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Health Care Claim: Institutional (X223A3)
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X12 837 Health Care Claim: Institutional (X223A3)

X12 Release 5010

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

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

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    ST
    0050
    Transaction Set Header
    Max use 1
    Required
    BHT
    0100
    Beginning of Hierarchical Transaction
    Max use 1
    Required
    Receiver Name Loop
    detail
    Billing Provider Hierarchical Level Loop
    HL
    0010
    Hierarchical Level
    Max use 1
    Required
    PRV
    0030
    Billing Provider Specialty Information
    Max use 1
    Optional
    CUR
    0100
    Foreign Currency Information
    Max use 1
    Optional
    Pay-to Address Name Loop
    Subscriber Hierarchical Level Loop
    HL
    0010
    Hierarchical Level
    Max use 1
    Required
    SBR
    0050
    Subscriber Information
    Max use 1
    Required
    Claim Information Loop
    CLM
    1300
    Claim Information
    Max use 1
    Required
    DTP
    1350
    Admission Date/Hour
    Max use 1
    Optional
    DTP
    1350
    Date - Repricer Received Date
    Max use 1
    Optional
    DTP
    1350
    Discharge Hour
    Max use 1
    Optional
    DTP
    1350
    Statement Dates
    Max use 1
    Required
    CL1
    1400
    Institutional Claim Code
    Max use 1
    Required
    PWK
    1550
    Claim Supplemental Information
    Max use 10
    Optional
    CN1
    1600
    Contract Information
    Max use 1
    Optional
    AMT
    1750
    Patient Estimated Amount Due
    Max use 1
    Optional
    REF
    1800
    Adjusted Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Auto Accident State
    Max use 1
    Optional
    REF
    1800
    Claim Identifier For Transmission Intermediaries
    Max use 1
    Optional
    REF
    1800
    Demonstration Project Identifier
    Max use 1
    Optional
    REF
    1800
    Investigational Device Exemption Number
    Max use 5
    Optional
    REF
    1800
    Medical Record Number
    Max use 1
    Optional
    REF
    1800
    Payer Claim Control Number
    Max use 1
    Optional
    REF
    1800
    Peer Review Organization (PRO) Approval Number
    Max use 1
    Optional
    REF
    1800
    Prior Authorization
    Max use 1
    Optional
    REF
    1800
    Referral Number
    Max use 1
    Optional
    REF
    1800
    Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Service Authorization Exception Code
    Max use 1
    Optional
    K3
    1850
    File Information
    Max use 10
    Optional
    NTE
    1900
    Billing Note
    Max use 1
    Optional
    NTE
    1900
    Claim Note
    Max use 10
    Optional
    CRC
    2200
    EPSDT Referral
    Max use 1
    Optional
    HI
    2310
    Admitting Diagnosis
    Max use 1
    Optional
    HI
    2310
    Condition Information
    Max use 2
    Optional
    HI
    2310
    Diagnosis Related Group (DRG) Information
    Max use 1
    Optional
    HI
    2310
    External Cause of Injury
    Max use 1
    Optional
    HI
    2310
    Occurrence Information
    Max use 2
    Optional
    HI
    2310
    Occurrence Span Information
    Max use 2
    Optional
    HI
    2310
    Other Diagnosis Information
    Max use 2
    Optional
    HI
    2310
    Other Procedure Information
    Max use 2
    Optional
    HI
    2310
    Patient's Reason For Visit
    Max use 1
    Optional
    HI
    2310
    Principal Diagnosis
    Max use 1
    Required
    HI
    2310
    Principal Procedure Information
    Max use 1
    Optional
    HI
    2310
    Treatment Code Information
    Max use 2
    Optional
    HI
    2310
    Value Information
    Max use 2
    Optional
    HCP
    2410
    Claim Pricing/Repricing Information
    Max use 1
    Optional
    Other Subscriber Information Loop
    SBR
    2900
    Other Subscriber Information
    Max use 1
    Required
    CAS
    2950
    Claim Level Adjustments
    Max use 5
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Payer Paid Amount
    Max use 1
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Total Non-Covered Amount
    Max use 1
    Optional
    AMT
    3000
    Remaining Patient Liability
    Max use 1
    Optional
    OI
    3100
    Other Insurance Coverage Information
    Max use 1
    Required
    MIA
    3150
    Inpatient Adjudication Information
    Max use 1
    Optional
    MOA
    3200
    Outpatient Adjudication Information
    Max use 1
    Optional
    Service Line Number Loop
    LX
    3650
    Service Line Number
    Max use 1
    Required
    SV2
    3750
    Institutional Service Line
    Max use 1
    Required
    PWK
    4200
    Line Supplemental Information
    Max use 10
    Optional
    DTP
    4550
    Date - Service Date
    Max use 1
    Optional
    REF
    4700
    Adjusted Repriced Line Item Reference Number
    Max use 1
    Optional
    REF
    4700
    Line Item Control Number
    Max use 1
    Optional
    REF
    4700
    Repriced Line Item Reference Number
