X12 HIPAA
/
Status Request Response (X212)
  • Specification
  • EDI Inspector
Import guide into your account
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X12 277 Status Request Response (X212)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Information Status Notification Transaction Set (277) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a health care claim or encounter or to request additional information from the provider regarding a health care claim or encounter, health care services review, or transactions related to the provisions of health care. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, will not be used for account payment posting. The notification may be at a summary or service line detail level. The notification may be solicited or unsolicited.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
  • Example 1: Claim Level Status
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
Information Source Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Information Receiver Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Information Receiver Trace Identifier Loop
Service Provider Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Subscriber Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
SE
2700
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

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

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

Code identifying the type of information in the Authorization Information

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

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

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

Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

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

Date of the interchange

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

Time of the interchange

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

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

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

Code specifying the version number of the interchange control segments

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

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

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

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

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

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

>
Component Element Separator

Functional Group Header

RequiredMax use 1

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

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

Code identifying a group of application related transaction sets

HN
Health Care Information Status Notification (277)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

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

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

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

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

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

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

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

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

Assigned number originated and maintained by the sender

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

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

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

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

005010X212

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

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

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

Code uniquely identifying a Transaction Set

  • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
277
Health Care Information Status Notification
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

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

Usage notes
  • The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there.
ST-03
1705
Version, Release, or Industry Identifier
Required
String (AN)

Reference assigned to identify Implementation Convention

  • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
Usage notes
  • This element must be populated with the implementation guide Version/Release/Industry Identifier Code 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 utilized at translation time.
005010X212
BHT
0200
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

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

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

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

0010
Information Source, Information Receiver, Provider of Service, Subscriber, Dependent
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

08
Status
BHT-03
127
Originator Application Transaction Identifier
Required
String (AN)
Min 1Max 50

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

  • BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

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

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

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

  • BHT05 is the time the transaction was created within the business application system.
BHT-06
640
Transaction Type Code
Required
Identifier (ID)

Code specifying the type of transaction

DG
Response
Heading end

Detail

2000A Information Source Level Loop
RequiredMax >1
HL
0100
Detail > Information Source Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2100A Payer Name Loop
RequiredMax 1
NM1
0500
Detail > Information Source Level Loop > Payer Name Loop > NM1

Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

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

PI
Payor Identification

Payer identification number established through trading partner agreement.

XV
Centers for Medicare and Medicaid Services PlanID

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

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

Code identifying a party or other code

PER
0800
Detail > Information Source Level Loop > Payer Name Loop > PER

Payer Contact Information

OptionalMax use 1

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

Usage notes
  • Required when the payer's contact information is not otherwise specified in a Trading Partner Agreement and the Information Receiver does not know how to contact the payer. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. A telephone extension, when applicable is reported in the communication number immediately after the telephone number.
Example
If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

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

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

Free-form name

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

Code identifying the type of communication number

ED
Electronic Data Interchange Access Number
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Payer Contact Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

Usage notes
  • When an extension or additional contact number is required, use PER06.
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

2100A Payer Name Loop end
2000B Information Receiver Level Loop
RequiredMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
21
Information Receiver
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2100B Information Receiver Name Loop
RequiredMax 1
NM1
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

Information Receiver Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This is the individual or organization requesting to receive the status information.;
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

NM1-05
1037
Information Receiver Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

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

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

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

Code identifying a party or other code

Usage notes
  • The ETIN is established through Trading Partner agreement.
2100B Information Receiver Name Loop end
2200B Information Receiver Trace Identifier Loop
OptionalMax 1
TRN
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Trace Identifier Loop > TRN

Information Receiver Trace Identifier

RequiredMax use 1

To uniquely identify a transaction to an application

Usage notes
  • Required when rejecting claim status requests for errors at Information Source or Information Receiver levels. If not required by this implementation guide, do not send.
  • If reporting error status at this level, 2000C, 2000D and 2000E Loops are not used.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

2
Referenced Transaction Trace Numbers
TRN-02
127
Claim Transaction Batch Number
Required
String (AN)
Min 1Max 50

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

  • TRN02 provides unique identification for the transaction.
Usage notes
  • This value must be the BHT03 data element value from the 276 Claim Status Request being rejected.
STC
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Trace Identifier Loop > STC

Information Receiver Status Information

RequiredMax use >1

To report the status, required action, and paid information of a claim or service line

Usage notes
  • See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Example
STC-01
C043
Health Care Claim Status
Required
Used to convey status of the entire claim or a specific service line
C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • Only the D0' Category Code and E' Category Codes are allowable at this level.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
41
Submitter
AY
Clearinghouse
PR
Payer
STC-02
373
Status Information Effective Date
Required
Date (DT)
CCYYMMDD format

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

  • STC02 is the effective date of the status information.
STC-10
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a second status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
STC-11
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a third status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
2200B Information Receiver Trace Identifier Loop end
2000C Service Provider Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
19
Provider of Service
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2100C Provider Name Loop
RequiredMax 2
NM1
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider Name Loop > NM1

Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
  • After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop may be sent with the NPI reported in the NM109 and NM108=XX.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

1P
Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

FI
Federal Taxpayer's Identification Number
SV
Service Provider Number
XX
Centers for Medicare and Medicaid Services National Provider Identifier

Required value when the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes must be used.

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

Code identifying a party or other code

2100C Provider Name Loop end
2200C Provider of Service Trace Identifier Loop
OptionalMax 1
TRN
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider of Service Trace Identifier Loop > TRN

Provider of Service Trace Identifier

RequiredMax use 1

To uniquely identify a transaction to an application

Usage notes
  • Required when rejecting the claim status request(s) for errors at the provider level. If not required by this implementation guide, do not send.
  • If reporting error status at this level, the 2000D and 2000E Loops related to this provider are not used.
  • The TRN Segment is syntactically required in order to use the Loop 2200C STC. TRN02 can be either a default value of zero (0) or any value the Information Source chooses to assign.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers
TRN-02
127
Provider of Service Information Trace Identifier
Required
String (AN)
Min 1Max 50

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

  • TRN02 provides unique identification for the transaction.
STC
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider of Service Trace Identifier Loop > STC

Provider Status Information

RequiredMax use >1

To report the status, required action, and paid information of a claim or service line

Usage notes
  • See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Example
STC-01
C043
Health Care Claim Status
Required
Used to convey status of the entire claim or a specific service line
C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • Only the D0' Category Code and E' Category Codes are allowable at this level.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
1P
Provider
STC-02
373
Status Information Effective Date
Required
Date (DT)
CCYYMMDD format

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

  • STC02 is the effective date of the status information.
STC-10
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a second status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid value.
STC-11
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a third status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid value.
2200C Provider of Service Trace Identifier Loop end
2000D Subscriber Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2100D Subscriber Name Loop
RequiredMax 1
NM1
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity

Use the value "2" in an employer-subscriber situation, such as Worker's Compensation.

