X12 HIPAA
/
Post-adjudicated Claims Data Reporting: Professional (X298A1)
  • Specification
  • EDI Inspector
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X12 837 Post-adjudicated Claims Data Reporting: Professional (X298A1)

X12 Release 5010

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

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

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI sample
—
  • Adjudicated Claim submitted to All Payer Claim Data Base (APCD)
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0050
Transaction Set Header
Max use 1
Required
BHT
0100
Beginning of Hierarchical Transaction
Max use 1
Required
Submitter Name Loop
NM1
0200
Submitter Name
Max use 1
Required
PER
0450
Submitter EDI Contact Information
Max use 2
Required
Receiver Name Loop
NM1
0200
Receiver Name
Max use 1
Required
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
CUR
0100
Foreign Currency Information
Max use 1
Optional
Billing Provider Name Loop
NM1
0150
Billing Provider Name
Max use 1
Required
N3
0250
Billing Provider Address
Max use 1
Required
N4
0300
Billing Provider City, State, ZIP Code
Max use 1
Required
REF
0350
Billing Provider Tax Identification
Max use 1
Required
REF
0350
Billing Provider License Information
Max use 2
Optional
REF
0350
Billing Provider Secondary Identification
Max use 2
Optional
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
Subscriber Name Loop
NM1
0150
Subscriber Name
Max use 1
Required
N3
0250
Subscriber Address
Max use 1
Required
N4
0300
Subscriber City, State, ZIP Code
Max use 1
Required
DMG
0320
Subscriber Demographic Information
Max use 1
Required
REF
0350
Subscriber Social Security Number
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
Data Receiver Loop
NM1
0150
Data Receiver
Max use 1
Required
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Patient Name Loop
NM1
0150
Patient Name
Max use 1
Required
N3
0250
Patient Address
Max use 1
Required
N4
0300
Patient City, State, ZIP Code
Max use 1
Required
DMG
0320
Patient Demographic Information
Max use 1
Required
REF
0350
Patient Social Security Number
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Acute Manifestation
Max use 1
Optional
DTP
1350
Date - Admission
Max use 1
Optional
DTP
1350
Date - Assumed and Relinquished Care Dates
Max use 2
Optional
DTP
1350
Date - Authorized Return to Work
Max use 1
Optional
DTP
1350
Date - Disability Dates
Max use 1
Optional
DTP
1350
Date - Discharge
Max use 1
Optional
DTP
1350
Date - Hearing and Vision Prescription Date
Max use 1
Optional
DTP
1350
Date - Initial Treatment Date
Max use 1
Optional
DTP
1350
Date - Last Menstrual Period
Max use 1
Optional
DTP
1350
Date - Last Seen Date
Max use 1
Optional
DTP
1350
Date - Last Worked
Max use 1
Optional
DTP
1350
Date - Last X-ray Date
Max use 1
Optional
DTP
1350
Date - Onset of Current Illness or Symptom
Max use 1
Optional
DTP
1350
Date - Property and Casualty Date of First Contact
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Mammography Certification Number
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Claim Note
Max use 1
Optional
CR1
1950
Ambulance Transport Information
Max use 1
Optional
CR2
2000
Spinal Manipulation Service Information
Max use 1
Optional
CRC
2200
Ambulance Certification
Max use 3
Optional
CRC
2200
Patient Condition Information: Vision
Max use 3
Optional
CRC
2200
Homebound Indicator
Max use 1
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Required
HI
2310
Anesthesia Related Procedure
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Referring Provider Name Loop
NM1
2500
Referring Provider Name
Max use 1
Required
REF
2710
Referring Provider Secondary Identification
Max use 2
Optional
Rendering Provider Name Loop
NM1
2500
Rendering Provider Name
Max use 1
Required
PRV
2550
Rendering Provider Specialty Information
Max use 1
Optional
REF
2710
Rendering Provider Secondary Identification
Max use 3
Optional
Service Facility Location Name Loop
NM1
2500
Service Facility Location Name
Max use 1
Required
N3
2650
Service Facility Location Address
Max use 1
Required
N4
2700
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
2710
Service Facility Location Secondary Identification
Max use 3
Optional
Supervising Provider Name Loop
NM1
2500
Supervising Provider Name
Max use 1
Required
REF
2710
Supervising Provider Secondary Identification
Max use 3
Optional
Ambulance Pick-up Location Loop
NM1
2500
Ambulance Pick-up Location
Max use 1
Required
N3
2650
Ambulance Pick-up Location Address
Max use 1
Required
N4
2700
Ambulance Pick-up Location City, State, ZIP Code
Max use 1
Required
Ambulance Drop-Off Location Loop
NM1
2500
Ambulance Drop-Off Location
Max use 1
Required
N3
2650
Ambulance Drop-Off Location Address
Max use 1
Required
N4
2700
Ambulance Drop-Off Location City, State, ZIP Code
Max use 1
Required
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Required
AMT
3000
Remaining Patient Liability
Max use 1
Optional
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Subscriber Name Loop
NM1
3250
Other Subscriber Name
Max use 1
Required
N3
3320
Other Subscriber Address
Max use 1
Optional
N4
3400
Other Subscriber City, State, ZIP Code
Max use 1
Optional
REF
3550
Other Subscriber Social Security Number
Max use 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
DTP
3450
Claim Check or Remittance Date
Max use 1
Required
REF
3550
Other Payer Secondary Identifier
Max use 4
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Adjusted Claim Control Number
Max use 1
Optional
Other Patient Name Loop
NM1
3250
Other Patient Name
Max use 1
Required
N3
3320
Other Patient Address
Max use 1
Optional
N4
3400
Other Patient City, State, ZIP Code
Max use 1
Optional
REF
3550
Other Patient Secondary Identification
Max use 3
Optional
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV1
3700
Professional Service
Max use 1
Required
PWK
4200
Line Supplemental Information
Max use 10
Optional
PWK
4200
Durable Medical Equipment Certificate of Medical Necessity Indicator
Max use 1
Optional
CR1
4250
Ambulance Transport Information
Max use 1
Optional
CR3
4350
Durable Medical Equipment Certification
Max use 1
Optional
CRC
4500
Ambulance Certification
Max use 3
Optional
CRC
4500
Hospice Employee Indicator
Max use 1
Optional
CRC
4500
Condition Indicator/Durable Medical Equipment
Max use 1
Optional
DTP
4550
Date - Initial Treatment Date
Max use 1
Optional
DTP
4550
Date - Last Seen Date
Max use 1
Optional
DTP
4550
Date - Last X-ray Date
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Required
DTP
4550
Date - Prescription Date
Max use 1
Optional
DTP
4550
Date - Certification Revision/Recertification Date
Max use 1
Optional
DTP
4550
Date - Begin Therapy Date
Max use 1
Optional
DTP
4550
Date - Last Certification Date
Max use 1
Optional
DTP
4550
Date - Shipped Date
Max use 1
Optional
DTP
4550
Date - Test Date
Max use 2
Optional
QTY
4600
Ambulance Patient Count
Max use 1
Optional
QTY
4600
Obstetric Anesthesia Additional Units
Max use 1
Optional
MEA
4620
Test Result
Max use 5
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
4700
Immunization Batch Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Mammography Certification Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 1
Optional
REF
4700
Referral Number
Max use 1
Optional
REF
4700
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
AMT
4750
Postage Claimed Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
NTE
4850
Line Note
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
PS1
4880
Purchased Service Information
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
Drug Identification Loop
LIN
4930
Drug Identification
Max use 1
Required
CTP
4940
Drug Quantity
Max use 1
Required
REF
4950
Prescription or Compound Drug Association Number
Max use 1
Optional
Rendering Provider Name Loop
NM1
5000
Rendering Provider Name
Max use 1
Required
PRV
5050
Rendering Provider Specialty Information
Max use 1
Optional
REF
5250
Rendering Provider Secondary Identification
Max use 3
Optional
Purchased Service Provider Name Loop
NM1
5000
Purchased Service Provider Name
Max use 1
Required
REF
5250
Purchased Service Provider Secondary Identification
Max use 2
Optional
Service Facility Location Name Loop
NM1
5000
Service Facility Location Name
Max use 1
Required
N3
5140
Service Facility Location Address
Max use 1
Required
N4
5200
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
5250
Service Facility Location Secondary Identification
Max use 3
Optional
Supervising Provider Name Loop
NM1
5000
Supervising Provider Name
Max use 1
Required
REF
5250
Supervising Provider Secondary Identification
Max use 3
Optional
Ordering Provider Name Loop
NM1
5000
Ordering Provider Name
Max use 1
Required
N3
5140
Ordering Provider Address
Max use 1
Optional
N4
5200
Ordering Provider City, State, ZIP Code
Max use 1
Optional
REF
5250
Ordering Provider Secondary Identification
Max use 2
Optional
PER
5300
Ordering Provider Contact Information
Max use 1
Optional
Referring Provider Name Loop
NM1
5000
Referring Provider Name
Max use 1
Required
REF
5250
Referring Provider Secondary Identification
Max use 2
Optional
Ambulance Pick-up Location Loop
NM1
5000
Ambulance Pick-up Location
Max use 1
Required
N3
5140
Ambulance Pick-up Location Address
Max use 1
Required
N4
5200
Ambulance Pick-up Location City, State, ZIP Code
Max use 1
Required
Ambulance Drop-Off Location Loop
NM1
5000
Ambulance Drop-Off Location
Max use 1
Required
N3
5140
Ambulance Drop-Off Location Address
Max use 1
Required
N4
5200
Ambulance Drop-Off Location City, State, ZIP Code
Max use 1
Required
Line Adjudication Information Loop
SVD
5400
Line Adjudication Information
Max use 1
Required
CAS
5450
Line Adjustment
Max use 5
Optional
DTP
5500
Line Check or Remittance Date
Max use 1
Required
AMT
5505
Remaining Patient Liability
Max use 1
Optional
SE
5550
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

