
- Excellent
- 7
- Less than 6 Months to Live
- 8
- Terminal
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR602 is the date covered home health services began.
Code indicating the date format, time format, or date and time format
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- CR604 is the certification period covered by this plan of treatment.
Code indicating a Yes or No condition or response
- CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.
- W
- Not Applicable
Code indicating the type of certification
- This element must have the same value as UM02.
- 1
- Appeal - Immediate
Use this value only for appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
- 5
- Notification
- 6
- Verification
This code is used to request the UMO to reconsider a previously denied referral or certification request.
- I
- Initial
- R
- Renewal
- S
- Revised
Additional Patient Information
To identify the type or transmission or both of paperwork or supporting information
- This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number inPWK06 would be referenced in the electronic attachment.
- Required when needed to identify missing teeth for dental services, or to identify additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
- The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
Expected outcomes of rehabilitative services.
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- 48
- Social Security Benefit Letter
- 55
- Rental Agreement
Use for medical or dental equipment rental.
- 59
- Benefit Letter
- 77
- Support Data for Verification
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
Information to support necessity of ambulance trip.
- AS
- Admission Summary
A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.
- AT
- Purchase Order Attachment
Use for purchase of medical or dental equipment.
- B2
- Prescription
- B3
- Physician Order
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
- CK
- Consent Form(s)
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- FM
- Family Medical History Document
- HC
- Health Certificate
- HP
- History and Physical
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- P4
- Pathology Report
- P5
- Patient Medical History Document
- P6
- Periodontal Charts
- P7
- Periodontal Reports
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- QC
- Cause and Corrective Action Report
- QR
- Quality Report
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- T7
- Therapy Notes
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- BM
- By Mail
- EL
- Electronically Only
Use to indicate that the attachment is being transmitted in a separate X12 functional group.
- EM
- FX
- By Fax
- VO
- Voice
Use this for voicemail or phone communication.
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
A free-form description to clarify the related data elements and their content
- PWK07 may be used to indicate special information to be shown on the specified report.
- To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2) bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the second byte with a space.
Message Text
To provide a free-form format that allows the transmission of text information
- Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.
- Free form text or description fields are not recommended because they require human interpretation.
- Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
Patient Event Provider Name
To supply the full name of an individual or organizational entity
- Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued of if loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.
- If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
- If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.
Code identifying an organizational entity, a physical location, property or an individual
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- AAJ
- Admitting Services
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DN
- Referring Provider
- FA
- Facility
- G3
- Clinic
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- QV
- Group Practice
- SJ
- Service Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
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 submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.If not required by this implementation guide, do not send.
Code identifying a party or other code
Patient Event Provider Supplemental Identification
To specify identifying information
- Use the NM1 segment for the primary identifier.
- Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
If not required by this implementation guide, do not send.
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 when the requestor has not been assigned an NPI, or NPI is not mandated for use and the UMO identified in loop 2010A has assigned its own identifier for this provider.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Patient Event Provider Address
To specify the location of the named party
- Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.
Patient Event Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Patient Event Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Patient Event Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.
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
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
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 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.
- 97
- Invalid or Missing Provider Address
- IP
- Inappropriate Provider Role
Patient Event Provider Information
To specify the identifying characteristics of a provider
- Required when the notification is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Additional Patient Information Contact Name
To supply the full name of an individual or organizational entity
- Required when additional information is sent by an information contact that is different from the information source identified in loop 2010A. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- L5
- Contact
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Use this name only if the destination is an individual, such as an individual primary care physician.
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
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 destination is a payer.
- XV
- Centers for Medicare and Medicaid Services PlanID
Use if the destination is a payer.
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Use if the destination is a provider.
Code identifying a party or other code
Additional Patient Information Contact Address
To specify the location of the named party
- Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.
Additional Patient Information City, State, ZIP Code
To specify the geographic place of the named party
- Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Additional Patient Information Contact Information
To identify a person or office to whom administrative communications should be directed
- 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 telephone 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.
- By definition of the standard, if PER03 is used, PER04 is required.