NM1-03
1035
Subscriber Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

24
Employer's Identification Number

This code may be used in conjunction with a workers compensation claim.

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

Required if the HIPAA Individual Patient Identifier is mandated for use. If not required, use one of the other values.

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

Code identifying a party or other code

2100D Subscriber Name Loop end
2200D Claim Status Tracking Number Loop
OptionalMax >1
TRN
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > TRN

Claim Status Tracking Number

RequiredMax use 1

To uniquely identify a transaction to an application

Usage notes
  • This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.
  • Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.
  • When the patient is not the subscriber or a dependent with a unique identification number, the Loop 2200E TRN and subsequent segments will be used to reflect the claim status information.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

2
Referenced Transaction Trace Numbers
TRN-02
127
Referenced Transaction Trace Number
Required
String (AN)
Min 1Max 50

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

  • TRN02 provides unique identification for the transaction.
STC
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > STC

Claim Level Status Information

RequiredMax use >1

To report the status, required action, and paid information of a claim or service line

Usage notes
  • See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Example
STC-01
C043
Health Care Claim Status
Required
Used to convey status of the entire claim or a specific service line
C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
1E
Health Maintenance Organization (HMO)
1G
Oncology Center
1H
Kidney Dialysis Unit
1I
Preferred Provider Organization (PPO)
1O
Acute Care Hospital
1P
Provider
1Q
Military Facility
1R
University, College or School
1S
Outpatient Surgicenter
1T
Physician, Clinic or Group Practice
1U
Long Term Care Facility
1V
Extended Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
1Y
Retail Pharmacy
1Z
Home Health Care
2A
Federal, State, County or City Facility
2B
Third-Party Administrator
2D
Miscellaneous Health Care Facility
2E
Non-Health Care Miscellaneous Facility
2I
Church Operated Facility
2K
Partnership
2P
Public Health Service Facility
2Q
Veterans Administration Facility
2S
Public Health Service Indian Service Facility
2Z
Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
03
Dependent
3A
Hospital Unit Within an Institution for the Mentally Retarded
3C
Tuberculosis and Other Respiratory Diseases Facility
3D
Obstetrics and Gynecology Facility
3E
Eye, Ear, Nose and Throat Facility
3F
Rehabilitation Facility
3G
Orthopedic Facility
3H
Chronic Disease Facility
3I
Other Specialty Facility
3J
Children's General Facility
3K
Children's Hospital Unit of an Institution
3L
Children's Psychiatric Facility
3M
Children's Tuberculosis and Other Respiratory Diseases Facility
3N
Children's Eye, Ear, Nose and Throat Facility
3O
Children's Rehabilitation Facility
3P
Children's Orthopedic Facility
3Q
Children's Chronic Disease Facility
3R
Children's Other Specialty Facility
3S
Institution for Mental Retardation
3T
Alcoholism and Other Chemical Dependency Facility
3U
General Inpatient Care for AIDS/ARC Facility
3V
AIDS/ARC Unit
3W
Specialized Outpatient Program for AIDS/ARC
3X
Alcohol/Drug Abuse or Dependency Inpatient Unit
3Y
Alcohol/Drug Abuse or Dependency Outpatient Services
3Z
Arthritis Treatment Center
4A
Birthing Room/LDRP Room
4B
Burn Care Unit
4C
Cardiac Catherization Laboratory
4D
Open-Heart Surgery Facility
4E
Cardiac Intensive Care Unit
4F
Angioplasty Facility
4G
Chronic Obstructive Pulmonary Disease Service Facility
4H
Emergency Department
4I
Trauma Center (Certified)
4J
Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
4L
Genetic Counseling/Screening Services
4M
Adult Day Care Program Facility
4N
Alzheimer's Diagnostic/Assessment Services
4O
Comprehensive Geriatric Assessment Facility
4P
Emergency Response (Geriatric) Unit
4Q
Geriatric Acute Care Unit
4R
Geriatric Clinics
4S
Respite Care Facility
4U
Patient Education Unit
4V
Community Health Promotion Facility
4W
Worksite Health Promotion Facility
4X
Hemodialysis Facility
4Y
Home Health Services
4Z
Hospice
5A
Medical Surgical or Other Intensive Care Unit
5B
Hisopathology Laboratory
5C
Blood Bank
5D
Neonatal Intensive Care Unit
5E
Obstetrics Unit
5F
Occupational Health Services
5G
Organized Outpatient Services
5H
Pediatric Acute Inpatient Unit
5I
Psychiatric Child/Adolescent Services
5J
Psychiatric Consultation-Liaison Services
5K
Psychiatric Education Services
5L
Psychiatric Emergency Services
5M
Psychiatric Geriatric Services
5N
Psychiatric Inpatient Unit
5O
Psychiatric Outpatient Services
5P
Psychiatric Partial Hospitalization Program
5Q
Megavoltage Radiation Therapy Unit
5R
Radioactive Implants Unit
5S
Therapeutic Radioisotope Facility
5T
X-Ray Radiation Therapy Unit
5U
CT Scanner Unit
5V
Diagnostic Radioisotope Facility
5W
Magnetic Resonance Imaging (MRI) Facility
5X
Ultrasound Unit
5Y
Rehabilitation Inpatient Unit
5Z
Rehabilitation Outpatient Services
6A
Reproductive Health Services
6B
Skilled Nursing or Other Long-Term Care Unit
6C
Single Photon Emission Computerized Tomography (SPECT) Unit
6D
Organized Social Work Service Facility
6E
Outpatient Social Work Services
6F
Emergency Department Social Work Services
6G
Sports Medicine Clinic/Services
6H
Hospital Auxiliary Unit
6I
Patient Representative Services
6J
Volunteer Services Department
6K
Outpatient Surgery Services
6L
Organ/Tissue Transplant Unit
6M
Orthopedic Surgery Facility
6N
Occupational Therapy Services
6O
Physical Therapy Services
6P
Recreational Therapy Services
6Q
Respiratory Therapy Services
6R
Speech Therapy Services
6S
Women's Health Center/Services
6U
Cardiac Rehabilitation Program Facility
6V
Non-Invasive Cardiac Assessment Services
6W
Emergency Medical Technician
6X
Disciplinary Contact
6Y
Case Manager
7C
Place of Occurrence
13
Contracted Service Provider
17
Consultant's Office
28
Subcontractor
30
Service Supplier
36
Employer
40
Receiver
43
Claimant Authorized Representative
44
Data Processing Service Bureau
61
Performed At
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
80
Hospital
82
Rendering Provider
84
Subscriber's Employer
85
Billing Provider
87
Pay-to Provider
95
Research Institute
CK
Pharmacist
CZ
Admitting Surgeon
D2
Commercial Insurer
DD
Assistant Surgeon
DJ
Consulting Physician
DK
Ordering Physician
DN
Referring Provider
DO
Dependent Name
DQ
Supervising Physician
E1
Person or Other Entity Legally Responsible for a Child
E2
Person or Other Entity With Whom a Child Resides
E7
Previous Employer
E9
Participating Laboratory
FA
Facility
FD
Physical Address
FE
Mail Address
G0
Dependent Insured
G3
Clinic
GB
Other Insured
GD
Guardian
GI
Paramedic
GJ
Paramedical Company
GK
Previous Insured
GM
Spouse Insured
GY
Treatment Facility
HF
Healthcare Professional Shortage Area (HPSA) Facility
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IJ
Injection Point
IL
Insured or Subscriber
IN
Insurer
LI
Independent Lab
LR
Legal Representative
MR
Medical Insurance Carrier
MSC
Mammography Screening Center
OB
Ordered By
OD
Doctor of Optometry
OX
Oxygen Therapy Facility
P0
Patient Facility
P2
Primary Insured or Subscriber
P3
Primary Care Provider
P4
Prior Insurance Carrier
P6
Third Party Reviewing Preferred Provider Organization (PPO)
P7
Third Party Repricing Preferred Provider Organization (PPO)
PRP
Primary Payer
PT
Party to Receive Test Report
PV
Party performing certification
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QD
Responsible Party
QE
Policyholder
QH
Physician
QK
Managed Care
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QV
Group Practice
QY
Medical Doctor
RC
Receiving Location
RW
Rural Health Clinic
S4
Skilled Nursing Facility
SEP
Secondary Payer
SJ
Service Provider
SU
Supplier/Manufacturer
T4
Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