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

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

Code identifying the type of information in the Authorization Information

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

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

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

Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

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

Date of the interchange

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

Time of the interchange

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

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

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

Code specifying the version number of the interchange control segments

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

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

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

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

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

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

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

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

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

Code identifying a group of application related transaction sets

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

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

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

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

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

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

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

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

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

Assigned number originated and maintained by the sender

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

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

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

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

005010X298A1

Heading

ST
0050
Heading > ST

Transaction Set Header

RequiredMax use 1

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

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

Code uniquely identifying a Transaction Set

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

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

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

Reference assigned to identify Implementation Convention

  • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
Usage notes
  • This element must be populated with the guide identifier named in Section 1.2.
  • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
005010X298A1
BHT
0100
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

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

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

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

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

Code identifying purpose of transaction set

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

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

18
Reissue

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

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

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

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

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

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

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

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

Code specifying the type of transaction

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

Submitter Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

46
Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

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

Code identifying a party or other code

PER
0450
Heading > Submitter Name Loop > PER

Submitter EDI Contact Information

RequiredMax use 2

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

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

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

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

Free-form name

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

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Receiver Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

46
Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement

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

Code identifying a party or other code

1000B Receiver Name Loop end
Heading end

Detail

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

Hierarchical Level

RequiredMax use 1

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

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

Billing Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

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

Code identifying the type of provider

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

Code qualifying the Reference Identification

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

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

CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR

Foreign Currency Information

OptionalMax use 1

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

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

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

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

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

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

Billing Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

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

Billing Provider Address

RequiredMax use 1

To specify the location of the named party

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

Address information

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

Address information

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

Billing Provider City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Billing Provider Tax Identification

RequiredMax use 1

To specify identifying information

Usage notes
  • This is the tax identification number (TIN) of the entity paid for the submitted services.
Example
Variants (all may be used)
REFBilling Provider License InformationREFBilling Provider Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EI
Employer's Identification Number

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

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

SY
Social Security Number

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

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

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

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

Billing Provider License Information

OptionalMax use 2

To specify identifying information

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

Code qualifying the Reference Identification

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

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

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

Billing Provider Secondary Identification

OptionalMax use 2

To specify identifying information

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

Code qualifying the Reference Identification

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

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

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

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

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

Subscriber Information

RequiredMax use 1

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

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

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

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

Code indicating the relationship between two individuals or entities

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

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

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

Code identifying a party or other code

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

Subscriber Address

RequiredMax use 1

To specify the location of the named party

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

Address information

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

Address information

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

Subscriber City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Subscriber Demographic Information

RequiredMax use 1

To supply demographic information

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

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

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

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

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

Code indicating the sex of the individual

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

Subscriber Social Security Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when:

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

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

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

Code qualifying the Reference Identification

SY
Social Security Number

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

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

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

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

Property and Casualty Claim Number

OptionalMax use 1

To specify identifying information

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

Code qualifying the Reference Identification

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

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

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

Data Receiver

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

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

Patient Information

RequiredMax use 1

To supply patient information

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

Code indicating the relationship between two individuals or entities

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

Patient Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

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

Code identifying a party or other code

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

Patient Address

RequiredMax use 1

To specify the location of the named party

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

Address information

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

Address information

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

Patient City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Patient Demographic Information

RequiredMax use 1

To supply demographic information

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

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

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

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

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

Code indicating the sex of the individual

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

Patient Social Security Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when:

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

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

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

Code qualifying the Reference Identification

SY
Social Security Number

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

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

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

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

Property and Casualty Claim Number

OptionalMax use 1

To specify identifying information

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

Code qualifying the Reference Identification

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

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

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

Claim Information

RequiredMax use 1

To specify basic data about the claim

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

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

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

Monetary amount

  • CLM02 is the total amount of all submitted charges of service segments for this claim.
Usage notes
  • The Total Claim Charge Amount must be greater than or equal to zero.
  • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim.
  • This amount represents the sum of the line charge amounts included in this portion of the claim.
CLM-05
C023
Health Care Service Location Information
Required
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
C023-01
1331
Place of Service Code
Required
String (AN)
Min 1Max 2

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

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

Code identifying the type of facility referenced

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

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

CLM-06
1073
Yes No Condition or Response Code
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

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

Code indicating whether the provider accepts assignment

Usage notes
  • Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
A
Assigned
B
Assignment Accepted on Clinical Lab Services Only
C
Not Assigned
CLM-08
1073
Yes No Condition or Response Code
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

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

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

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

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

I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
CLM-10
1351
Patient Signature Source Code
Optional
Identifier (ID)

Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

P
Signature generated by provider because the patient was not physically present for services

Signature generated by an entity other than the patient according to State or Federal law.