- Required when the request for additional patient information must be routed to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Patient Event Transport Information
To supply the full name of an individual or organizational entity
- Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.
- At least two iterations of this loop are necessary to indicate the pick;up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
- When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop
Code identifying an organizational entity, a physical location, property or an individual
- 45
- Drop-off Location
- FS
- Final Scheduled Destination
- ND
- Next Destination
- PW
- Pickup Address
- R3
- Next Scheduled Destination
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Patient Event Transport Location Address
To specify the location of the named party
Address information
- Use this element for the first line of the transport location address.
Address information
Patient Event Transport Location City/State/ZIP Code
To specify the geographic place of the named party
Required when N403 is not valued. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Patient Event Transport Information Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.
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
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 transport information.
- 33
- Input Errors
Use for input errors not covered by another reject reason code.
- 47
- Invalid/Missing Provider State
Use to code to indicate that the transport location state is invalid or missing.
- 97
- Invalid or Missing Provider Address
Use this code to indicate that the transport location address is invalid or missing.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Patient Event Other UMO Name
To supply the full name of an individual or organizational entity
- Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 00
- Alternate Insurer
Use this code to indate that the other UMO is commerical insurance.
- CA
- Carrier
Use this code to indicate that the other UMO is Medicare Part B.
- GG
- Intermediary
Use this code to indicate that the other UMO is Medicare Part A.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Other UMO Denial Reason
To specify identifying information
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other UMO Denial Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 598
- Rejected
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
Expression of a date, a time, or range of dates, times or dates and times
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
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.
Service Trace Number
To uniquely identify a transaction to an application
- This enables the requester to
- uniquely identify this service line request
- trace the request
- match the response to the request
- reference this request in any associated attachments containing additional service information related to this service line request.
- Required when the requester needs to assign a unique trace number to the service line request. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
- If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
- Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
- If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.
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 notification 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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- 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 UMO 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.
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.
Service Request Validation
To specify the validity of the request and indicate follow-up action authorized
- If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service information. If not required by this implementation guide, do not send.
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
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
Use for invalid/missing service, admission, surgery, or discharge dates.
- 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
- AG
- Invalid/Missing Procedure Code(s)
- T5
- Certification Information Missing
Use to indicate missing previous certification number information.
Health Care Services Review Information
To specify health care services review information
- Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
Code indicating a type of request
- 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.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value only for appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Use this value for an extension request to a prior approved service.
- 5
- Notification
- I
- Initial
- R
- Renewal
Various services, such as physical therapy, spinal manipulation, and allergy treatment, 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 this value when revising the specifics of a notification for which services have not been rendered. For example, the Information Source may be identifying additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- Values at the Service Level override the values entered at the Patient Event Level for this 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 services.
- 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
Required when different from the UM04 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
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
Health Care Services Review
To specify the outcome of a health care services review
- If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.
- Required when the HCR segment is not used in 2000E, or if HCR01 in 2000E is A2. If not required by this implementation guide, do not send.
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
Use only if certification is not required.
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.
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
- The HCR03 data element is a repeating data element and can be repeated up to the maximum allowed by the standard in this implementation guide.
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
Previous Review Authorization Number
To specify identifying information
- Required when different from the Previous Review Authorization Number specified at the Patient Event Level (2000E). If not required by this implementation guide, do not send.
- This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Administrative Reference Number
To specify identifying information
- This is the administrative number assigned by the Information receiver for the original acknowledgment of the notification associated with this service review. This is not the trace number assigned by the requester.
- Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Date
To specify any or all of a date, a time, or a time period
- Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.
- Use this segment for the valid date(s) during which the service can be performed.
Code specifying type of date or time, or both date and time
- 472
- Service
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Required when Certification Issue Date is different from the Patient Event Certification Issue Date in Loop 2000E. If not required by this implementation guide, do not send.
- Use this segment for the date when the certification was issued.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Required when Certification Expiration Date is different from the Patient Event Certification Expiration Date in Loop 2000E. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Expression of a date, a time, or range of dates, times or dates and times
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Required when different from the Certification Effective Date in Loop 2000E. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Expression of a date, a time, or range of dates, times or dates and times
Professional Service
To specify the service line item detail for a health care professional
- Required when identifying a specific Professional Service. If not required by this implementation guide, do not send.