TL
Testing Laboratory
TQ
Third Party Reviewing Organization (TPO)
TT
Transfer To
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
UH
Nursing Home
X3
Utilization Management Organization
X4
Spouse
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-02
373
Status Information Effective Date
Required
Date (DT)
CCYYMMDD format

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

  • STC02 is the effective date of the status information.
Usage notes
  • This is the date the claim was placed in this status by the Information Source's adjudication process.
STC-04
782
Total Claim Charge Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • STC04 is the amount of original submitted charges.
Usage notes
  • The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
STC-05
782
Claim Payment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • STC05 is the amount paid.
Usage notes
  • Zero is an acceptable amount when no payment is being made.
  • Some payers are able to provide the adjudicated payment amount prior to the remittance being issued.
STC-06
373
Adjudication Finalized Date
Optional
Date (DT)
CCYYMMDD format

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

  • STC06 is the paid date.
Usage notes
  • This is the date of denial or approval for the claim. This date may or may not be the same as the issue date of the check, EFT or non-payment remittance (STC08).
  • Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.
STC-08
373
Remittance Date
Optional
Date (DT)
CCYYMMDD format

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

  • STC08 is the check issue date.
Usage notes
  • This is the check issue or EFT funds available date.
  • This could include a non-payment remittance advice date if available from the Information Source's system.
STC-09
429
Remittance Trace Number
Optional
String (AN)
Min 1Max 16

Check identification number

Usage notes
  • This is the check or EFT Trace Number.
  • This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.
STC-10
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a second claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-11
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a third claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when received on the 276 status request. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription NumberREFVoucher Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

D9
Claim Number
REF-02
127
Clearinghouse Trace Number
Required
String (AN)
Min 1Max 50

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Institutional Bill Type Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required on institutional claims when different than the value submitted on the 276 request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BLT
Billing Type
REF-02
127
Bill Type Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
    Code Source 236: Uniform Billing Claim Form Bill Type
    Code Source 235: Claim Frequency Type Code
REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Patient Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Patient Control Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
  • The maximum number of characters supported for the Patient Control Number is `20'.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EJ
Patient Account Number
REF-02
127
Patient Control Number
Required
String (AN)
Min 1Max 50

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.
  • This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Pharmacy Prescription Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Pharmacy Prescription Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

XZ
Pharmacy Prescription Number
REF-02
127
Pharmacy Prescription Number
Required
String (AN)
Min 1Max 50

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Voucher Identifier

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.
  • Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

VV
Voucher
REF-02
127
Voucher Identifier
Required
String (AN)
Min 1Max 50

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

DTP
1200
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > DTP

Claim Service Date

OptionalMax use 1

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

Usage notes
  • For professional claims, this date is derived from the service level dates.
  • When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.
  • Required for institutional claims or for professional and dental claims when the service line date is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

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

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

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

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

2220D Service Line Information Loop
OptionalMax >1
SVC
1800
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

Service Line Information

RequiredMax use 1

To supply payment and control information to a provider for a particular service

Usage notes
  • Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
  • For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
Example
SVC-01
C003
Composite Medical Procedure Identifier
Required
To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
AD
American Dental Association Codes
ER
Jurisdiction Specific Procedure and Supply Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

N4
National Drug Code in 5-4-2 Format
NU
National Uniform Billing Committee (NUBC) UB92 Codes

This code is the NUBC Revenue Code.

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
Usage notes
  • If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-03 modifies the value in C003-02 and C003-08.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-04 modifies the value in C003-02 and C003-08.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-05 modifies the value in C003-02 and C003-08.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-06 modifies the value in C003-02 and C003-08.
SVC-02
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVC02 is the submitted service charge.
Usage notes
  • This is the line item total on the current claim service status.
SVC-03
782
Line Item Payment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVC03 is the amount paid this service.
SVC-04
234
Revenue Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • SVC04 is the National Uniform Billing Committee Revenue Code.
SVC-07
380
Units of Service Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SVC07 is the original submitted units of service.
STC
1900
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > STC

Service Line Status Information

RequiredMax use >1

To report the status, required action, and paid information of a claim or service line