CLM-11
C024
Related Causes Information
Optional
To identify one or more related causes and associated state or country information
Usage notes

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

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

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

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

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

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

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

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

Code identifying the country

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

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

02
Physically Handicapped Children's Program
03
Special Federal Funding
05
Disability
09
Second Opinion or Surgery
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)

Code indicating the reason why a request was delayed

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

Date - Accident

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

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

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

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

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

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

Date - Acute Manifestation

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

453
Acute Manifestation of a Chronic Condition
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Admission

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

435
Admission
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Assumed and Relinquished Care Dates

OptionalMax use 2

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

Usage notes
  • Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates.

Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A".

  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

090
Report Start

Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care.

091
Report End

Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider.

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

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

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

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

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

Date - Authorized Return to Work

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

296
Initial Disability Period Return To Work

This is the date the provider has authorized the patient to return to work.

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

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

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

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

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

Date - Disability Dates

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

314
Disability

Use code 314 when both disability start and end date are being reported.

360
Initial Disability Period Start

Use code 360 if patient is currently disabled and disability end date is unknown.

361
Initial Disability Period End

Use code 361 if patient is no longer disabled and the start date is unknown.

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD

Use code D8 when DTP01 is 360 or 361.

RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use code RD8 when DTP01 is 314.

DTP-03
1251
Disability From Date
Required
String (AN)
Min 1Max 35

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

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

Date - Discharge

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

096
Discharge
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Hearing and Vision Prescription Date

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

471
Prescription
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Initial Treatment Date

OptionalMax use 1

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

Usage notes
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

454
Initial Treatment
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Last Menstrual Period

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

484
Last Menstrual Period
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Last Seen Date

OptionalMax use 1

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

Usage notes
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
  • This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

304
Latest Visit or Consultation
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Last Worked

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

297
Initial Disability Period Last Day Worked
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Last X-ray Date

OptionalMax use 1

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

Usage notes
  • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

455
Last X-Ray
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Onset of Current Illness or Symptom

OptionalMax use 1

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

Usage notes
  • This date is the onset of acute symptoms for the current illness or condition.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

431
Onset of Current Symptoms or Illness
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Property and Casualty Date of First Contact

OptionalMax use 1

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

Usage notes
  • This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Repricer Received Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

444
First Visit or Consultation
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Date - Repricer Received Date

OptionalMax use 1

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

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First Contact
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > PWK

Claim Supplemental Information

OptionalMax use 10

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

03
Report Justifying Treatment Beyond Utilization Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification
AS
Admission Summary
B2
Prescription
B3
Physician Order
B4
Referral Form
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
CK
Consent Form(s)
CT
Certification
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
EB
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
MT
Models
NN
Nursing Notes
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
OE
Objective Physical Examination (including vital signs) Document
OX
Oxygen Therapy Certification
OZ
Support Data for Claim
P4
Pathology Report
P5
Patient Medical History Document
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician's Report
PZ
Physical Therapy Certification
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

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

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1

To specify basic data about the contract or contract line item

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

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

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

Code identifying a contract type

01
Diagnosis Related Group (DRG)
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

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

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

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

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

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

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

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

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

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

Patient Amount Paid

OptionalMax use 1

To indicate the total monetary amount

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

Code to qualify amount

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

Monetary amount

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

Adjusted Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

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

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

Investigational Device Exemption Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

LX
Qualified Products List
REF-02
127
Investigational Device Exemption Identifier
Required
String (AN)
Min 1Max 50

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

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

Claim Identifier For Transmission Intermediaries

OptionalMax use 1

To specify identifying information

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

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

Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

Usage notes
  • The value carried in this element is limited to a maximum of 20 positions.
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF

Mammography Certification Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EW
Mammography Certification Number
REF-02
127
Mammography Certification Number
Required
String (AN)
Min 1Max 50

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

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

Prior Authorization

OptionalMax use 1

To specify identifying information

Usage notes
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50

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

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

Clinical Laboratory Improvement Amendment (CLIA) Number

OptionalMax use 1

To specify identifying information

Usage notes
  • If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
  • In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

X4
Clinical Laboratory Improvement Amendment Number
REF-02
127
Clinical Laboratory Improvement Amendment Number
Required
String (AN)
Min 1Max 50

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

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

Medical Record Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EA
Medical Record Identification Number
REF-02
127
Medical Record Number
Required
String (AN)
Min 1Max 50

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

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

Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFRepriced Claim NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

Repriced Claim Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFService Authorization Exception Code
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50

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

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

Service Authorization Exception Code

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFMedical Record NumberREFReferral NumberREFRepriced Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Allowable values for this element are:
    1 Immediate/Urgent Care
    2 Services Rendered in a Retroactive Period
    3 Emergency Care
    4 Client has Temporary Medicaid
    5 Request from County for Second Opinion to Determine
    if Recipient Can Work
    6 Request for Override Pending
    7 Special Handling
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10

To transmit a fixed-format record or matrix contents

Usage notes

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

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

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

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

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

Data in fixed format agreed upon by sender and receiver

NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE

Claim Note

OptionalMax use 1

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300.
  • The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

AAD
Nationality Details
CER
Certification Narrative
DCP
Goals, Rehabilitation Potential, or Discharge Plans
DGN
Diagnosis Description
TPO
Third Party Organization Notes
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80

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

CR1
1950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CR1

Ambulance Transport Information

OptionalMax use 1

To supply information related to the ambulance service rendered to a patient

Usage notes

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

  • The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required
CR1-01
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

LB
Pound
CR1-02
81
Patient Weight
Optional
Decimal number (R)
Min 1Max 10

Numeric value of weight

  • CR102 is the weight of the patient at time of transport.
CR1-04
1317
Ambulance Transport Reason Code
Required
Identifier (ID)

Code indicating the reason for ambulance transport

A
Patient was transported to nearest facility for care of symptoms, complaints, or both

Can be used to indicate that the patient was transferred to a residential facility.

B
Patient was transported for the benefit of a preferred physician
C
Patient was transported for the nearness of family members
D
Patient was transported for the care of a specialist or for availability of specialized equipment
E
Patient Transferred to Rehabilitation Facility
CR1-05
355
Unit or Basis for Measurement Code
Required
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

DH
Miles
CR1-06
380
Transport Distance
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR106 is the distance traveled during transport.
Usage notes
  • 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
CR1-09
352
Round Trip Purpose Description
Optional
String (AN)
Min 1Max 80

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

  • CR109 is the purpose for the round trip ambulance service.
CR1-10
352
Stretcher Purpose Description
Optional
String (AN)
Min 1Max 80

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

  • CR110 is the purpose for the usage of a stretcher during ambulance service.
CR2
2000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CR2

Spinal Manipulation Service Information

OptionalMax use 1

To supply information related to the chiropractic service rendered to a patient

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
CR2-08
1342
Patient Condition Code
Required
Identifier (ID)

Code indicating the nature of a patient's condition

A
Acute Condition
C
Chronic Condition
D
Non-acute
E
Non-Life Threatening
F
Routine
G
Symptomatic
M
Acute Manifestation of a Chronic Condition
CR2-10
352
Patient Condition Description
Optional
String (AN)
Min 1Max 80

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

  • CR210 is a description of the patient's condition.
CR2-11
352
Patient Condition Description
Optional
String (AN)
Min 1Max 80

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

  • CR211 is an additional description of the patient's condition.
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC

Ambulance Certification

OptionalMax use 3

To supply information on conditions

Usage notes
  • The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01.
  • Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
CRCPatient Condition Information: VisionCRCHomebound IndicatorCRCEPSDT Referral
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
07
Ambulance Certification
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

01
Patient was admitted to a hospital
04
Patient was moved by stretcher
05
Patient was unconscious or in shock
06
Patient was transported in an emergency situation
07
Patient had to be physically restrained
08
Patient had visible hemorrhaging
09
Ambulance service was medically necessary
12
Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

