X12 HIPAA
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Post-adjudicated Claims Data Reporting: Dental (X300A1)
  • Specification
  • EDI Inspector
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X12 837 Post-adjudicated Claims Data Reporting: Dental (X300A1)

X12 Release 5010

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

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

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
  • None included
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0050
Transaction Set Header
Max use 1
Required
BHT
0100
Beginning of Hierarchical Transaction
Max use 1
Required
Submitter Name Loop
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
CUR
0100
Foreign Currency Information
Max use 1
Optional
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Appliance Placement
Max use 1
Optional
DTP
1350
Date - Service Date
Max use 1
Optional
DN1
1450
Orthodontic Total Months of Treatment
Max use 1
Optional
DN2
1500
Tooth Status
Max use 35
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Optional
SE
5550
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

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

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

Code identifying the type of information in the Authorization Information

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

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

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

Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

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

Date of the interchange

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

Time of the interchange

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

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

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

Code specifying the version number of the interchange control segments

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

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

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

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

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

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

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

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

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

Code identifying a group of application related transaction sets

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

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

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

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

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

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

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

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

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

Assigned number originated and maintained by the sender

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

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

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

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

005010X300A1

Heading

ST
0050
Heading > ST

Transaction Set Header

RequiredMax use 1

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

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

Code uniquely identifying a Transaction Set

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

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

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

Reference assigned to identify Implementation Convention

  • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
Usage notes
  • This element must be populated with the guide identifier named in Section 1.2.
  • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
005010X300A1
BHT
0100
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

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

Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)

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

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

Code identifying purpose of transaction set

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

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

18
Reissue

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

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

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

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

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

  • BHT04 is the date the transaction was created within the business application system.
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

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

  • BHT05 is the time the transaction was created within the business application system.
BHT-06
640
Claim or Encounter Identifier
Required
Identifier (ID)

Code specifying the type of transaction

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

Submitter Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

46
Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

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

Code identifying a party or other code

PER
0450
Heading > Submitter Name Loop > PER

Submitter EDI Contact Information

RequiredMax use 2

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

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
  • The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
  • There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

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

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

Free-form name

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

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Receiver Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

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

Code identifying a party or other code

1000B Receiver Name Loop end
Heading end

Detail

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

Hierarchical Level

RequiredMax use 1

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

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

Billing Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

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

Code qualifying the Reference Identification

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

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

CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR

Foreign Currency Information

OptionalMax use 1

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

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

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

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

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

Usage notes
  • The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.
2010AA Billing Provider Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1

Billing Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI.
  • When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment.
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Billing Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3

Billing Provider Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.
Example
N3-01
166
Billing Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

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

Billing Provider City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Usage notes
  • The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.
Example
Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Billing Provider City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Billing Provider Tax Identification

RequiredMax use 1

To specify identifying information

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

Code qualifying the Reference Identification

EI
Employer's Identification Number

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

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

SY
Social Security Number

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

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

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

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

Billing Provider License Information

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
REF-02
127
Billing Provider License Information
Required
String (AN)
Min 1Max 50

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

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

Billing Provider Secondary Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number
LU
Location Number
REF-02
127
Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2010AA Billing Provider Name Loop end
2000B Subscriber Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

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

Subscriber Information

RequiredMax use 1

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

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

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

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

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
18
Self
2010BA Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Data Receiver Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
  • When submitting to an All Payer Claims Database or Health Benefit Exchange, this is the Subscriber as defined within the payers enrollment files. When submitting Medicare or Medicaid encounters, the patient is always the subscriber.
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

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

Code identifying a party or other code

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

Subscriber Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

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

Subscriber City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Subscriber City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Subscriber Demographic Information

RequiredMax use 1

To supply demographic information

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Code indicating the sex of the individual

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

Subscriber Social Security Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when:

The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange.
AND
The social security number is allowed to be used for this purpose under applicable law or regulation.
AND
The social security number is available in the payer's system.

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

  • Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

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

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

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

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

Property and Casualty Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFSubscriber Social Security Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

Data Receiver

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

ZD
Party to Receive Reports
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

2010BB Data Receiver Loop end
2000C Patient Hierarchical Level Loop
OptionalMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
23
Dependent
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT

Patient Information

RequiredMax use 1

To supply patient information

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
PAT-01
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

Usage notes
  • Specifies the patient's relationship to the person insured.
01
Spouse
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
2010CA Patient Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1

Patient Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
If either Identification Code Qualifier (NM1-08) or Patient Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

MI
Member Identification Number
NM1-09
67
Patient Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

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

Patient Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
N3-01
166
Patient Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

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

Patient City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Patient City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Patient Demographic Information

RequiredMax use 1

To supply demographic information

Usage notes
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Code indicating the sex of the individual

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

Patient Social Security Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when:

The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange.
AND
The social security number is allowed to be used for this purpose under applicable law or regulation.
AND
The social security number is available in the payer's system.