Usage notes
  • See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Example
STC-01
C043
Health Care Claim Status
Required
Used to convey status of the entire claim or a specific service line
C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
1E
Health Maintenance Organization (HMO)
1G
Oncology Center
1H
Kidney Dialysis Unit
1I
Preferred Provider Organization (PPO)
1O
Acute Care Hospital
1P
Provider
1Q
Military Facility
1R
University, College or School
1S
Outpatient Surgicenter
1T
Physician, Clinic or Group Practice
1U
Long Term Care Facility
1V
Extended Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
1Y
Retail Pharmacy
1Z
Home Health Care
2A
Federal, State, County or City Facility
2B
Third-Party Administrator
2D
Miscellaneous Health Care Facility
2E
Non-Health Care Miscellaneous Facility
2I
Church Operated Facility
2K
Partnership
2P
Public Health Service Facility
2Q
Veterans Administration Facility
2S
Public Health Service Indian Service Facility
2Z
Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
03
Dependent
3A
Hospital Unit Within an Institution for the Mentally Retarded
3C
Tuberculosis and Other Respiratory Diseases Facility
3D
Obstetrics and Gynecology Facility
3E
Eye, Ear, Nose and Throat Facility
3F
Rehabilitation Facility
3G
Orthopedic Facility
3H
Chronic Disease Facility
3I
Other Specialty Facility
3J
Children's General Facility
3K
Children's Hospital Unit of an Institution
3L
Children's Psychiatric Facility
3M
Children's Tuberculosis and Other Respiratory Diseases Facility
3N
Children's Eye, Ear, Nose and Throat Facility
3O
Children's Rehabilitation Facility
3P
Children's Orthopedic Facility
3Q
Children's Chronic Disease Facility
3R
Children's Other Specialty Facility
3S
Institution for Mental Retardation
3T
Alcoholism and Other Chemical Dependency Facility
3U
General Inpatient Care for AIDS/ARC Facility
3V
AIDS/ARC Unit
3W
Specialized Outpatient Program for AIDS/ARC
3X
Alcohol/Drug Abuse or Dependency Inpatient Unit
3Y
Alcohol/Drug Abuse or Dependency Outpatient Services
3Z
Arthritis Treatment Center
4A
Birthing Room/LDRP Room
4B
Burn Care Unit
4C
Cardiac Catherization Laboratory
4D
Open-Heart Surgery Facility
4E
Cardiac Intensive Care Unit
4F
Angioplasty Facility
4G
Chronic Obstructive Pulmonary Disease Service Facility
4H
Emergency Department
4I
Trauma Center (Certified)
4J
Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
4L
Genetic Counseling/Screening Services
4M
Adult Day Care Program Facility
4N
Alzheimer's Diagnostic/Assessment Services
4O
Comprehensive Geriatric Assessment Facility
4P
Emergency Response (Geriatric) Unit
4Q
Geriatric Acute Care Unit
4R
Geriatric Clinics
4S
Respite Care Facility
4U
Patient Education Unit
4V
Community Health Promotion Facility
4W
Worksite Health Promotion Facility
4X
Hemodialysis Facility
4Y
Home Health Services
4Z
Hospice
5A
Medical Surgical or Other Intensive Care Unit
5B
Hisopathology Laboratory
5C
Blood Bank
5D
Neonatal Intensive Care Unit
5E
Obstetrics Unit
5F
Occupational Health Services
5G
Organized Outpatient Services
5H
Pediatric Acute Inpatient Unit
5I
Psychiatric Child/Adolescent Services
5J
Psychiatric Consultation-Liaison Services
5K
Psychiatric Education Services
5L
Psychiatric Emergency Services
5M
Psychiatric Geriatric Services
5N
Psychiatric Inpatient Unit
5O
Psychiatric Outpatient Services
5P
Psychiatric Partial Hospitalization Program
5Q
Megavoltage Radiation Therapy Unit
5R
Radioactive Implants Unit
5S
Therapeutic Radioisotope Facility
5T
X-Ray Radiation Therapy Unit
5U
CT Scanner Unit
5V
Diagnostic Radioisotope Facility
5W
Magnetic Resonance Imaging (MRI) Facility
5X
Ultrasound Unit
5Y
Rehabilitation Inpatient Unit
5Z
Rehabilitation Outpatient Services
6A
Reproductive Health Services
6B
Skilled Nursing or Other Long-Term Care Unit
6C
Single Photon Emission Computerized Tomography (SPECT) Unit
6D
Organized Social Work Service Facility
6E
Outpatient Social Work Services
6F
Emergency Department Social Work Services
6G
Sports Medicine Clinic/Services
6H
Hospital Auxiliary Unit
6I
Patient Representative Services
6J
Volunteer Services Department
6K
Outpatient Surgery Services
6L
Organ/Tissue Transplant Unit
6M
Orthopedic Surgery Facility
6N
Occupational Therapy Services
6O
Physical Therapy Services
6P
Recreational Therapy Services
6Q
Respiratory Therapy Services
6R
Speech Therapy Services
6S
Women's Health Center/Services
6U
Cardiac Rehabilitation Program Facility
6V
Non-Invasive Cardiac Assessment Services
6W
Emergency Medical Technician
6X
Disciplinary Contact
6Y
Case Manager
7C
Place of Occurrence
13
Contracted Service Provider
17
Consultant's Office
28
Subcontractor
30
Service Supplier
36
Employer
40
Receiver
43
Claimant Authorized Representative
44
Data Processing Service Bureau
61
Performed At
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
80
Hospital
82
Rendering Provider
84
Subscriber's Employer
85
Billing Provider
87
Pay-to Provider
95
Research Institute
CK
Pharmacist
CZ
Admitting Surgeon
D2
Commercial Insurer
DD
Assistant Surgeon
DJ
Consulting Physician
DK
Ordering Physician
DN
Referring Provider
DO
Dependent Name
DQ
Supervising Physician
E1
Person or Other Entity Legally Responsible for a Child
E2
Person or Other Entity With Whom a Child Resides
E7
Previous Employer
E9
Participating Laboratory
FA
Facility
FD
Physical Address
FE
Mail Address
G0
Dependent Insured
G3
Clinic
GB
Other Insured
GD
Guardian
GI
Paramedic
GJ
Paramedical Company
GK
Previous Insured
GM
Spouse Insured
GY
Treatment Facility
HF
Healthcare Professional Shortage Area (HPSA) Facility
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IJ
Injection Point
IL
Insured or Subscriber
IN
Insurer
LI
Independent Lab
LR
Legal Representative
MR
Medical Insurance Carrier
MSC
Mammography Screening Center
OB
Ordered By
OD
Doctor of Optometry
OX
Oxygen Therapy Facility
P0
Patient Facility
P2
Primary Insured or Subscriber
P3
Primary Care Provider
P4
Prior Insurance Carrier
P6
Third Party Reviewing Preferred Provider Organization (PPO)
P7
Third Party Repricing Preferred Provider Organization (PPO)
PRP
Primary Payer
PT
Party to Receive Test Report
PV
Party performing certification
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QD
Responsible Party
QE
Policyholder
QH
Physician
QK
Managed Care
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QV
Group Practice
QY
Medical Doctor
RC
Receiving Location
RW
Rural Health Clinic
S4
Skilled Nursing Facility
SEP
Secondary Payer
SJ
Service Provider
SU
Supplier/Manufacturer
T4
Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