    Max use 1
    Optional
    AMT
    4750
    Facility Tax Amount
    Max use 1
    Optional
    AMT
    4750
    Service Tax Amount
    Max use 1
    Optional
    NTE
    4850
    Third Party Organization Notes
    Max use 1
    Optional
    HCP
    4920
    Line Pricing/Repricing Information
    Max use 1
    Optional
    Patient Hierarchical Level Loop
    HL
    0010
    Hierarchical Level
    Max use 1
    Required
    PAT
    0070
    Patient Information
    Max use 1
    Required
    Claim Information Loop
    CLM
    1300
    Claim Information
    Max use 1
    Required
    DTP
    1350
    Admission Date/Hour
    Max use 1
    Optional
    DTP
    1350
    Date - Repricer Received Date
    Max use 1
    Optional
    DTP
    1350
    Discharge Hour
    Max use 1
    Optional
    DTP
    1350
    Statement Dates
    Max use 1
    Required
    CL1
    1400
    Institutional Claim Code
    Max use 1
    Required
    PWK
    1550
    Claim Supplemental Information
    Max use 10
    Optional
    CN1
    1600
    Contract Information
    Max use 1
    Optional
    AMT
    1750
    Patient Estimated Amount Due
    Max use 1
    Optional
    REF
    1800
    Adjusted Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Auto Accident State
    Max use 1
    Optional
    REF
    1800
    Claim Identifier For Transmission Intermediaries
    Max use 1
    Optional
    REF
    1800
    Demonstration Project Identifier
    Max use 1
    Optional
    REF
    1800
    Investigational Device Exemption Number
    Max use 5
    Optional
    REF
    1800
    Medical Record Number
    Max use 1
    Optional
    REF
    1800
    Payer Claim Control Number
    Max use 1
    Optional
    REF
    1800
    Peer Review Organization (PRO) Approval Number
    Max use 1
    Optional
    REF
    1800
    Prior Authorization
    Max use 1
    Optional
    REF
    1800
    Referral Number
    Max use 1
    Optional
    REF
    1800
    Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Service Authorization Exception Code
    Max use 1
    Optional
    K3
    1850
    File Information
    Max use 10
    Optional
    NTE
    1900
    Billing Note
    Max use 1
    Optional
    NTE
    1900
    Claim Note
    Max use 10
    Optional
    CRC
    2200
    EPSDT Referral
    Max use 1
    Optional
    HI
    2310
    Admitting Diagnosis
    Max use 1
    Optional
    HI
    2310
    Condition Information
    Max use 2
    Optional
    HI
    2310
    Diagnosis Related Group (DRG) Information
    Max use 1
    Optional
    HI
    2310
    External Cause of Injury
    Max use 1
    Optional
    HI
    2310
    Occurrence Information
    Max use 2
    Optional
    HI
    2310
    Occurrence Span Information
    Max use 2
    Optional
    HI
    2310
    Other Diagnosis Information
    Max use 2
    Optional
    HI
    2310
    Other Procedure Information
    Max use 2
    Optional
    HI
    2310
    Patient's Reason For Visit
    Max use 1
    Optional
    HI
    2310
    Principal Diagnosis
    Max use 1
    Required
    HI
    2310
    Principal Procedure Information
    Max use 1
    Optional
    HI
    2310
    Treatment Code Information
    Max use 2
    Optional
    HI
    2310
    Value Information
    Max use 2
    Optional
    HCP
    2410
    Claim Pricing/Repricing Information
    Max use 1
    Optional
    Other Subscriber Information Loop
    SBR
    2900
    Other Subscriber Information
    Max use 1
    Required
    CAS
    2950
    Claim Level Adjustments
    Max use 5
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Payer Paid Amount
    Max use 1
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Total Non-Covered Amount
    Max use 1
    Optional
    AMT
    3000
    Remaining Patient Liability
    Max use 1
    Optional
    OI
    3100
    Other Insurance Coverage Information
    Max use 1
    Required
    MIA
    3150
    Inpatient Adjudication Information
    Max use 1
    Optional
    MOA
    3200
    Outpatient Adjudication Information
    Max use 1
    Optional
    Service Line Number Loop
    LX
    3650
    Service Line Number
    Max use 1
    Required
    SV2
    3750
    Institutional Service Line
    Max use 1
    Required
    PWK
    4200
    Line Supplemental Information
    Max use 10
    Optional
    DTP
    4550
    Date - Service Date
    Max use 1
    Optional
    REF
    4700
    Adjusted Repriced Line Item Reference Number
    Max use 1
    Optional
    REF
    4700
    Line Item Control Number
    Max use 1
    Optional
    REF
    4700
    Repriced Line Item Reference Number
    Max use 1
    Optional
    AMT
    4750
    Facility Tax Amount
    Max use 1
    Optional
    AMT
    4750
    Service Tax Amount
    Max use 1
    Optional
    NTE
    4850
    Third Party Organization Notes
    Max use 1
    Optional
    HCP
    4920
    Line Pricing/Repricing Information
    Max use 1
    Optional
    SE
    5550
    Transaction Set Trailer
    Max use 1
    Required
    GE
    -
    Functional Group Trailer
    Max use 1
    Required
    IEA
    -
    Interchange Control Trailer
    Max use 1
    Required
    ISA

