X12 HIPAA
/
Post-adjudicated Claims Data Reporting: Professional (X298A1)
  • Specification
  • EDI Inspector
Import
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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
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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 - Onset of Current Illness or Symptom
    Max use 1
    Optional
    DTP
    1350
    Date - Initial Treatment Date
    Max use 1
    Optional
    DTP
    1350
    Date - Last Seen Date
    Max use 1
    Optional
    DTP
    1350
    Date - Acute Manifestation
    Max use 1
    Optional
    DTP
    1350
    Date - Accident
    Max use 1
    Optional
    DTP
    1350
    Date - Last Menstrual Period
    Max use 1
    Optional
    DTP
    1350
    Date - Last X-ray Date
    Max use 1
    Optional
    DTP
    1350
    Date - Hearing and Vision Prescription Date
    Max use 1
    Optional
    DTP
    1350
    Date - Disability Dates
    Max use 1
    Optional
    DTP
    1350
    Date - Last Worked
    Max use 1
    Optional
    DTP
    1350
    Date - Authorized Return to Work
    Max use 1
    Optional
    DTP
    1350
    Date - Admission
    Max use 1
    Optional
    DTP
    1350
    Date - Discharge
    Max use 1
    Optional
    DTP
    1350
    Date - Assumed and Relinquished Care Dates
    Max use 2
    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
    Service Authorization Exception Code
    Max use 1
    Optional
    REF
    1800
    Mammography Certification Number
    Max use 1
    Optional
    REF
    1800
    Referral 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
    Repriced Claim Number
    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
    Medical Record Number
    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 - 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 - Last Seen Date
    Max use 1
    Optional
    DTP
    4550
    Date - Test Date
    Max use 2
    Optional
    DTP
    4550
    Date - Shipped Date
    Max use 1
    Optional
    DTP
    4550
    Date - Last X-ray Date
    Max use 1
    Optional
    DTP
    4550
    Date - Initial Treatment Date
    Max use 1
    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
    Repriced Line Item Reference Number
    Max use 1
    Optional
    REF
    4700
    Adjusted Repriced Line Item Reference Number
    Max use 1
    Optional
    REF
    4700
    Prior Authorization
    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
    Clinical Laboratory Improvement Amendment (CLIA) Number
    Max use 1
    Optional
    REF
    4700
    Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
    Max use 1
    Optional
    REF
    4700
    Immunization Batch Number
    Max use 1
    Optional
    REF
    4700
    Referral 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

    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
    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

    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
    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
    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
    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
    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
    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
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    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

    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
    Min 9Max 9

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    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
    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
    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

    Code identifying a group of application related transaction sets

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

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

    GS-03
    124
    Application Receiver's Code
    Required
    Min 2Max 15

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

    GS-04
    373
    Date
    Required
    CCYYMMDD format

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

    GS-05
    337
    Time
    Required
    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
    Min 1Max 9

    Assigned number originated and maintained by the sender

    GS-07
    455
    Responsible Agency Code
    Required
    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

    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

    005010X298

    Heading

    ST
    0050

    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

    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
    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

    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.
    005010X298
    BHT
    0100

    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

    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

    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
    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
    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
    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

    Code specifying the type of transaction

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

    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

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

    41
    Submitter
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

    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
    Min 2Max 80

    Code identifying a party or other code

    PER
    0450

    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

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

    IC
    Information Contact
    PER-02
    93
    Submitter Contact Name
    Optional
    Min 1Max 60

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    1000B Receiver Name Loop
    RequiredMax 1
    Variants (all may be used)
    1000ASubmitter Name Loop
    NM1
    0200

    Receiver Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    40
    Receiver
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

    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
    Min 2Max 80

    Code identifying a party or other code

    Detail

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

    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
    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

    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

    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

    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

    Code identifying the type of provider

    BI
    Billing
    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    PXC
    Health Care Provider Taxonomy Code
    PRV-03
    127
    Provider Taxonomy Code
    Required
    Min 1Max 50

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

    CUR
    0100

    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

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

    85
    Billing Provider
    CUR-02
    100
    Currency Code
    Required
    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

    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

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

    85
    Billing Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    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
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Billing Provider First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Billing Provider Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Billing Provider Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    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
    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

    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
    Min 1Max 55

    Address information

    N3-02
    166
    Billing Provider Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    0300

    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
    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
    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
    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
    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
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    REF
    0350

    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

    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
    Min 1Max 50

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

    REF
    0350

    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

    Code qualifying the Reference Identification

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

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

    REF
    0350

    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

    Code qualifying the Reference Identification

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

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

    2000B Subscriber Hierarchical Level Loop
    RequiredMax >1
    HL
    0010

    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
    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
    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

    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

    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

    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

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

    N
    Unconfirmed
    SBR-02
    1069
    Individual Relationship Code
    Optional

    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)
    2010BBData Receiver Loop
    NM1
    0150

    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

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

    IL
    Insured or Subscriber
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-04
    1036
    Subscriber First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Subscriber Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Subscriber Name Suffix
    Optional
    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

    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
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    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
    Min 1Max 55

    Address information

    N3-02
    166
    Subscriber Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    0300

    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
    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
    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
    Min 3Max 15

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

    N4-04
    26
    Country Code
    Optional
    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
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    DMG
    0320

    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

    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
    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

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    REF
    0350

    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

    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
    Min 1Max 50

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

    REF
    0350

    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

    Code qualifying the Reference Identification

    Y4
    Agency Claim Number
    REF-02
    127
    Property Casualty Claim Number
    Required
    Min 1Max 50