TL
Testing Laboratory
TQ
Third Party Reviewing Organization (TPO)
TT
Transfer To
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
UH
Nursing Home
X3
Utilization Management Organization
X4
Spouse
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-02
373
Status Information Effective Date
Required
Date (DT)
CCYYMMDD format

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

  • STC02 is the effective date of the status information.
Usage notes
  • This is the date the service was placed in this status by the Information Source's adjudication process.
STC-10
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a second claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-11
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a third claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
REF
2000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

Service Line Item Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

FJ
Line Item Control Number
REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50

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

DTP
2100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

Service Line Date

RequiredMax use 1

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

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

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

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

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

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

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

2220D Service Line Information Loop end
2200D Claim Status Tracking Number Loop end
2000E Dependent Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
2100E Dependent Name Loop
RequiredMax 1
NM1
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

Dependent Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

2100E Dependent Name Loop end
2200E Claim Status Tracking Number Loop
RequiredMax >1
TRN
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > TRN

Claim Status Tracking Number

RequiredMax use 1

To uniquely identify a transaction to an application

Usage notes
  • This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

2
Referenced Transaction Trace Numbers
TRN-02
127
Referenced Transaction Trace Number
Required
String (AN)
Min 1Max 50

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

  • TRN02 provides unique identification for the transaction.
STC
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > STC

Claim Level Status Information

RequiredMax use >1

To report the status, required action, and paid information of a claim or service line

Usage notes
  • See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Example
STC-01
C043
Health Care Claim Status
Required
Used to convey status of the entire claim or a specific service line
C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
1E
Health Maintenance Organization (HMO)
1G
Oncology Center
1H
Kidney Dialysis Unit
1I
Preferred Provider Organization (PPO)
1O
Acute Care Hospital
1P
Provider
1Q
Military Facility
1R
University, College or School
1S
Outpatient Surgicenter
1T
Physician, Clinic or Group Practice
1U
Long Term Care Facility
1V
Extended Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
1Y
Retail Pharmacy
1Z
Home Health Care
2A
Federal, State, County or City Facility
2B
Third-Party Administrator
2D
Miscellaneous Health Care Facility
2E
Non-Health Care Miscellaneous Facility
2I
Church Operated Facility
2K
Partnership
2P
Public Health Service Facility
2Q
Veterans Administration Facility
2S
Public Health Service Indian Service Facility
2Z
Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
03
Dependent
3A
Hospital Unit Within an Institution for the Mentally Retarded
3C
Tuberculosis and Other Respiratory Diseases Facility
3D
Obstetrics and Gynecology Facility
3E
Eye, Ear, Nose and Throat Facility
3F
Rehabilitation Facility
3G
Orthopedic Facility
3H
Chronic Disease Facility
3I
Other Specialty Facility
3J
Children's General Facility
3K
Children's Hospital Unit of an Institution
3L
Children's Psychiatric Facility
3M
Children's Tuberculosis and Other Respiratory Diseases Facility
3N
Children's Eye, Ear, Nose and Throat Facility
3O
Children's Rehabilitation Facility
3P
Children's Orthopedic Facility
3Q
Children's Chronic Disease Facility
3R
Children's Other Specialty Facility
3S
Institution for Mental Retardation
3T
Alcoholism and Other Chemical Dependency Facility
3U
General Inpatient Care for AIDS/ARC Facility
3V
AIDS/ARC Unit
3W
Specialized Outpatient Program for AIDS/ARC
3X
Alcohol/Drug Abuse or Dependency Inpatient Unit
3Y
Alcohol/Drug Abuse or Dependency Outpatient Services
3Z
Arthritis Treatment Center
4A
Birthing Room/LDRP Room
4B
Burn Care Unit
4C
Cardiac Catherization Laboratory
4D
Open-Heart Surgery Facility
4E
Cardiac Intensive Care Unit
4F
Angioplasty Facility
4G
Chronic Obstructive Pulmonary Disease Service Facility
4H
Emergency Department
4I
Trauma Center (Certified)
4J
Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
4L
Genetic Counseling/Screening Services
4M
Adult Day Care Program Facility
4N
Alzheimer's Diagnostic/Assessment Services
4O
Comprehensive Geriatric Assessment Facility
4P
Emergency Response (Geriatric) Unit
4Q
Geriatric Acute Care Unit
4R
Geriatric Clinics
4S
Respite Care Facility
4U
Patient Education Unit
4V
Community Health Promotion Facility
4W
Worksite Health Promotion Facility
4X
Hemodialysis Facility
4Y
Home Health Services
4Z
Hospice
5A
Medical Surgical or Other Intensive Care Unit
5B
Hisopathology Laboratory
5C
Blood Bank
5D
Neonatal Intensive Care Unit
5E
Obstetrics Unit
5F
Occupational Health Services
5G
Organized Outpatient Services
5H
Pediatric Acute Inpatient Unit
5I
Psychiatric Child/Adolescent Services
5J
Psychiatric Consultation-Liaison Services
5K
Psychiatric Education Services
5L
Psychiatric Emergency Services
5M
Psychiatric Geriatric Services
5N
Psychiatric Inpatient Unit
5O
Psychiatric Outpatient Services
5P
Psychiatric Partial Hospitalization Program
5Q
Megavoltage Radiation Therapy Unit
5R
Radioactive Implants Unit
5S
Therapeutic Radioisotope Facility
5T
X-Ray Radiation Therapy Unit
5U
CT Scanner Unit
5V
Diagnostic Radioisotope Facility
5W
Magnetic Resonance Imaging (MRI) Facility
5X
Ultrasound Unit
5Y
Rehabilitation Inpatient Unit
5Z
Rehabilitation Outpatient Services
6A
Reproductive Health Services
6B
Skilled Nursing or Other Long-Term Care Unit
6C
Single Photon Emission Computerized Tomography (SPECT) Unit
6D
Organized Social Work Service Facility
6E
Outpatient Social Work Services
6F
Emergency Department Social Work Services
6G
Sports Medicine Clinic/Services
6H
Hospital Auxiliary Unit
6I
Patient Representative Services
6J
Volunteer Services Department
6K
Outpatient Surgery Services
6L
Organ/Tissue Transplant Unit
6M
Orthopedic Surgery Facility
6N
Occupational Therapy Services
6O
Physical Therapy Services
6P
Recreational Therapy Services
6Q
Respiratory Therapy Services
6R
Speech Therapy Services
6S
Women's Health Center/Services
6U
Cardiac Rehabilitation Program Facility
6V
Non-Invasive Cardiac Assessment Services
6W
Emergency Medical Technician
6X
Disciplinary Contact
6Y
Case Manager
7C
Place of Occurrence
13
Contracted Service Provider
17
Consultant's Office
28
Subcontractor
30
Service Supplier
36
Employer
40
Receiver
43
Claimant Authorized Representative
44
Data Processing Service Bureau
61
Performed At
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
80
Hospital
82
Rendering Provider
84
Subscriber's Employer
85
Billing Provider
87
Pay-to Provider
95
Research Institute
CK
Pharmacist
CZ
Admitting Surgeon
D2
Commercial Insurer
DD
Assistant Surgeon
DJ
Consulting Physician
DK
Ordering Physician
DN
Referring Provider
DO
Dependent Name
DQ
Supervising Physician
E1
Person or Other Entity Legally Responsible for a Child
E2
Person or Other Entity With Whom a Child Resides
E7
Previous Employer
E9
Participating Laboratory
FA
Facility
FD
Physical Address
FE
Mail Address
G0
Dependent Insured
G3
Clinic
GB
Other Insured
GD
Guardian
GI
Paramedic
GJ
Paramedical Company
GK
Previous Insured
GM
Spouse Insured
GY
Treatment Facility
HF
Healthcare Professional Shortage Area (HPSA) Facility
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IJ
Injection Point
IL
Insured or Subscriber
IN
Insurer
LI
Independent Lab
LR
Legal Representative
MR
Medical Insurance Carrier
MSC
Mammography Screening Center
OB
Ordered By
OD
Doctor of Optometry
OX
Oxygen Therapy Facility
P0
Patient Facility
P2
Primary Insured or Subscriber
P3
Primary Care Provider
P4
Prior Insurance Carrier
P6
Third Party Reviewing Preferred Provider Organization (PPO)
P7
Third Party Repricing Preferred Provider Organization (PPO)
PRP
Primary Payer
PT
Party to Receive Test Report
PV
Party performing certification
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QD
Responsible Party
QE
Policyholder
QH
Physician
QK
Managed Care
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QV
Group Practice
QY
Medical Doctor
RC
Receiving Location
RW
Rural Health Clinic
S4
Skilled Nursing Facility
SEP
Secondary Payer
SJ
Service Provider
SU
Supplier/Manufacturer
T4
Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