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

  • Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

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

REF-02
127
Patient Social Security Number
Required
String (AN)
Min 1Max 50

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

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

Property and Casualty Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFPatient Social Security Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

2010CA Patient Name Loop end
2300 Claim Information Loop
RequiredMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CLM

Claim Information

RequiredMax use 1

To specify basic data about the claim

Usage notes
  • For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the patient hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the patient. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent.
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38

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

Usage notes
  • The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CLM02 is the total amount of all submitted charges of service segments for this claim.
Usage notes
  • The Total Claim Charge Amount must be greater than or equal to zero.
  • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.
  • This amount represents the sum of the line charge amounts included in this portion of the claim.
CLM-05
C023
Health Care Service Location Information
RequiredMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Place of Service Code
Required
String (AN)
Min 1Max 2

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

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

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
B
Place of Service Codes for Professional or Dental Services
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1

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

CLM-06
1073
Provider or Supplier Signature Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
N
No
Y
Yes
CLM-07
1359
Assignment or Plan Participation Code
Optional
Identifier (ID)

Code indicating whether the provider accepts assignment

Usage notes
  • Within this element the context of the word assignment is related to the relationship between the provider and the payer.
A
Assigned
C
Not Assigned
CLM-08
1073
Benefits Assignment Certification Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

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

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

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

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

I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
CLM-11
C024
Related Causes Information
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes

Required when available in the payer's system.
If not required by this implementation guide, do not send.

C024-01
1362
Related Causes Code
Required
Identifier (ID)

Code identifying an accompanying cause of an illness, injury or an accident

AA
Auto Accident
EM
Employment
OA
Other Accident
C024-02
1362
Related Causes Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying an accompanying cause of an illness, injury or an accident

C024-04
156
Auto Accident State or Province Code
Optional
Identifier (ID)
Min 2Max 2

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

  • C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
C024-05
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

CLM-12
1366
Special Program Indicator
Optional
Identifier (ID)

Code indicating the Special Program under which the services rendered to the patient were performed

01
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
02
Physically Handicapped Children's Program
03
Special Federal Funding
05
Disability
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)

Code indicating the reason why a request was delayed

1
Proof of Eligibility Unknown or Unavailable
2
Litigation
3
Authorization Delays
4
Delay in Certifying Provider
5
Delay in Supplying Billing Forms
6
Delay in Delivery of Custom-made Appliances
7
Third Party Processing Delay
8
Delay in Eligibility Determination
9
Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10
Administration Delay in the Prior Approval Process
11
Other
15
Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP

Date - Accident

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Appliance Placement

OptionalMax use 1

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

Usage notes
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Service Date

OptionalMax use 1

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

Usage notes
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35

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

DN1
1450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DN1

Orthodontic Total Months of Treatment

OptionalMax use 1

To supply orthodontic information

Usage notes

Required when available in the payer's system.
If not required by this implementation guide, do not send.

  • When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
DN1-01
380
Orthodontic Treatment Months Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • DN101 is the estimated number of treatment months.
DN1-02
380
Orthodontic Treatment Months Remaining Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • DN102 is the number of treatment months remaining.
DN1-04
352
Orthodontic Treatment Indicator
Optional
String (AN)
Min 1Max 80

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

  • DN104 is the appliance description.
Usage notes
  • The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.
DN2
1500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DN2

Tooth Status

OptionalMax use 35

To specify the status of individual teeth

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
DN2-01
127
Tooth Number
Required
String (AN)
Min 1Max 50

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

  • DN201 is the tooth number.
Usage notes
  • The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
DN2-02
1368
Tooth Status Code
Required
Identifier (ID)

Code specifying the status of the tooth

E
To Be Extracted
M
Missing
DN2-06
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • DN206 designates the code set used to identify the tooth in DN201.
JP
Universal National Tooth Designation System
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1

To specify basic data about the contract or contract line item

Usage notes
  • Required when this information is necessary to satisfy contract requirements.