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
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.
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.
- Use this data element for the first procedure code modifier.
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.
- Use this data element for the second procedure code modifier.
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.
- Use this data element for the third procedure code modifier.
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.
- Use this data element for the fourth procedure code modifier.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- Use SV101-2 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.
Monetary amount
- SV102 is the submitted service line item amount.
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
Required when this procedure relates to a specific diagnosis reported in HI Loop 2000E to point to the specific diagnosis. If not required by this implementation guide, do not send.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
- Use this pointer for the second diagnosis code pointer.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
- Use this pointer for the third diagnosis code pointer.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
- Use this pointer for the fourth diagnosis code pointer.
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
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
Institutional Service Line
To specify the service line item detail for a health care institution
Required when the service review decision was determined using a revenue code. If not required by this implementation guide, do not send.
- Required when identifying a specific Institutional Service, or a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.
Identifying number for a product or service
- SV201 is the revenue code.
- See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
Required when identifying a specific procedure code. If not required by this implementation guide, do not send.
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
- 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. - 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
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.
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.
- Use this data element for the first procedure code modifier.
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.
- Use this data element for the second procedure code modifier.
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.
- Use this data element for the third procedure code modifier.
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.
- Use this data element for the fourth procedure code modifier.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- Use SV202-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.
Monetary amount
- SV203 is the submitted service line item amount.
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
The rate per unit of associate revenue for hospital accommodation
Code specifying the status of a nursing home resident at the time of service
- 1
- Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
- 2
- Newly Admitted
- 3
- Newly Eligible
- 4
- No Longer Eligible
- 5
- Still a Resident
- 6
- Temporary Absence - Hospital
- 7
- Temporary Absence - Other
- 8
- Transferred to Intermediate Care Facility - Level II (ICF II)
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
Dental Service
To specify the service line item detail for dental work
- Required when identifying a specific Dental Service. If not required by this implementation guide, do not send.
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
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.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the first procedure code modifier.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the second procedure code modifier.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the third procedure code modifier.
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.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature', if such modifier is available.
- Use this data element for the fourth procedure code modifier.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
- Use SV301-2 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.
Monetary amount
- SV302 is the submitted service line item amount.
Required when necessary to report areas of the mouth that are being treated. If not required by this implementation guide, do not send.
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code specifying the placement status for the dental work
- I
- Initial Placement
- R
- Replacement
Numeric value of quantity
- SV306 is the number of procedures.
- Number of procedures.
A free-form description to clarify the related data elements and their content
- SV307 is the reason for replacement.
Tooth Information
To identify a tooth by number and, if applicable, one or more tooth surfaces
- Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- JP
- Universal National Tooth Designation System
Code indicating a code from a specific industry code list
Required when reporting tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.
Code identifying the area of the tooth that was treated
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Health Care Services Delivery
To specify the delivery pattern of health care services
Required when needed to indicate the type of service count quantified in HSD02. If not required by this implementation guide, do not send.
- An explanation of the uses of this segment follows.
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".
Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".
- Required when identifying services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.
Code specifying the type of quantity
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- If HSD02 is not valued, do not use.
- DA
- Days
- MO
- Months
- WK
- Week
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
Code defining periods
- 6
- Hour
- 7
- Day
- 21
- Years
- 26
- Episode
- 27
- Visit
- 34
- Month
- 35
- Week
Code which specifies the routine shipments, deliveries, or calendar pattern
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SA
- Sunday, Monday, Thursday, Friday, Saturday
- SB
- Tuesday through Saturday
- SC
- Sunday, Wednesday, Thursday, Friday, Saturday
- SD
- Monday, Wednesday, Thursday, Friday, Saturday
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Code which specifies the time for routine shipments or deliveries
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Additional Service Information
To identify the type or transmission or both of paperwork or supporting information
- Required when the information source has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) in this Service loop, and the 278 Notification, or Information Copy (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
- Additional information requested at the Service level should apply to a specific service and/or all the services requested in this service loop.