TL
Testing Laboratory
TQ
Third Party Reviewing Organization (TPO)
TT
Transfer To
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
UH
Nursing Home
X3
Utilization Management Organization
X4
Spouse
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-02
373
Status Information Effective Date
Required
Date (DT)
CCYYMMDD format

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

  • STC02 is the effective date of the status information.
Usage notes
  • This is the date the claim was placed in this status by the Information Source's adjudication process.
STC-04
782
Total Claim Charge Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • STC04 is the amount of original submitted charges.
Usage notes
  • The total claim charge may change from the submitted claim total charge based on claims processing instructions, i.e. claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
STC-05
782
Claim Payment Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

  • STC05 is the amount paid.
Usage notes
  • Zero is an acceptable amount when no payment is being made.
  • Some payers are able to provide the adjudicated payment amount prior to the remittance being issued.
STC-06
373
Adjudication Finalized Date
Optional
Date (DT)
CCYYMMDD format

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

  • STC06 is the paid date.
Usage notes
  • This is the date of denial or approval for the claim. This date may or may not be the same as the issue date of the check, EFT or non-payment remittance (STC08).
  • Some payers are able to provide the final claim adjudicated date prior to the remittance being issued.
STC-08
373
Remittance Date
Optional
Date (DT)
CCYYMMDD format

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

  • STC08 is the check issue date.
Usage notes
  • This is the check issue or EFT funds available date.
  • This could include a non-payment remittance advice date if available from the Information Source's system.
STC-09
429
Remittance Trace Number
Optional
String (AN)
Min 1Max 16

Check identification number

Usage notes
  • This is the check or EFT Trace Number.
  • This could include a non-payment remittance advice Trace Number (835 or paper) if available from the Information Source's system.
STC-10
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a second claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-11
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a third claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when received on the 276 status request. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

D9
Claim Number
REF-02
127
Clearinghouse Trace Number
Required
String (AN)
Min 1Max 50

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

Institutional Bill Type Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required on institutional claims when different than the value submitted on the 276 request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BLT
Billing Type
REF-02
127
Bill Type Identifier
Required
String (AN)
Min 1Max 50

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

Usage notes
  • Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
    Code Source 236: Uniform Billing Claim Form Bill Type
    Code Source 235: Claim Frequency Type Code
REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

Patient Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Patient Control Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
  • The maximum number of characters supported for the Patient Control Number is `20'.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EJ
Patient Account Number
REF-02
127
Patient Control Number
Required
String (AN)
Min 1Max 50

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.
  • This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

Pharmacy Prescription Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Pharmacy Prescription Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

XZ
Pharmacy Prescription Number
REF-02
127
Pharmacy Prescription Number
Required
String (AN)
Min 1Max 50

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

REF
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

Voucher Identifier

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.
  • Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

VV
Voucher
REF-02
127
Voucher Identifier
Required
String (AN)
Min 1Max 50

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

DTP
1200
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > DTP

Claim Service Date

OptionalMax use 1

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

Usage notes
  • For professional claims, this date is derived from the service level dates.
  • When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.
  • Required for institutional claims or for professional and dental claims when the service line date is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

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

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

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

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

2220E Service Line Information Loop
OptionalMax >1
SVC
1800
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

Service Line Information

RequiredMax use 1

To supply payment and control information to a provider for a particular service

Usage notes
  • Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
  • For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
Example
SVC-01
C003
Composite Medical Procedure Identifier
Required
To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
AD
American Dental Association Codes
ER
Jurisdiction Specific Procedure and Supply Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, the CPT codes are reported under the code HC.

HP
Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Home Infusion EDI Coalition Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA.

N4
National Drug Code in 5-4-2 Format
NU
National Uniform Billing Committee (NUBC) UB92 Codes

This code is the NUBC Revenue Code.

WK
Advanced Billing Concepts (ABC) Codes

At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law.
The qualifier may only be used in transactions covered under HIPAA;
By parties registered in the pilot project and their trading partners,
OR
If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA,
OR
For claims which are not covered under HIPAA.

