X12 837 Post-adjudicated Claims Data Reporting: Dental (X300A1)
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.
- ~ Segment
- * Element
- > Component
- ^ Repetition
- None included
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HC
- Health Care Claim (837)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X300A1
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
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
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control 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.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (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
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0019
- Information Source, Subscriber, Dependent
Code identifying purpose of transaction set
- 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.
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.
- The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
Code specifying the type of transaction
- RP
- Reporting
Submitter Name
To supply the full name of an individual or organizational entity
- The submitter is the entity responsible for the creation and formatting of this transaction.
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Established by trading partner agreement
Submitter EDI Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number 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.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Receiver Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- 40
- Receiver
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Billing Provider Specialty Information
To specify the identifying characteristics of a provider
- 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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Foreign Currency Information
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code (Standard ISO) for country in whose currency the charges are specified
- 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.
Billing Provider Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 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
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Billing Provider Address
To specify the location of the named party
- 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.
Billing Provider City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Billing Provider Tax Identification
To specify identifying information
- This is the tax identification number (TIN) of the entity paid for the submitted services.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider License Information
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 0B
- State License Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Secondary Identification
To specify identifying information
- 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.
Code qualifying the Reference Identification
- G2
- Provider Commercial Number
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- N
- Unconfirmed
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
- 18
- Self
Subscriber Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
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
Code identifying a party or other code
Subscriber Address
To specify the location of the named party
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Demographic Information
To supply demographic information
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Subscriber Social Security Number
To specify identifying information
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Property and Casualty Claim Number
To specify identifying information
- 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.
Code qualifying the Reference Identification
- Y4
- Agency Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Data Receiver
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- ZD
- Party to Receive Reports
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Patient Information
To supply patient information
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Code indicating the relationship between two individuals or entities
- 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
Patient Name
To supply the full name of an individual or organizational entity
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.
- MI
- Member Identification Number
Code identifying a party or other code
Patient Address
To specify the location of the named party
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Patient City, State, ZIP Code
To specify the geographic place of the named party
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Patient Demographic Information
To supply demographic information
- The information provided in this segment is intended to be representative of the information as known to the payer's system.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Patient Social Security Number
To specify identifying information
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Property and Casualty Claim Number
To specify identifying information
- 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.
Code qualifying the Reference Identification
- Y4
- Agency Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Information
To specify basic data about the claim
- 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.
Identifier used to track a claim from creation by the health care provider through payment
- 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.
Monetary amount
- CLM02 is the total amount of all submitted charges of service segments for this claim.
- 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.
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.
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
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
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
Code indicating whether the provider accepts assignment
- 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
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.
- 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
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
Required when available in the payer's system.
If not required by this implementation guide, do not send.
Code identifying an accompanying cause of an illness, injury or an accident
- AA
- Auto Accident
- EM
- Employment
- OA
- Other Accident
Code identifying an accompanying cause of an illness, injury or an accident
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".
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
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
Date - Appliance Placement
To specify any or all of a date, a time, or a time period
- 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.
Code specifying type of date or time, or both date and time
- 452
- Appliance Placement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Service Date
To specify any or all of a date, a time, or a time period
- 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.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Accident
To specify any or all of a date, a time, or a time period
- 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.
Code specifying type of date or time, or both date and time
- 439
- Accident
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Orthodontic Total Months of Treatment
To supply orthodontic information
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.
Numeric value of quantity
- DN101 is the estimated number of treatment months.
Numeric value of quantity
- DN102 is the number of treatment months remaining.
A free-form description to clarify the related data elements and their content
- DN104 is the appliance description.
- 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.
Tooth Status
To specify the status of individual teeth
- 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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- DN201 is the tooth number.
- The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
Code specifying the status of the tooth
- E
- To Be Extracted
- M
- Missing
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
Contract Information
To specify basic data about the contract or contract line item
- Required when this information is necessary to satisfy contract requirements.
If not required by this implementation guide, do not send.
Code identifying a contract type
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
Monetary amount
- CN102 is the contract amount.