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

    2010BB Data Receiver Loop
    RequiredMax 1
    Variants (all may be used)
    2010BASubscriber Name Loop
    NM1
    0150

    Data Receiver

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    ZD
    Party to Receive Reports
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    2000C Patient Hierarchical Level Loop
    OptionalMax >1
    HL
    0010

    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
    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
    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

    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

    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

    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

    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

    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

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

    QC
    Patient
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-04
    1036
    Patient First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Patient Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Patient Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    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
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    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
    Min 1Max 55

    Address information

    N3-02
    166
    Patient Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    0300

    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
    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
    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
    Min 3Max 15

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

    N4-04
    26
    Country Code
    Optional
    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
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    DMG
    0320

    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

    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
    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

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    REF
    0350

    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

    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
    Min 1Max 50

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

    REF
    0350

    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

    Code qualifying the Reference Identification

    Y4
    Agency Claim Number
    REF-02
    127
    Property Casualty Claim Number
    Required
    Min 1Max 50

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

    2300 Claim Information Loop
    RequiredMax 100
    CLM
    1300

    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
    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
    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
    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
    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

    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
    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

    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

    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

    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

    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

    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
    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

    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
    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
    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
    Min 2Max 3

    Code identifying the country

    CLM-12
    1366
    Special Program Indicator
    Optional

    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

    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

    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 - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    454
    Initial Treatment
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    439
    Accident
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    471
    Prescription
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    435
    Admission
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    096
    Discharge
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Repricer Received Date
    DTP-01
    374
    Date Time Qualifier
    Required

    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

    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
    Min 1Max 35

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

    DTP
    1350

    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 - Onset of Current Illness or SymptomDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Acute ManifestationDTPDate - AccidentDTPDate - Last Menstrual PeriodDTPDate - Last X-ray DateDTPDate - Hearing and Vision Prescription DateDTPDate - Disability DatesDTPDate - Last WorkedDTPDate - Authorized Return to WorkDTPDate - AdmissionDTPDate - DischargeDTPDate - Assumed and Relinquished Care DatesDTPDate - Property and Casualty Date of First Contact
    DTP-01
    374
    Date Time Qualifier
    Required

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

    050
    Received
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    Min 1Max 35

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

    PWK
    1550

    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

    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

    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

    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
    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

    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

    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
    Min 1Max 15

    Monetary amount

    • CN102 is the contract amount.
    CN1-03
    332
    Contract Percentage
    Optional
    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
    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
    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
    Min 1Max 30

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

    • CN106 is an additional identifying number for the contract.
    AMT
    1750

    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

    Code to qualify amount

    F5
    Patient Amount Paid
    AMT-02
    782
    Patient Amount Paid
    Required
    Min 1Max 15

    Monetary amount

    REF
    1800

    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)
    REFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    4N
    Special Payment Reference Number
    REF-02
    127
    Service Authorization Exception Code
    Required
    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
    REF
    1800

    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)
    REFService Authorization Exception CodeREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EW
    Mammography Certification Number
    REF-02
    127
    Mammography Certification Number
    Required
    Min 1Max 50

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    9F
    Referral Number
    REF-02
    127
    Referral Number
    Required
    Min 1Max 50

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    G1
    Prior Authorization Number
    REF-02
    127
    Prior Authorization Number
    Required
    Min 1Max 50

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    X4
    Clinical Laboratory Improvement Amendment Number
    REF-02
    127
    Clinical Laboratory Improvement Amendment Number
    Required
    Min 1Max 50

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    9A
    Repriced Claim Reference Number
    REF-02
    127
    Repriced Claim Reference Number
    Required
    Min 1Max 50

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFMedical Record Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    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
    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

    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)
    REFService Authorization Exception CodeREFMammography Certification NumberREFReferral NumberREFPrior AuthorizationREFPayer Claim Control NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFRepriced Claim NumberREFAdjusted Repriced Claim NumberREFInvestigational Device Exemption NumberREFClaim Identifier For Transmission Intermediaries
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EA
    Medical Record Identification Number
    REF-02
    127
    Medical Record Number
    Required
    Min 1Max 50

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

    K3
    1850

    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
    Min 1Max 80

    Data in fixed format agreed upon by sender and receiver

    NTE
    1900

    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

    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
    Min 1Max 80

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

    CR1
    1950

    Ambulance Transport Information

    OptionalMax use 1

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

    Usage notes
    • 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

    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
    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

    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

    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
    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
    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
    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

    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

    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
    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
    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

    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

    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

    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

    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
    Min 2Max 3

    Code indicating a condition

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

    Code indicating a condition

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

    Code indicating a condition

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

    Code indicating a condition

    Usage notes
    • Use the codes listed in CRC03.
    CRC
    2200

    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

    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

    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

    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
    Min 2Max 3

    Code indicating a condition

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

    Code indicating a condition

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

    Code indicating a condition

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

    Code indicating a condition

    Usage notes
    • Use the codes listed in CRC03.
    CRC
    2200

    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

    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

    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

    Code indicating a condition

    IH
    Independent at Home
    CRC
    2200

    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

    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

    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

    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
    Min 2Max 3

    Code indicating a condition

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

    Code indicating a condition

    Usage notes
    • Use the codes listed in CRC03.
    HI
    2310

    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
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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

    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
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    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
    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
    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

    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
    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

    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
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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

    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
    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
    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