C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48

Identifying number for a product or service

  • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
Usage notes
  • If the value in SVC01-1 is "NU", then this is an NUBC Revenue Code. If the revenue code is present here, then SVC04 is not used.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-03 modifies the value in C003-02 and C003-08.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-04 modifies the value in C003-02 and C003-08.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-05 modifies the value in C003-02 and C003-08.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

This identifies special circumstances related to the performance of the service, as defined by trading partners

  • C003-06 modifies the value in C003-02 and C003-08.
SVC-02
782
Line Item Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVC02 is the submitted service charge.
Usage notes
  • This is the line item total on the current claim service status.
SVC-03
782
Line Item Payment Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • SVC03 is the amount paid this service.
SVC-04
234
Revenue Code
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • SVC04 is the National Uniform Billing Committee Revenue Code.
SVC-07
380
Units of Service Count
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • SVC07 is the original submitted units of service.
STC
1900
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > STC

Service Line Status Information

RequiredMax use >1

To report the status, required action, and paid information of a claim or service line

Usage notes
  • See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.
Example
STC-01
C043
Health Care Claim Status
Required
Used to convey status of the entire claim or a specific service line
C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • All Category Codes except `Request for Additional Information' (R Category Codes) are allowable at this level.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC01-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
1E
Health Maintenance Organization (HMO)
1G
Oncology Center
1H
Kidney Dialysis Unit
1I
Preferred Provider Organization (PPO)
1O
Acute Care Hospital
1P
Provider
1Q
Military Facility
1R
University, College or School
1S
Outpatient Surgicenter
1T
Physician, Clinic or Group Practice
1U
Long Term Care Facility
1V
Extended Care Facility
1W
Psychiatric Health Facility
1X
Laboratory
1Y
Retail Pharmacy
1Z
Home Health Care
2A
Federal, State, County or City Facility
2B
Third-Party Administrator
2D
Miscellaneous Health Care Facility
2E
Non-Health Care Miscellaneous Facility
2I
Church Operated Facility
2K
Partnership
2P
Public Health Service Facility
2Q
Veterans Administration Facility
2S
Public Health Service Indian Service Facility
2Z
Hospital Unit of an Institution (prison hospital, college infirmary, etc.)
03
Dependent
3A
Hospital Unit Within an Institution for the Mentally Retarded
3C
Tuberculosis and Other Respiratory Diseases Facility
3D
Obstetrics and Gynecology Facility
3E
Eye, Ear, Nose and Throat Facility
3F
Rehabilitation Facility
3G
Orthopedic Facility
3H
Chronic Disease Facility
3I
Other Specialty Facility
3J
Children's General Facility
3K
Children's Hospital Unit of an Institution
3L
Children's Psychiatric Facility
3M
Children's Tuberculosis and Other Respiratory Diseases Facility
3N
Children's Eye, Ear, Nose and Throat Facility
3O
Children's Rehabilitation Facility
3P
Children's Orthopedic Facility
3Q
Children's Chronic Disease Facility
3R
Children's Other Specialty Facility
3S
Institution for Mental Retardation
3T
Alcoholism and Other Chemical Dependency Facility
3U
General Inpatient Care for AIDS/ARC Facility
3V
AIDS/ARC Unit
3W
Specialized Outpatient Program for AIDS/ARC
3X
Alcohol/Drug Abuse or Dependency Inpatient Unit
3Y
Alcohol/Drug Abuse or Dependency Outpatient Services
3Z
Arthritis Treatment Center
4A
Birthing Room/LDRP Room
4B
Burn Care Unit
4C
Cardiac Catherization Laboratory
4D
Open-Heart Surgery Facility
4E
Cardiac Intensive Care Unit
4F
Angioplasty Facility
4G
Chronic Obstructive Pulmonary Disease Service Facility
4H
Emergency Department
4I
Trauma Center (Certified)
4J
Extracorporeal Shock-Wave Lithotripter (ESWL) Unit
4L
Genetic Counseling/Screening Services
4M
Adult Day Care Program Facility
4N
Alzheimer's Diagnostic/Assessment Services
4O
Comprehensive Geriatric Assessment Facility
4P
Emergency Response (Geriatric) Unit
4Q
Geriatric Acute Care Unit
4R
Geriatric Clinics
4S
Respite Care Facility
4U
Patient Education Unit
4V
Community Health Promotion Facility
4W
Worksite Health Promotion Facility
4X
Hemodialysis Facility
4Y
Home Health Services
4Z
Hospice
5A
Medical Surgical or Other Intensive Care Unit
5B
Hisopathology Laboratory
5C
Blood Bank
5D
Neonatal Intensive Care Unit
5E
Obstetrics Unit
5F
Occupational Health Services
5G
Organized Outpatient Services
5H
Pediatric Acute Inpatient Unit
5I
Psychiatric Child/Adolescent Services
5J
Psychiatric Consultation-Liaison Services
5K
Psychiatric Education Services
5L
Psychiatric Emergency Services
5M
Psychiatric Geriatric Services
5N
Psychiatric Inpatient Unit
5O
Psychiatric Outpatient Services
5P
Psychiatric Partial Hospitalization Program
5Q
Megavoltage Radiation Therapy Unit
5R
Radioactive Implants Unit
5S
Therapeutic Radioisotope Facility
5T
X-Ray Radiation Therapy Unit
5U
CT Scanner Unit
5V
Diagnostic Radioisotope Facility
5W
Magnetic Resonance Imaging (MRI) Facility
5X
Ultrasound Unit
5Y
Rehabilitation Inpatient Unit
5Z
Rehabilitation Outpatient Services
6A
Reproductive Health Services
6B
Skilled Nursing or Other Long-Term Care Unit
6C
Single Photon Emission Computerized Tomography (SPECT) Unit
6D
Organized Social Work Service Facility
6E
Outpatient Social Work Services
6F
Emergency Department Social Work Services
6G
Sports Medicine Clinic/Services
6H
Hospital Auxiliary Unit
6I
Patient Representative Services
6J
Volunteer Services Department
6K
Outpatient Surgery Services
6L
Organ/Tissue Transplant Unit
6M
Orthopedic Surgery Facility
6N
Occupational Therapy Services
6O
Physical Therapy Services
6P
Recreational Therapy Services
6Q
Respiratory Therapy Services
6R
Speech Therapy Services
6S
Women's Health Center/Services
6U
Cardiac Rehabilitation Program Facility
6V
Non-Invasive Cardiac Assessment Services
6W
Emergency Medical Technician
6X
Disciplinary Contact
6Y
Case Manager
7C
Place of Occurrence
13
Contracted Service Provider
17
Consultant's Office
28
Subcontractor
30
Service Supplier
36
Employer
40
Receiver
43
Claimant Authorized Representative
44
Data Processing Service Bureau
61
Performed At
71
Attending Physician
72
Operating Physician
73
Other Physician
74
Corrected Insured
77
Service Location
80
Hospital
82
Rendering Provider
84
Subscriber's Employer
85
Billing Provider
87
Pay-to Provider
95
Research Institute
CK
Pharmacist
CZ
Admitting Surgeon
D2
Commercial Insurer
DD
Assistant Surgeon
DJ
Consulting Physician
DK
Ordering Physician
DN
Referring Provider
DO
Dependent Name
DQ
Supervising Physician
E1
Person or Other Entity Legally Responsible for a Child
E2
Person or Other Entity With Whom a Child Resides
E7
Previous Employer
E9
Participating Laboratory
FA
Facility
FD
Physical Address
FE
Mail Address
G0
Dependent Insured
G3
Clinic
GB
Other Insured
GD
Guardian
GI
Paramedic
GJ
Paramedical Company
GK
Previous Insured
GM
Spouse Insured
GY
Treatment Facility
HF
Healthcare Professional Shortage Area (HPSA) Facility
HH
Home Health Agency
I3
Independent Physicians Association (IPA)
IJ
Injection Point
IL
Insured or Subscriber
IN
Insurer
LI
Independent Lab
LR
Legal Representative
MR
Medical Insurance Carrier
MSC
Mammography Screening Center
OB
Ordered By
OD
Doctor of Optometry
OX
Oxygen Therapy Facility
P0
Patient Facility
P2
Primary Insured or Subscriber
P3
Primary Care Provider
P4
Prior Insurance Carrier
P6
Third Party Reviewing Preferred Provider Organization (PPO)
P7
Third Party Repricing Preferred Provider Organization (PPO)
PRP
Primary Payer
PT
Party to Receive Test Report
PV
Party performing certification
PW
Pickup Address
QA
Pharmacy
QB
Purchase Service Provider
QC
Patient
QD
Responsible Party
QE
Policyholder
QH
Physician
QK
Managed Care
QL
Chiropractor
QN
Dentist
QO
Doctor of Osteopathy
QS
Podiatrist
QV
Group Practice
QY
Medical Doctor
RC
Receiving Location
RW
Rural Health Clinic
S4
Skilled Nursing Facility
SEP
Secondary Payer
SJ
Service Provider
SU
Supplier/Manufacturer
T4
Transfer Point