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
- CN103 is the allowance or charge percent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CN104 is the contract code.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
Revision level of a particular format, program, technique or algorithm
- CN106 is an additional identifying number for the contract.
Patient Amount Paid
To indicate the total monetary amount
- 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.
Referral Number
To specify identifying information
- Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
- Required when 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.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Prior Authorization
To specify identifying information
- Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
- Required when 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.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identifier For Transmission Intermediaries
To specify identifying information
- 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.
Code qualifying the Reference Identification
- Number assigned by clearinghouse, van, etc.
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The value carried in this element is limited to a maximum of 20 positions.
File Information
To transmit a fixed-format record or matrix contents
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.
Data in fixed format agreed upon by sender and receiver
Health Care Diagnosis Code
To supply information related to the delivery of health care
- 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.
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.
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.
Required when available in the payer's system.
If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- 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.
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.
Required when available in the payer's system.
If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- See element HI02-1 for a list of valid values.
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.
Required when available in the payer's system.
If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- See element HI02-1 for a list of valid values.
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.
Referring Provider Name
To supply the full name of an individual or organizational entity
- 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.
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.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Referring Provider Specialty Information
To specify the identifying characteristics of a provider
- 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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referring Provider Secondary Identification
To specify identifying information
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
- 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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Facility Location Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- 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.
Service Facility Location Address
To specify the location of the named party
- 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.
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- DD
- Assistant Surgeon
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Assistant Surgeon Specialty Information
To specify the identifying characteristics of a provider
- 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.
Code identifying the type of provider
- AS
- Assistant Surgeon
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Supervising Provider Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Supervising Provider Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
- 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.
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- 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
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- 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.
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.
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.
Claim Level Adjustments
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- 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.
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
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Coordination of Benefits (COB) Payer Paid Amount
To indicate the total monetary amount
Monetary amount
- 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.
Remaining Patient Liability
To indicate the total monetary amount
- 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.
Outpatient Adjudication Information
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
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.
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
- MOA01 is the reimbursement rate.
Monetary amount
- MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
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.
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.
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.
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.
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.
Monetary amount
- MOA09 is the professional component amount billed but not payable.
Other Subscriber Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
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
Code identifying a party or other code
Other Subscriber Address
To specify the location of the named party
- 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.
Other Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Other Subscriber Social Security Number
To specify identifying information
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 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:
- Both the sender and receiver agree to use the National Plan ID,
- The receiver has a National Plan ID, and
- 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
Code identifying a party or other code
- 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.;
Claim Check or Remittance Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Other Payer Secondary Identifier
To specify identifying information
- Required when available in the payer's system.
If not required by this implementation guide, do not send.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Claim Adjustment Indicator
To specify identifying information
- 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.
Code qualifying the Reference Identification
- T4
- Signal Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The only valid value for this element is `Y'.
Other Payer Claim Control Number
To specify identifying information
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Adjusted Claim Control Number
To specify identifying information
- 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.
Code qualifying the Reference Identification
- BP
- Adjustment Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Patient Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
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
Code identifying a party or other code
Other Patient Address
To specify the location of the named party
- 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.
Other Patient City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Other Patient Secondary Identification
To specify identifying information
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Number
To reference a line number in a transaction set
- The LX functions as a line counter.
- The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
- LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.2.4 for more information on bundling and section 1.4.2.6 for more information on unbundling.
Number assigned for differentiation within a transaction set
Dental Service
To specify the service line item detail for dental work
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
CDT = Current Dental Terminology
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Monetary amount
- SV302 is the submitted service line item amount.
- This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
- Zero "0" is an acceptable value for this element.
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.
- SV303 is the place of service code representing the location where the dental treatment was rendered.
- See CODE SOURCE 237: Place of Service Codes for Professional Claims
Required when available in the payer's system.
If not required by this implementation guide, do not send.
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code specifying the placement status for the dental work
- If, for whatever reason, the data is not stored within the payer's system, do not use.
- I
- Initial Placement
- R
- Replacement
When SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is Required.
Numeric value of quantity
- SV306 is the number of procedures.