CRC-04
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC

Patient Condition Information: Vision

OptionalMax use 3

To supply information on conditions

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
CRCAmbulance CertificationCRCHomebound IndicatorCRCEPSDT Referral
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
E1
Spectacle Lenses
E2
Contact Lenses
E3
Spectacle Frames
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

L1
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
L2
Replacement Due to Loss or Theft
L3
Replacement Due to Breakage or Damage
L4
Replacement Due to Patient Preference
L5
Replacement Due to Medical Reason
CRC-04
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC

Homebound Indicator

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
CRCAmbulance CertificationCRCPatient Condition Information: VisionCRCEPSDT Referral
CRC-01
1136
Condition Code
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
75
Functional Limitations
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Y
Yes
CRC-03
1321
Homebound Indicator
Required
Identifier (ID)

Code indicating a condition

IH
Independent at Home
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC

EPSDT Referral

OptionalMax use 1

To supply information on conditions

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
CRCAmbulance CertificationCRCPatient Condition Information: VisionCRCHomebound Indicator
CRC-01
1136
Code Qualifier
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
ZZ
Mutually Defined

EPSDT Screening referral information.

CRC-02
1073
Certification Condition Code Applies Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Usage notes
  • The response answers the question: Was an EPSDT referral given to the patient?
N
No

If no, then choose "NU" in CRC03 indicating no referral given.

Y
Yes
CRC-03
1321
Condition Indicator
Required
Identifier (ID)

Code indicating a condition

Usage notes
  • The codes for CRC03 also can be used for CRC04 through CRC05.
AV
Available - Not Used

Patient refused referral.

NU
Not Used

This condition indicator must be used when the submitter answers "N" in CRC02.

S2
Under Treatment

Patient is currently under treatment for referred diagnostic or corrective health problem.

ST
New Services Requested

Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
OR
Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).;

CRC-04
1321
Condition Indicator
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-05
1321
Condition Indicator
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Health Care Diagnosis Code

RequiredMax use 1

To supply information related to the delivery of health care

Usage notes
  • Do not transmit the decimal point for ICD codes. The decimal point is implied.
Example
Variants (all may be used)
HIAnesthesia Related ProcedureHICondition Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

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

ICD-9 Codes

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

Code indicating a code from a specific industry code list

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

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Anesthesia Related Procedure

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
HIHealth Care Diagnosis CodeHICondition Information
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BP
Health Care Financing Administration Common Procedural Coding System Principal Procedure
C022-02
1271
Anesthesia Related Surgical Procedure
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BO
Health Care Financing Administration Common Procedural Coding System
C022-02
1271
Industry Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI

Condition Information

OptionalMax use 2

To supply information related to the delivery of health care

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
HIHealth Care Diagnosis CodeHIAnesthesia Related Procedure
HI-01
C022
Health Care Code Information
Required
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-05
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-06
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-07
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

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

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-09
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-10
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-11
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HI-12
C022
Health Care Code Information
Optional
To send health care codes and their associated dates, amounts and quantities
Usage notes

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

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

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
BG
Condition
C022-02
1271
Condition Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP

Claim Pricing/Repricing Information

OptionalMax use 1

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

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

  • HCP04 is the repricing organization identification number.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
HCP-06
127
Repriced Approved Ambulatory Patient Group (APG) Code
Optional
String (AN)
Min 1Max 50

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

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
HCP-07
782
Repriced Approved Ambulatory Patient Group (APG) Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP07 is the approved DRG amount.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)

Code specifying policy compliance

1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2310A Referring Provider Name Loop
OptionalMax 2
Variants (all may be used)
Rendering Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • 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.
  • When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
  • 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.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

DN
Referring Provider

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

P3
Primary Care Provider

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

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

Referring Provider Secondary Identification

OptionalMax use 2

To specify identifying information

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

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

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

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

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

2310A Referring Provider Name Loop end
2310B Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

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

Rendering Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

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

Code identifying the type of provider

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

Code qualifying the Reference Identification

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

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

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

Rendering Provider Secondary Identification

OptionalMax use 3

To specify identifying information

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

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

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

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

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

2310B Rendering Provider Name Loop end
2310C Service Facility Location Name Loop
RequiredMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopSupervising Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

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

Code identifying a party or other code

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

Service Facility Location Address

RequiredMax use 1

To specify the location of the named party

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

Address information

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

Address information

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

Service Facility Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Service Facility Location Secondary Identification

OptionalMax use 3

To specify identifying information

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

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

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

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

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

2310C Service Facility Location Name Loop end
2310D Supervising Provider Name Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopService Facility Location Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

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

Supervising Provider Secondary Identification

OptionalMax use 3

To specify identifying information

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

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

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

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

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

2310D Supervising Provider Name Loop end
2310E Ambulance Pick-up Location Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopAmbulance Drop-Off Location Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > NM1

Ambulance Pick-up Location

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N3

Ambulance Pick-up Location Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
  • The information provided in this segment is intended to be representative of the information as known to the payer's system.
Example
N3-01
166
Ambulance Pick-up Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Ambulance Pick-up Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N4

Ambulance Pick-up Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2310E Ambulance Pick-up Location Loop end
2310F Ambulance Drop-Off Location Loop
OptionalMax 1
Variants (all may be used)
Referring Provider Name LoopRendering Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopAmbulance Pick-up Location Loop
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-Off Location Loop > NM1

Ambulance Drop-Off Location

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

45
Drop-off Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Ambulance Drop-off Location
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-Off Location Loop > N3

Ambulance Drop-Off Location Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Ambulance Drop-off Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Ambulance Drop-off Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-Off Location Loop > N4

Ambulance Drop-Off Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of Ambulance Drop-off State or Province Code (N4-02) or Ambulance Drop-off Country Subdivision Code (N4-07) may be present
If Ambulance Drop-off Country Subdivision Code (N4-07) is present, then Ambulance Drop-off Country Code (N4-04) is required
N4-01
19
Ambulance Drop-off City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2310F Ambulance Drop-Off Location Loop end
2320 Other Subscriber Information Loop
RequiredMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1

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

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

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

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

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

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

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

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

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

Code indicating the relationship between two individuals or entities

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

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

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

Free-form name

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

Code identifying whether there is a coordination of benefits

1
Coordination of Benefits

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

6
No Coordination of Benefits

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

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

Code identifying type of claim

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

Use code OF when submitting Medicare Part D claims.

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

Use Code ZZ when Type of Insurance is not known.