Used to identify the geographic location where a patient is transferred or diverted.

TL
Testing Laboratory
TQ
Third Party Reviewing Organization (TPO)
TT
Transfer To
TTP
Tertiary Payer
TU
Third Party Repricing Organization (TPO)
UH
Nursing Home
X3
Utilization Management Organization
X4
Spouse
X5
Durable Medical Equipment Supplier
ZZ
Mutually Defined
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-02
373
Status Information Effective Date
Required
Date (DT)
CCYYMMDD format

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

  • STC02 is the effective date of the status information.
Usage notes
  • This is the date the service was placed in this status by the Information Source's adjudication process.
STC-10
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a second claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC10-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
STC-11
C043
Health Care Claim Status
Optional
Used to convey status of the entire claim or a specific service line
Usage notes

Required when a third claim status is needed. If not required by this implementation guide, do not send.

C043-01
1271
Health Care Claim Status Category Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
Usage notes
  • See STC01-1 for valid values.
C043-02
1271
Status Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • C043-02 is used to identify the status of an entire claim or a serviceline.
    Code Source 508 is referenced unless qualified by C043-04.
Usage notes
  • The Status Code is either a Health Care Claim Status Code (Code Source 508) or a National Council for Prescription Drug Programs Reject/Payment Code (Code Source 530).
  • The National Council for Prescription Drug Programs Reject/Payment Codes may be used for status related to pharmacy claims. When these codes are used, STC11-4 must have the value `RX'.
C043-03
98
Entity Identifier Code
Optional
Identifier (ID)
Min 2Max 3

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

  • C043-03 identifies the entity associated with the Health Care Claim Status Code.
Usage notes
  • See STC01-3 for valid values.
C043-04
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C043-04 is used to identify the Code Source referenced in C043-02.
RX
National Council for Prescription Drug Programs Reject/Payment Codes
REF
2000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

Service Line Item Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

FJ
Line Item Control Number
REF-02
127
Line Item Control Number
Required
String (AN)
Min 1Max 50

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

DTP
2100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

Service Line Date

RequiredMax use 1

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

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

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

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

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

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

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

2220E Service Line Information Loop end
2200E Claim Status Tracking Number Loop end
2000E Dependent Level Loop end
2000D Subscriber Level Loop end
2000C Service Provider Level Loop end
2000B Information Receiver Level Loop end
2000A Information Source Level Loop end
SE
2700
Detail > SE

Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Example
SE-01
96
Transaction Segment Count
Required
Numeric (N0)
Min 1Max 10

Total number of segments included in a transaction set including ST and SE segments

SE-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

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

Usage notes
  • Data value in SE02 must be identical to ST02.
Detail end

Functional Group Trailer

RequiredMax use 1

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

Example
GE-01
97
Number of Transaction Sets Included
Required
Numeric (N0)
Min 1Max 6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

GE-02
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Example
IEA-01
I16
Number of Included Functional Groups
Required
Numeric (N0)
Min 1Max 5

A count of the number of functional groups included in an interchange

IEA-02
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

EDI Samples

Example 1: Claim Level Status

ST*277*0001*005010X212~
BHT*0010*08*277X212*20050916*0810*DG~
HL*1**20*1~
NM1*PR*2*ABC INSURANCE*****PI*12345~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*2*ABCXYZ1~
STC*P3>317*20050913**8513.88~
REF*1K*05347006051~
REF*BLT*111~
REF*EJ*SM123456~
DTP*472*RD8*20050831-20050906~
HL*5*3*22*0~
NM1*IL*1*JONES*MARY****MI*234567890A~
TRN*2*ABCXYZ2~
STC*F0>3*20050915**7599*7599~
REF*1K*0529675341~
REF*BLT*111~
REF*EJ*JO234567~
DTP*472*RD8*20050731-20050809~
HL*6*2*19*1~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~
HL*7*6*22*1~
NM1*IL*1*MANN*JOHN****MI*345678901~
HL*8*7*23~
NM1*QC*1*MANN*JOSEPH~
TRN*2*ABCXYC3~
STC*F2>88>QC*20050612**150*0~
REF*1K*051681010827~
REF*EJ*MA345678~
SVC*HC>99203*150*0****1~
STC*F2>88>QC*20050612~
DTP*472*D8*20050501~
SE*38*0001~

Example 2: Provider Level Status

ST*277*0001*005010X212~
BHT*0010*08*277X212*20050916*0810*DG~
HL*1**20*1~
NM1*PR*2*ABC INSURANCE*****PI*12345~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*2*ABCXYZ1~
STC*P3>317*20050913**8513.88~
REF*1K*05347006051~
REF*BLT*111~
REF*EJ*SM123456~
DTP*472*RD8*20050831-20050906~
HL*5*2*19*0~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*6166666666~
TRN*1*0~
STC*E0>24>1P*20050916~
SE*21*0001~

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