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

Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)

Code identifying a contract type

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

Monetary amount

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

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

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

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

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

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

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

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

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

Patient Amount Paid

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

F5
Patient Amount Paid
AMT-02
782
Patient Amount Paid
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

Prior Authorization

OptionalMax use 1

To specify identifying information

Usage notes
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

Claim Identifier For Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
  • The data conveyed in this segment is not related to the provider submission to the payer.

This segment is used only when the payer is submitting this transaction to the Data Receiver through an intermediary that assigns their own unique claim number.

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

Usage notes
  • The value carried in this element is limited to a maximum of 20 positions.
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10

To transmit a fixed-format record or matrix contents

Usage notes
  • The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used:

  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.

  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.

Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.

  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

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

Health Care Diagnosis Code

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)

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 SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when available in the payer's system.
If not required by this implementation guide, do not send.

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)

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 SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when available in the payer's system.
If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes
  • See element HI02-1 for a list of valid values.
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when available in the payer's system.
If not required by this implementation guide, do not send.

C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
Usage notes
  • See element HI02-1 for a list of valid values.
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
  • When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

P3
Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Referring Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > PRV

Referring Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

RF
Referring
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 2

To specify identifying information

Usage notes
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310A Referring Provider Name Loop end
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
  • Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider.

If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV

Rendering Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

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

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

2310B Rendering Provider Name Loop end
2310C Service Facility Location Name Loop
RequiredMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
  • This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

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

Code identifying a party or other code

Usage notes
  • When an NPI is reported at this level, it must be different than the NPI reported in NM109 of Loop ID 2010AA (Billing Provider). When an NPI is present in this position, the service was performed in a location that is not a component of the Billing Provider.
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Usage notes
  • This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.
Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50

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

2310C Service Facility Location Name Loop end
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > NM1

Assistant Surgeon Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Assistant Surgeon Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > PRV

Assistant Surgeon Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > REF

Assistant Surgeon Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

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

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

2310D Assistant Surgeon Name Loop end
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DQ
Supervising Physician

Use this code for the supervising dentist or physician.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF

Supervising Provider Secondary Identification

OptionalMax use 4

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

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

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

2310E Supervising Provider Name Loop end
2320 Other Subscriber Information Loop
RequiredMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1

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

Usage notes
  • All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
  • Loop ID 2320 and its suboordinate 2330 and 2430 loops convey information demonstrating how this claim was adjudicated by both the submitting payer and other payers who have previously adjudicated the claim.

This loop is not to be provided for payers who have not adjudicated the claim. For example, the provider submitted claim includes payer information that is subsequent to the payer submitting this transaction.

SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer.

When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider.

When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.

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

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

Usage notes
  • When this field is populated based upon the adjudication of the submitting payer, the selection of this code value is similar to how CLP02 in the 835 transaction is performed.
A
Payer Responsibility Four
B
Payer Responsibility Five
C
Payer Responsibility Six
D
Payer Responsibility Seven
E
Payer Responsibility Eight
F
Payer Responsibility Nine
G
Payer Responsibility Ten
H
Payer Responsibility Eleven
P
Primary
S
Secondary
T
Tertiary
U
Unknown
SBR-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

  • SBR02 specifies the relationship to the person insured.
01
Spouse
18
Self
19
Child
20
Employee
21
Unknown
39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
SBR-03
127
Insured Group or Policy Number
Optional
String (AN)
Min 1Max 50

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

  • SBR03 is policy or group number.
Usage notes
  • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
SBR-04
93
Other Insured Group Name
Optional
String (AN)
Min 1Max 60

Free-form name

  • SBR04 is plan name.
SBR-06
1143
Coordination of Benefits Code
Required
Identifier (ID)

Code identifying whether there is a coordination of benefits

1
Coordination of Benefits

Use this code when the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 was submitted on the original claim from the provider.

6
No Coordination of Benefits

Use this code when the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication of the payer submitting this transaction.

SBR-09
1032
Claim Filing Indicator Code
Required
Identifier (ID)

Code identifying type of claim

11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization
AM
Automobile Medical
BL
Blue Cross/Blue Shield
CH
Champus
CI
Commercial Insurance Co.
DS
Disability
FI
Federal Employees Program
HM
Health Maintenance Organization
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
OF
Other Federal Program

Use code OF when submitting Medicare Part D claims.

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

Use Code ZZ when Type of Insurance is not known.

CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS

Claim Level Adjustments

OptionalMax use 5

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • Required when the claim has claim level adjustment information. If not required by this implementation guide, do not send.
  • Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
  • Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
  • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
  • When the payer identified is not the submitting payer, codes and associated amounts must be reported as submitted by the provider.

When the payer identified is the submitting payer, codes and amounts must be reported the same as if creating the 835 to send to the provider.

Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)

Code identifying the general category of payment adjustment

CO
Contractual Obligations
CR
Correction and Reversals
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Coordination of Benefits (COB) Payer Paid Amount

RequiredMax use 1

To indicate the total monetary amount

Example
Variants (all may be used)
AMTRemaining Patient Liability
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

D
Payor Amount Paid
AMT-02
782
Payer Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • It is acceptable to show "0" as the amount paid.
  • When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

MOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA

Outpatient Adjudication Information

OptionalMax use 1

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Usage notes

Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

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

  • Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider.

OR

Required when SBR06 = 1; and this information was provided on the original claim from the provider.

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

Example
MOA-01
954
Reimbursement Rate
Optional
Decimal number (R)
Min 1Max 10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

  • MOA01 is the reimbursement rate.
MOA-02
782
HCPCS Payable Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
MOA-03
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA-04
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA04 is the Claim Payment Remark Code. See Code Source 411.
MOA-05
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA05 is the Claim Payment Remark Code. See Code Source 411.
MOA-06
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA06 is the Claim Payment Remark Code. See Code Source 411.
MOA-07
127
Claim Payment Remark Code
Optional
String (AN)
Min 1Max 50

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

  • MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA09 is the professional component amount billed but not payable.
2330A Other Subscriber Name Loop
RequiredMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1

Other Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • When SBR06 = 1, the information in this segment represents the Subscriber as submitted by the provider for the payer identified in Loop ID 2330B.

When SBR06 = 6, the information in this segment represents the Subscriber as known by the submitting payer.

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

MI
Member Identification Number
NM1-09
67
Other Insured Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3

Other Subscriber Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
N3-01
166
Other Insured Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4

Other Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Other Insured City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF

Other Subscriber Social Security Number

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when:

The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange.
AND
The social security number is allowed to be used for this purpose under applicable law or regulation.
AND
The social security number is available in the payer's system.

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

  • Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

SY
Social Security Number

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

REF-02
127
Other Insured Additional Identifier
Required
String (AN)
Min 1Max 50

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

2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1

Other Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

Usage notes
  • On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

If a phase-in period is designated, PI must be sent unless:

  1. Both the sender and receiver agree to use the National Plan ID,
  2. The receiver has a National Plan ID, and
  3. The sender has the capability to send the National Plan ID.

If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
DTP
3500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP

Claim Check or Remittance Date

RequiredMax use 1

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

Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Secondary Identifier

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
EI
Employer's Identification Number

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

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

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

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Adjustment Indicator

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when SBR06 = 6; and this claim is a void or adjustment of a previously adjudicated claim.

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

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

T4
Signal Code
REF-02
127
Other Payer Claim Adjustment Indicator
Required
String (AN)
Min 1Max 50

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

Usage notes
  • The only valid value for this element is `Y'.
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when SBR06 = 6.
    OR
    Required when available in the payer's system.

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

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F8
Original Reference Number

This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.

REF-02
127
Other Payer's Claim Control Number
Required
String (AN)
Min 1Max 50

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

REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF

Other Payer Adjusted Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when SBR06 = 6 and the submitting payer has adjusted this claim.
    OR
    Required when available in the payer's system.

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

Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BP
Adjustment Control Number
REF-02
127
Other Payer's Adjusted Claim Control Number
Required
String (AN)
Min 1Max 50

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

2330B Other Payer Name Loop end
2330C Other Patient Name Loop
OptionalMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > NM1

Other Patient Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • When SBR06 = 1, the information in this segment represents the Patient as submitted by the provider for the payer identified in Loop ID 2330B.

When SBR06 = 6, the information in this segment represents the Patient as known by the submitting payer.

  • Required when the entity reported in Loop ID 2330A (Other Payer Subscriber) is not the patient.
Example
If either Identification Code Qualifier (NM1-08) or Other Insured Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Other Insured Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

MI
Member Identification Number
NM1-09
67
Other Insured Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > N3

Other Patient Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
N3-01
166
Other Patient Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > N4

Other Patient City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Only one of Other Patient State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Other Patient City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.