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

Claim Level Adjustments

OptionalMax use 5

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

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

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

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

Code identifying the general category of payment adjustment

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

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

Numeric value of quantity

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

Code identifying the detailed reason the adjustment was made

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

Monetary amount

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

Numeric value of quantity

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

Code identifying the detailed reason the adjustment was made

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

Monetary amount

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

Numeric value of quantity

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

Code identifying the detailed reason the adjustment was made

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

Monetary amount

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

Numeric value of quantity

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

Code identifying the detailed reason the adjustment was made

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

Monetary amount

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

Numeric value of quantity

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

Code identifying the detailed reason the adjustment was made

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

Monetary amount

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

Numeric value of quantity

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

Coordination of Benefits (COB) Payer Paid Amount

RequiredMax use 1

To indicate the total monetary amount

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

Code to qualify amount

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

Monetary amount

Usage notes
  • It is acceptable to show "0" as the amount paid.
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1

To indicate the total monetary amount

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

Code to qualify amount

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

Monetary amount

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

Outpatient Adjudication Information

OptionalMax use 1

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

Usage notes

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

OR

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

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

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

OR

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

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

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

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

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

Monetary amount

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

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

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

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

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

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

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

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

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

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

  • MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA-08
782
End Stage Renal Disease Payment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA08 is the End Stage Renal Disease (ESRD) payment amount.
MOA-09
782
Non-Payable Professional Component Billed Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • MOA09 is the professional component amount billed but not payable.
2330A Other Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Other Payer Name LoopOther Patient Name Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1

Other Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

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

Code identifying a party or other code

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

Other Subscriber Address

OptionalMax use 1

To specify the location of the named party

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

Address information

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

Address information

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

Other Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Other Subscriber Social Security Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when:

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

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

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

Code qualifying the Reference Identification

SY
Social Security Number

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

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

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

2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Patient Name Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1

Other Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

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

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

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

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

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

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

Code identifying a party or other code

Usage notes
  • When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
DTP
3450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP

Claim Check or Remittance Date

RequiredMax use 1

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

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

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

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

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

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

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

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

Other Payer Secondary Identifier

OptionalMax use 4

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control NumberREFOther Payer Adjusted Claim Control Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

2U
Payer Identification Number
EI
Employer's Identification Number

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

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

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

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

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

Other Payer Claim Adjustment Indicator

OptionalMax use 1

To specify identifying information

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

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

Example
Variants (all may be used)
REFOther Payer Secondary IdentifierREFOther Payer Claim Control NumberREFOther Payer Adjusted Claim Control Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

Other Payer Claim Control Number

OptionalMax use 1

To specify identifying information

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

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

Example
Variants (all may be used)
REFOther Payer Secondary IdentifierREFOther Payer Claim Adjustment IndicatorREFOther Payer Adjusted Claim Control Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F8
Original Reference Number
REF-02
127
Other Payer's Claim Control Number
Required
String (AN)
Min 1Max 50

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

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

Other Payer Adjusted Claim Control Number

OptionalMax use 1

To specify identifying information

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

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

Example
Variants (all may be used)
REFOther Payer Secondary IdentifierREFOther Payer Claim Adjustment IndicatorREFOther Payer Claim Control Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

2330B Other Payer Name Loop end
2330C Other Patient Name Loop
OptionalMax 1
Variants (all may be used)
Other Subscriber Name LoopOther Payer Name Loop
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > NM1

Other Patient Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • NM1QC1DOEJOHNT**JRMI*123456~
  • When SBR06 = 1, the information in this segment represents the Patient as submitted by the provider for the payer identified in Loop ID 2330B.

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

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

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

Code identifying a party or other code

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

Other Patient Address

OptionalMax use 1

To specify the location of the named party

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

Address information

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

Address information

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

Other Patient City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

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

Free-form text for city name

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

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

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

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

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

Code identifying the country

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

Code identifying the country subdivision

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

Other Patient Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when:

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

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

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

Code qualifying the Reference Identification

SY
Social Security Number

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

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

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

2330C Other Patient Name Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 50
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX

Service Line Number

RequiredMax use 1

To reference a line number in a transaction set

Usage notes
  • 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.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

SV1
3700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV1

Professional Service

RequiredMax use 1

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

Example
SV1-01
C003
Composite Medical Procedure Identifier
Required
To identify a medical procedure by its standardized codes and applicable modifiers
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
Usage notes
  • The intent is to capture the data as provided on the original claim from the submitter.
ER
Jurisdiction Specific Procedure and Supply Codes
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

WK
Advanced Billing Concepts (ABC) Codes
C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-03 modifies the value in C003-02 and C003-08.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-04 modifies the value in C003-02 and C003-08.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-05 modifies the value in C003-02 and C003-08.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-06 modifies the value in C003-02 and C003-08.
C003-07
352
Description
Optional
String (AN)
Min 1Max 80

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.
SV1-02
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SV102 is the submitted service line item amount.
Usage notes
  • Zero "0" is an acceptable value for this element.
  • This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments.
SV1-03
355
Unit or Basis for Measurement Code
Required
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

Usage notes
  • The intent is to capture the data as provided on the original claim from the submitter.
MJ
Minutes

Required for Anesthesia claims.

Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel.

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

Numeric value of quantity

Usage notes
  • Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
  • 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.
  • The intent is to capture the data as provided on the original claim from the submitter.
SV1-05
1331
Place of Service Code
Optional
String (AN)
Min 1Max 2

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

  • SV105 is the place of service.
Usage notes
  • See CODE SOURCE 237: Place of Service Codes for Professional Claims
SV1-07
C004
Composite Diagnosis Code Pointer
Required
To identify one or more diagnosis code pointers
C004-01
1328
Diagnosis Code Pointer
Required
Numeric (N0)
Min 1Max 2

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.
Usage notes
  • This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300.
C004-02
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

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.
C004-03
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

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.
C004-04
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

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.
SV1-09
1073
Emergency Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related.
Usage notes
  • For this implementation, the listed value takes precedence over the semantic note.

Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions.

  • The intent is to capture the data as provided on the original claim from the submitter.
Y
Yes
SV1-11
1073
EPSDT Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
Usage notes
  • For this implementation, the listed value takes precedence over the semantic note.
  • When this element is used, this service is not the screening service.
Y
Yes
SV1-12
1073
Family Planning Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement.
Usage notes
  • For this implementation, the listed value takes precedence over the semantic note.
Y
Yes
SV1-15
1327
Copay Status Code
Optional
Identifier (ID)

Code indicating whether or not co-payment requirements were met on a line by line basis

Usage notes
  • When this field is populated, the related service was exempt from copay.
0
Copay exempt
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK

Line Supplemental Information

OptionalMax use 10

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
PWKDurable Medical Equipment Certificate of Medical Necessity Indicator
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

03
Report Justifying Treatment Beyond Utilization Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification
AS
Admission Summary
B2
Prescription
B3
Physician Order
B4
Referral Form
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
CK
Consent Form(s)
CT
Certification
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
EB
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
MT
Models
NN
Nursing Notes
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
OE
Objective Physical Examination (including vital signs) Document
OX
Oxygen Therapy Certification
OZ
Support Data for Claim
P4
Pathology Report
P5
Patient Medical History Document
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician's Report
PZ
Physical Therapy Certification
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

AA
Available on Request at Provider Site

This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

BM
By Mail
EL
Electronically Only

Indicates that the attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FT
File Transfer

Required when the actual attachment is maintained by an attachment warehouse or similar vendor.

FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

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

  • PWK05 and PWK06 may be used to identify the addressee by a code number.
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
  • For the purpose of this implementation, the maximum field length is 50.
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK

Durable Medical Equipment Certificate of Medical Necessity Indicator

OptionalMax use 1

To identify the type or transmission or both of paperwork or supporting information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
PWKLine Supplemental Information
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

Code indicating the title or contents of a document, report or supporting item

CT
Certification
PWK-02
756
Attachment Transmission Code
Required
Identifier (ID)

Code defining timing, transmission method or format by which reports are to be sent

AB
Previously Submitted to Payer
AD
Certification Included in this Claim
AF
Narrative Segment Included in this Claim
AG
No Documentation is Required
NS
Not Specified

NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.