- This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
- The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
Expected outcomes of rehabilitative services.
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- 48
- Social Security Benefit Letter
- 55
- Rental Agreement
Use for medical or dental equipment rental.
- 59
- Benefit Letter
- 77
- Support Data for Verification
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
Information to support necessity of ambulance trip.
- AS
- Admission Summary
A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.
- AT
- Purchase Order Attachment
Use for purchase of medical or dental equipment.
- B2
- Prescription
- B3
- Physician Order
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
- CK
- Consent Form(s)
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- FM
- Family Medical History Document
- HC
- Health Certificate
- HP
- History and Physical
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- P4
- Pathology Report
- P5
- Patient Medical History Document
- P6
- Periodontal Charts
- P7
- Periodontal Reports
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- QC
- Cause and Corrective Action Report
- QR
- Quality Report
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- T7
- Therapy Notes
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- AA
- Available on Request at Provider Site
This means that the paperwork is not being sent with the notification at this time. Instead, it is available to the Information Receiver upon request.
- BM
- By Mail
- EL
- Electronically Only
Use to indicate that the attachment is being transmitted in a separate X12 functional group.
- EM
- FX
- By Fax
- VO
- Voice
Use this for voicemail or phone communication.
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- The Information Source can use when PWK02 equals "AA" if the Inforamtion Source wants to send a document control number for an attachment remaining at the Provider's office.
A free-form description to clarify the related data elements and their content
- PWK07 may be used to indicate special information to be shown on the specified report.
Message Text
To provide a free-form format that allows the transmission of text information
- Free form text or description fields are not recommended because they require human interpretation.
- Required when needed to transmit a message to the Information Receiver about the service. If not required by this implementation guide, do not send.
- Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
Service Provider Name
To supply the full name of an individual or organizational entity
- Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
- If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event.
- Required when identifying a service provider, specialist, or specialty entity for this service and is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying an organizational entity, a physical location, property or an individual
- 1T
- Physician, Clinic or Group Practice
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DQ
- Supervising Physician
- FA
- Facility
- G3
- Clinic
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- QV
- Group Practice
- SJ
- Service Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- Not Used if identifying a specialty entity.
Individual middle name or initial
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 submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.;If not required by this implementation guide, do not send.
Code identifying a party or other code
Service Provider Supplemental Identification
To specify identifying information
- Use the NM1 segment for the primary identifier.
- Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F).
If not required by this implementation guide, do not send.
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.
- 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 any Federally administered programs such as Medicare or CHAMPUS. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
- See code source 22: State and Outlying Areas of the US.
Service Provider Address
To specify the location of the named party
- Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.
Service Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when needed to identify a specific location for a provider that has multiple locations. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
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.
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Service Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.
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
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 service 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
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 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
- 79
- Invalid Participant Identification
- 97
- Invalid or Missing Provider Address
Service Provider Information
To specify the identifying characteristics of a provider
- Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
Code identifying the type of provider
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- 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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- 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.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1: Notification
GS*HI*SENDERGS*RECEIVERGS*20240222*011931*000000001*X*005010X216~
ST*278*0001*005010X216~
BHT*0007*CN*2004000345628*20040601*1410*NO~
HL*1**20*1~
NM1*1P*2*St JosephHospital*****46*0000012121~
REF*1J*162354~
HL*2*1*21*1~
NM1*X3*2*MarylandCapital InsuranceCompany*****46*789312~
HL*3*2*22*1~
NM1*IL*1*Smith*Joe****MI*12345678901~
DMG*D8*19580322*M~
HL*4*3*EV*0~
TRN*1*040601002349A*9000012121~
UM*AR*I*2*21>B~
HCR*A1*A0405295498~
DTP*435*D8*20040530~
HI*BF>410.90~
CL1*2~
NM1*SJ*2*St JosephHospital*****46*0000012121~
REF*1J*162354~
PER*IC**TE*6107771212~
SE*21*0001~
GE*1*000000001~
IEA*1*000000001~
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