- Number of procedures
- 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.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
Tooth Information
To identify a tooth by number and, if applicable, one or more tooth surfaces
- 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.
Code identifying a specific industry code list
- JP
- Universal National Tooth Designation System
Code indicating a code from a specific industry code list
- See Appendix A for code source 135: American Dental Association Codes.
- This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304.
Required when available in the payer's system.
If not required by this implementation guide, do not send.
Code identifying the area of the tooth that was treated
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1.
Code identifying the area of the tooth that was treated
Code identifying the area of the tooth that was treated
Code identifying the area of the tooth that was treated
Date - Service Date
To specify any or all of a date, a time, or a time period
- Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
- 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.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Prior Placement
To specify any or all of a date, a time, or a time period
- 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.
Code specifying type of date or time, or both date and time
- 139
- Estimated
Required when the exact Prior Placement Date is not known.
- 441
- Prior Placement
Required when the exact Prior Placement Date is known.
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Appliance Placement
To specify any or all of a date, a time, or a time period
- 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.
Code specifying type of date or time, or both date and time
- 452
- Appliance Placement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Replacement
To specify any or all of a date, a time, or a time period
- 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.
Code specifying type of date or time, or both date and time
- 446
- Replacement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Treatment Start
To specify any or all of a date, a time, or a time period
- When the Treatment Start Date is used, the Date of Service must not be used.
- 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.
Code specifying type of date or time, or both date and time
- 196
- Start
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Treatment Completion
To specify any or all of a date, a time, or a time period
- When the Treatment Completion Date is used, the Date of Service must not be used.
- 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.
Code specifying type of date or time, or both date and time
- 198
- Completion
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Contract Information
To specify basic data about the contract or contract line item
- Required when this information is necessary to satisfy contract requirements.
If not required by this implementation guide, do not send.
Code identifying a contract type
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
Monetary amount
- CN102 is the contract amount.
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
- CN103 is the allowance or charge percent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CN104 is the contract code.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
Revision level of a particular format, program, technique or algorithm
- CN106 is an additional identifying number for the contract.
Prior Authorization
To specify identifying information
- 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.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
File Information
To transmit a fixed-format record or matrix contents
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.
Data in fixed format agreed upon by sender and receiver
Rendering Provider Name
To supply the full name of an individual or organizational entity
- 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 NM1 information is different than that carried in the Loop ID-2310B Rendering Provider.
OR
Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is 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.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
- 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.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- DD
- Assistant Surgeon
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Assistant Surgeon Specialty Information
To specify the identifying characteristics of a provider
- 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.
Code identifying the type of provider
- AS
- Assistant Surgeon
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Supervising Provider Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
- If, for whatever reason, the data is not stored within the payer's system, do not use.
Supervising Provider Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Line Adjudication Information
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
- Loop ID 2430 conveys information demonstrating how this line was adjudicated by both the submitting payer and other payers who have previously adjudicated the line.
Loop 2430 and the related 2320 loop are linked using the value reported in Loop 2320 SBR01 and Loop 2430 SVD01.
Loop 2320 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.
- Required when 2320 SBR06 = 6 and an 835 sent to the provider would have included service line detail.
OR
Required when the related Loop ID 2320 SBR06 = 1; and the data was present on the provider submitted claim.
If not required by this implementation guide, do not send.
Code identifying a party or other code
- SVD01 is the payer identification code.
- This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
Monetary amount
- SVD02 is the amount paid for this service line.
- Zero "0" is an acceptable value for this element.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- This is the first procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- This is the second procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- This is the third procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- This is the fourth procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
Numeric value of quantity
- SVD05 is the paid units of service.
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
- This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
Number assigned for differentiation within a transaction set
- SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
Line Adjustment
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- 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).
- Required when the payer identified in this Line Adjudication Information Loop ID-2430 made line level adjustments which caused the dollar amount paid for the service line (SVD02) to differ from the amount originally charged for this service. If not required by this implementation guide, do not send.
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
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Line Check or Remittance Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Remaining Patient Liability
To indicate the total monetary amount
- In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
- 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.
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control 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.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
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