CR1
4250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR1

Ambulance Transport Information

OptionalMax use 1

To supply information related to the ambulance service rendered to a patient

Usage notes

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

  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required
CR1-01
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

LB
Pound
CR1-02
81
Patient Weight
Optional
Decimal number (R)
Min 1Max 10

Numeric value of weight

  • CR102 is the weight of the patient at time of transport.
CR1-04
1317
Ambulance Transport Reason Code
Required
Identifier (ID)

Code indicating the reason for ambulance transport

A
Patient was transported to nearest facility for care of symptoms, complaints, or both
B
Patient was transported for the benefit of a preferred physician
C
Patient was transported for the nearness of family members
D
Patient was transported for the care of a specialist or for availability of specialized equipment
E
Patient Transferred to Rehabilitation Facility
CR1-05
355
Unit or Basis for Measurement Code
Required
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

DH
Miles
CR1-06
380
Transport Distance
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR106 is the distance traveled during transport.
Usage notes
  • 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
CR1-09
352
Round Trip Purpose Description
Optional
String (AN)
Min 1Max 80

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

  • CR109 is the purpose for the round trip ambulance service.
CR1-10
352
Stretcher Purpose Description
Optional
String (AN)
Min 1Max 80

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

  • CR110 is the purpose for the usage of a stretcher during ambulance service.
CR3
4350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR3

Durable Medical Equipment Certification

OptionalMax use 1

To supply information regarding a physician's certification for durable medical equipment

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
CR3-01
1322
Certification Type Code
Required
Identifier (ID)

Code indicating the type of certification

I
Initial
R
Renewal
S
Revised
CR3-02
355
Unit or Basis for Measurement Code
Required
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

  • CR302 and CR303 specify the time period covered by this certification.
MO
Months
CR3-03
380
Durable Medical Equipment Duration
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • Length of time DME equipment is needed.
CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC

Ambulance Certification

OptionalMax use 3

To supply information on conditions

Usage notes
  • The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
CRCHospice Employee IndicatorCRCCondition Indicator/Durable Medical Equipment
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
07
Ambulance Certification
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Code
Required
Identifier (ID)

Code indicating a condition

Usage notes
  • The codes for CRC03 also can be used for CRC04 through CRC07.
01
Patient was admitted to a hospital
04
Patient was moved by stretcher
05
Patient was unconscious or in shock
06
Patient was transported in an emergency situation
07
Patient had to be physically restrained
08
Patient had visible hemorrhaging
09
Ambulance service was medically necessary
12
Patient is confined to a bed or chair

Use code 12 to indicate patient was bedridden during transport.

CRC-04
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-05
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-06
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC-07
1321
Condition Code
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC

Hospice Employee Indicator

OptionalMax use 1

To supply information on conditions

Usage notes
  • The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
  • The example shows the method used to indicate whether the rendering provider is an employee of the hospice.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
CRCAmbulance CertificationCRCCondition Indicator/Durable Medical Equipment
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
70
Hospice
CRC-02
1073
Hospice Employed Provider Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Usage notes
  • A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice.
N
No
Y
Yes
CRC-03
1321
Condition Indicator
Required
Identifier (ID)

Code indicating a condition

65
Open

This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement.

CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC

Condition Indicator/Durable Medical Equipment

OptionalMax use 1

To supply information on conditions

Usage notes
  • The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
  • The first example shows a case where an item billed was not a replacement item.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
CRCAmbulance CertificationCRCHospice Employee Indicator
CRC-01
1136
Code Category
Required
Identifier (ID)

Specifies the situation or category to which the code applies

  • CRC01 qualifies CRC03 through CRC07.
09
Durable Medical Equipment Certification
CRC-02
1073
Certification Condition Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
N
No
Y
Yes
CRC-03
1321
Condition Indicator
Required
Identifier (ID)

Code indicating a condition

38
Certification signed by the physician is on file at the supplier's office
ZV
Replacement Item
CRC-04
1321
Condition Indicator
Optional
Identifier (ID)
Min 2Max 3

Code indicating a condition

Usage notes
  • Use the codes listed in CRC03.
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Initial Treatment Date

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

454
Initial Treatment
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Last Seen Date

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

304
Latest Visit or Consultation
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Last X-ray Date

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

455
Last X-Ray
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Service Date

RequiredMax use 1

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

Usage notes
  • The intent is to capture the data as provided on the original claim from the submitter.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
Usage notes
  • RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Prescription Date

OptionalMax use 1

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

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

471
Prescription
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Certification Revision/Recertification Date

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

607
Certification Revision
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Begin Therapy Date

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Last Certification DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

463
Begin Therapy
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Last Certification Date

OptionalMax use 1

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

Usage notes
  • This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF).
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Shipped DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

461
Last Certification
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Shipped Date

OptionalMax use 1

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Test Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

011
Shipped
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP

Date - Test Date

OptionalMax use 2

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

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
DTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Service DateDTPDate - Prescription DateDTPDate - Certification Revision/Recertification DateDTPDate - Begin Therapy DateDTPDate - Last Certification DateDTPDate - Shipped Date
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

738
Most Recent Hemoglobin or Hematocrit or Both
739
Most Recent Serum Creatine
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

QTY
4600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY

Ambulance Patient Count

OptionalMax use 1

To specify quantity information

Usage notes
  • The QTY02 is the only place to report the number of patients when there are multiple patients transported.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
QTYObstetric Anesthesia Additional Units
QTY-01
673
Quantity Qualifier
Required
Identifier (ID)

Code specifying the type of quantity

PT
Patients
QTY-02
380
Ambulance Patient Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

QTY
4600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY

Obstetric Anesthesia Additional Units

OptionalMax use 1

To specify quantity information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
QTYAmbulance Patient Count
QTY-01
673
Quantity Qualifier
Required
Identifier (ID)

Code specifying the type of quantity

FL
Units
QTY-02
380
Obstetric Additional Units
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • The number of additional units reported by an anesthesia provider to reflect additional complexity of services.
MEA
4620
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > MEA

Test Result

OptionalMax use 5

To specify physical measurements or counts, including dimensions, tolerances, variances, and weights

(See Figures Appendix for example of use of C001)

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
MEA-01
737
Measurement Reference Identification Code
Required
Identifier (ID)

Code identifying the broad category to which a measurement applies

OG
Original

Use OG to report Starting Dosage.

TR
Test Results
MEA-02
738
Measurement Qualifier
Required
Identifier (ID)

Code identifying a specific product or process characteristic to which a measurement applies

HT
Height
R1
Hemoglobin
R2
Hematocrit
R3
Epoetin Starting Dosage
R4
Creatinine
MEA-03
739
Test Results
Required
Decimal number (R)
Min 1Max 15

The value of the measurement

CN1
4650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CN1

Contract Information

OptionalMax use 1

To specify basic data about the contract or contract line item

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

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

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

Code identifying a contract type

01
Diagnosis Related Group (DRG)
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

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

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

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

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

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

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date

CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30

Revision level of a particular format, program, technique or algorithm

  • CN106 is an additional identifying number for the contract.
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Adjusted Repriced Line Item Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9D
Adjusted Repriced Line Item Reference Number
REF-02
127
Adjusted Repriced Line Item Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Clinical Laboratory Improvement Amendment (CLIA) Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

X4
Clinical Laboratory Improvement Amendment Number
REF-02
127
Clinical Laboratory Improvement Amendment Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Immunization Batch Number

OptionalMax use 1

To specify identifying information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BT
Batch Number
REF-02
127
Immunization Batch Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Line Item Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

6R
Provider Control Number
REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Mammography Certification Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EW
Mammography Certification Number
REF-02
127
Mammography Certification Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Prior Authorization

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G1
Prior Authorization Number
REF-02
127
Prior Authorization or Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Referral Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFRepriced Line Item Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

F4
Facility Certification Number
REF-02
127
Referring CLIA Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF

Repriced Line Item Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

9B
Repriced Line Item Reference Number
REF-02
127
Repriced Line Item Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Sales Tax Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
AMTPostage Claimed Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

T
Tax
AMT-02
782
Sales Tax Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

AMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT

Postage Claimed Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
AMTSales Tax Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

F4
Postage Claimed
AMT-02
782
Postage Claimed Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

K3
4800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3

File Information

OptionalMax use 10

To transmit a fixed-format record or matrix contents

Usage notes

  • The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used:

  • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.

  • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.

Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.

  • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
  • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80

Data in fixed format agreed upon by sender and receiver

NTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE

Line Note

OptionalMax use 1

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
NTEThird Party Organization Notes
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

ADD
Additional Information
DCP
Goals, Rehabilitation Potential, or Discharge Plans
NTE-02
352
Line Note Text
Required
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

NTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE

Third Party Organization Notes

OptionalMax use 1

To transmit information in a free-form format, if necessary, for comment or special instruction

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Variants (all may be used)
NTELine Note
NTE-01
363
Note Reference Code
Required
Identifier (ID)

Code identifying the functional area or purpose for which the note applies

TPO
Third Party Organization Notes
NTE-02
352
Line Note Text
Required
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

PS1
4880
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1

Purchased Service Information

OptionalMax use 1

To specify the information about services that are purchased

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
PS1-01
127
Purchased Service Provider Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • PS101 is provider identification number.
Usage notes
  • This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109.
PS1-02
782
Purchased Service Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • PS102 is cost of the purchased service.
HCP
4920
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP

Line Pricing/Repricing Information

OptionalMax use 1

To specify pricing or repricing information about a health care claim or line item

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required
If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)

Code specifying pricing methodology at which the claim or line item has been priced or repriced

Usage notes
  • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
HCP-02
782
Repriced Allowed Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP02 is the allowed amount.
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP03 is the savings amount.
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP04 is the repricing organization identification number.
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9

Rate expressed in the standard monetary denomination for the currency specified

  • HCP05 is the pricing rate associated with per diem or flat rate repricing.
HCP-06
127
Repriced Approved Ambulatory Patient Group (APG) Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • HCP06 is the approved DRG code.
  • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
HCP-07
782
Repriced Approved Ambulatory Patient Group (APG) Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • HCP07 is the approved DRG amount.
HCP-09
235
Product or Service ID Qualifier
Optional
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

ER
Jurisdiction Specific Procedure and Supply Codes
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

IV
Home Infusion EDI Coalition (HIEC) Product/Service Code
WK
Advanced Billing Concepts (ABC) Codes
HCP-10
234
Repriced Approved HCPCS Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • HCP10 is the approved procedure code.
HCP-11
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

MJ
Minutes
UN
Unit
HCP-12
380
Repriced Approved Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • HCP12 is the approved service units or inpatient days.
Usage notes
  • Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
  • 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.
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)

Code assigned by issuer to identify reason for rejection

  • HCP13 is the rejection message returned from the third party organization.
T1
Cannot Identify Provider as TPO (Third Party Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
HCP-14
1526
Policy Compliance Code
Optional
Identifier (ID)

Code specifying policy compliance

1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not Made)
3
Not Medically Necessary (Non-Compliance Non-Medically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
HCP-15
1527
Exception Code
Optional
Identifier (ID)

Code specifying the exception reason for consideration of out-of-network health care services

  • HCP15 is the exception reason generated by a third party organization.
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
2410 Drug Identification Loop
OptionalMax 1
LIN
4930
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN

Drug Identification

RequiredMax use 1

To specify basic item identification data

Usage notes
  • Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
LIN-02
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU.
Usage notes
  • At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation.
EN
EAN/UCC - 13
EO
EAN/UCC - 8
HI
HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message
N4
National Drug Code in 5-4-2 Format

Receivers are advised not to attempt validation using only the FDA code list identified by the code source as there are valid NDC values assigned by other sources that are not included in the FDA listing.

ON
Customer Order Number
UK
GTIN 14-digit Data Structure
UP
UCC - 12
LIN-03
234
National Drug Code, Universal Product Number or Device Identifier of the Unique Device Identifier
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

CTP
4940
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP

Drug Quantity

RequiredMax use 1

To specify pricing information

Usage notes
  • The intent is to capture the information as stored in the payer's system.
Example
CTP-04
380
National Drug Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

CTP-05
C001
Composite Unit of Measure
Required
To identify a composite unit of measure (See Figures Appendix for examples of use)
C001-01
355
Code Qualifier
Required
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

F2
International Unit
GR
Gram
ME
Milligram
ML
Milliliter
UN
Unit
REF
4950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF

Prescription or Compound Drug Association Number

OptionalMax use 1

To specify identifying information

Usage notes
  • In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
  • For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

VY
Link Sequence Number
XZ
Pharmacy Prescription Number
REF-02
127
Prescription Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2410 Drug Identification Loop end
2420A Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Purchased Service Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopOrdering Provider Name LoopReferring Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • 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.

Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Rendering Provider First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Rendering Provider Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV

Rendering Provider Specialty Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2420A Rendering Provider Name Loop end
2420B Purchased Service Provider Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopOrdering Provider Name LoopReferring Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1

Purchased Service Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
If either Identification Code Qualifier (NM1-08) or Purchased Service Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

Usage notes
  • The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
QB
Purchase Service Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Purchased Service Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > REF

Purchased Service Provider Secondary Identification

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Purchased Service Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2420B Purchased Service Provider Name Loop end
2420C Service Facility Location Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopPurchased Service Provider Name LoopSupervising Provider Name LoopOrdering Provider Name LoopReferring Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
  • The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.;
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when the Service Facility Location for this line is different than the Service Facility Location reported in Loop ID-2310C (claim level) and is available in the payer's system.

If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Laboratory or Facility City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

Usage notes
  • When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Service Facility Location Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2420C Service Facility Location Name Loop end
2420D Supervising Provider Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopPurchased Service Provider Name LoopService Facility Location Name LoopOrdering Provider Name LoopReferring Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when the Supervising Provider for this line is different than the Supervising Provider reported in Loop ID-2310D (claim level) and is available in the payer's system.

If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DQ
Supervising Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Supervising Provider First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Supervising Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Supervising Provider Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > REF

Supervising Provider Secondary Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2420D Supervising Provider Name Loop end
2420E Ordering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopPurchased Service Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopReferring Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1

Ordering Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
If either Identification Code Qualifier (NM1-08) or Ordering Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

Usage notes
  • The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
DK
Ordering Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Ordering Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Ordering Provider First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Ordering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Ordering Provider Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Ordering Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3

Ordering Provider Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
N3-01
166
Ordering Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Ordering Provider Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N4

Ordering Provider City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
Only one of Ordering Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Ordering Provider City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Ordering Provider State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Ordering Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > REF

Ordering Provider Secondary Identification

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Ordering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

PER
5300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > PER

Ordering Provider Contact Information

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number 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-".
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

IC
Information Contact
PER-02
93
Ordering Provider Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

2420E Ordering Provider Name Loop end
2420F Referring Provider Name Loop
OptionalMax 2
Variants (all may be used)
Rendering Provider Name LoopPurchased Service Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopOrdering Provider Name LoopAmbulance Pick-up Location LoopAmbulance Drop-Off Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
  • 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.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
  • Required when the Referring Provider for this line is different than the Referring Provider reported in Loop ID-2310A (claim level) and is available in the payer's system.

If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

DN
Referring Provider

Use on the first iteration of this loop. Use if loop is used only once.

P3
Primary Care Provider

Use only if loop is used twice. Use only on second iteration of this loop.

NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Referring Provider Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Referring Provider First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Referring Provider Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Referring Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 2

To specify identifying information

Usage notes
  • Required when available in the payer's system.
    If not required by this implementation guide, do not send.
  • If, for whatever reason, the data is not stored within the payer's system, do not use.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
G2
Provider Commercial Number

This code designates a proprietary provider number for the submitting payer identified in the Payer Name loop, Loop ID-2330B where 2320 SBR06 equals 6. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

2420F Referring Provider Name Loop end
2420G Ambulance Pick-up Location Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopPurchased Service Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopOrdering Provider Name LoopReferring Provider Name LoopAmbulance Drop-Off Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > NM1

Ambulance Pick-up Location

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location reported in Loop ID-2310E and is available in the payer's system. If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

PW
Pickup Address
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N3

Ambulance Pick-up Location Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Ambulance Pick-up Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Ambulance Pick-up Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N4

Ambulance Pick-up Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of Ambulance Pick-up State or Province Code (N4-02) or Ambulance Pick-up Country Subdivision Code (N4-07) may be present
If Ambulance Pick-up Country Subdivision Code (N4-07) is present, then Ambulance Pick-up Country Code (N4-04) is required
N4-01
19
Ambulance Pick-up City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Ambulance Pick-up State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Ambulance Pick-up Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Ambulance Pick-up Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Ambulance Pick-up Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2420G Ambulance Pick-up Location Loop end
2420H Ambulance Drop-Off Location Loop
OptionalMax 1
Variants (all may be used)
Rendering Provider Name LoopPurchased Service Provider Name LoopService Facility Location Name LoopSupervising Provider Name LoopOrdering Provider Name LoopReferring Provider Name LoopAmbulance Pick-up Location Loop
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-Off Location Loop > NM1

Ambulance Drop-Off Location

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location reported in Loop ID-2310F and is available in the payer's system. If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

45
Drop-off Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Ambulance Drop-off Location
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-Off Location Loop > N3

Ambulance Drop-Off Location Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Ambulance Drop-off Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Ambulance Drop-off Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-Off Location Loop > N4

Ambulance Drop-Off Location City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of Ambulance Drop-off State or Province Code (N4-02) or Ambulance Drop-off Country Subdivision Code (N4-07) may be present
If Ambulance Drop-off Country Subdivision Code (N4-07) is present, then Ambulance Drop-off Country Code (N4-04) is required
N4-01
19
Ambulance Drop-off City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Ambulance Drop-off State or Province Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Ambulance Drop-off Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Ambulance Drop-off Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Ambulance Drop-off Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2420H Ambulance Drop-Off Location Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD

Line Adjudication Information

RequiredMax use 1

To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

Usage notes
  • 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.

Example
SVD-01
67
Other Payer Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • SVD01 is the payer identification code.
Usage notes
  • 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).
SVD-02
782
Service Line Paid Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVD02 is the amount paid for this service line.
Usage notes
  • Zero "0" is an acceptable value for this element.
SVD-03
C003
Composite Medical Procedure Identifier
Required
To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
ER
Jurisdiction Specific Procedure and Supply Codes
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

WK
Advanced Billing Concepts (ABC) Codes
C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-03 modifies the value in C003-02 and C003-08.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-04 modifies the value in C003-02 and C003-08.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-05 modifies the value in C003-02 and C003-08.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-06 modifies the value in C003-02 and C003-08.
SVD-05
380
Paid Service Unit Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SVD05 is the paid units of service.
Usage notes
  • 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.
SVD-06
554
Bundled or Unbundled Line Number
Optional
Numeric (N0)
Min 1Max 6

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.
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS

Line Adjustment

OptionalMax use 5

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

Usage notes
  • 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.
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
CAS-01
1033
Claim Adjustment Group Code
Required
Identifier (ID)

Code identifying the general category of payment adjustment

CO
Contractual Obligations
OA
Other adjustments
PI
Payor Initiated Reductions
PR
Patient Responsibility
CAS-02
1034
Adjustment Reason Code
Required
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

CAS-03
782
Adjustment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS03 is the amount of adjustment.
CAS-04
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS04 is the units of service being adjusted.
CAS-05
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-06
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS06 is the amount of the adjustment.
CAS-07
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS07 is the units of service being adjusted.
CAS-08
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-09
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS09 is the amount of the adjustment.
CAS-10
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS10 is the units of service being adjusted.
CAS-11
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-12
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS12 is the amount of the adjustment.
CAS-13
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS13 is the units of service being adjusted.
CAS-14
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-15
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS15 is the amount of the adjustment.
CAS-16
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS16 is the units of service being adjusted.
CAS-17
1034
Adjustment Reason Code
Optional
Identifier (ID)
Min 1Max 5

Code identifying the detailed reason the adjustment was made

Usage notes
  • See CODE SOURCE 139: Claim Adjustment Reason Code
CAS-18
782
Adjustment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • CAS18 is the amount of the adjustment.
CAS-19
380
Adjustment Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CAS19 is the units of service being adjusted.
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP

Line Check or Remittance Date

RequiredMax use 1

To specify any or all of a date, a time, or a time period

Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

573
Date Claim Paid
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Adjudication or Payment Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT

Remaining Patient Liability

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer 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.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

EAF
Amount Owed
AMT-02
782
Remaining Patient Liability
Required
Decimal number (R)
Min 1Max 15

Monetary amount

2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000C Patient Hierarchical Level Loop end
2000B Subscriber Hierarchical Level Loop end
2000A Billing Provider Hierarchical Level Loop end
SE
5550
Detail > SE

Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Example
SE-01
96
Transaction Segment Count
Required
Numeric (N0)
Min 1Max 10

Total number of segments included in a transaction set including ST and SE segments

SE-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Detail end
GE

Functional Group Trailer

RequiredMax use 1

To indicate the end of a functional group and to provide control information

Example
GE-01
97
Number of Transaction Sets Included
Required
Numeric (N0)
Min 1Max 6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

GE-02
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Example
IEA-01
I16
Number of Included Functional Groups
Required
Numeric (N0)
Min 1Max 5

A count of the number of functional groups included in an interchange

IEA-02
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

EDI Samples

Adjudicated Claim submitted to All Payer Claim Data Base (APCD)

ST*837*0021*005010X298A1~
BHT*0019*00*244579*20120315*1023*RP~
NM1*41*2*ABC PLAN*****46*TGJ23~
PER*IC*IT GROUP*TE*3055552222*EX*231~
NM1*40*2*REPORTING ENTITY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*207Q00000X~
NM1*85*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*N~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*F~
NM1*ZD*2*DATA RECEIVER~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19730501*M~
CLM*26463774*100***11>B>1~
REF*F8*20121092600001~
HI*ABK>M25375*ABF>M19072~
NM1*82*1*JONES*BARNABY****XX*1234567890~
NM1*77*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
SBR*P*19*2222-SJ***6***CI~
AMT*D*75~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*ABC PLAN*****PI*59999~
DTP*573*D8*20120314~
REF*F8*20121092600001~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
LX*1~
SV1*HC>99213*100*UN*1*11**1**Y**Y*Y~
DTP*472*D8*20120204~
SVD*59999*75*HC>99213**1~
CAS*CO*45*25~
DTP*573*D8*20120314~
SE*49*0021~

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