    Interchange Control Header

    RequiredMax use 1

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

    Example
    ISA-01
    I01
    Authorization Information Qualifier
    Required

    Code identifying the type of information in the Authorization Information

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

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

    ISA-03
    I03
    Security Information Qualifier
    Required

    Code identifying the type of information in the Security Information

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

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

    ISA-05
    I05
    Interchange ID Qualifier
    Required
    Min 2Max 2

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

    Codes
    ISA-06
    I06
    Interchange Sender ID
    Required
    Min 15Max 15

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

    ISA-07
    I05
    Interchange ID Qualifier
    Required
    Min 2Max 2

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

    Codes
    ISA-08
    I07
    Interchange Receiver ID
    Required
    Min 15Max 15

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

    ISA-09
    I08
    Interchange Date
    Required
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    Min 1Max 1

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

    ^
    Repetition Separator
    ISA-12
    I11
    Interchange Control Version Number
    Required

    Code specifying the version number of the interchange control segments

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

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    Min 1Max 1

    Code indicating sender's request for an interchange acknowledgment

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

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

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

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

    >
    Component Element Separator

    Functional Group Header

    RequiredMax use 1

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

    Example
    GS-01
    479
    Functional Identifier Code
    Required

    Code identifying a group of application related transaction sets

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

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

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

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

    GS-04
    373
    Date
    Required
    CCYYMMDD format

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

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

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

    GS-06
    28
    Group Control Number
    Required
    Min 1Max 9

    Assigned number originated and maintained by the sender

    GS-07
    455
    Responsible Agency Code
    Required
    Min 1Max 2

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

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

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

    005010X223A3
    ANSI ASC X12N 837 Health Care Claims (837) for institutional claims and/or encounters through June 2014

    Heading

    ST
    0050

    Transaction Set Header

    RequiredMax use 1

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

    Example
    ST-01
    143
    Transaction Set Identifier Code
    Required

    Code uniquely identifying a Transaction Set

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

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

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

    Reference assigned to identify Implementation Convention

    • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
    Usage notes
    • This element must be populated with the guide identifier named in Section 1.2.
    • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
    005010X223A3
    BHT
    0100

    Beginning of Hierarchical Transaction

    RequiredMax use 1

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

    Usage notes
    • The second example denotes the case where the entire transaction set contains ENCOUNTERS.
    Example
    BHT-01
    1005
    Hierarchical Structure Code
    Required

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

    0019
    Information Source, Subscriber, Dependent
    BHT-02
    353
    Transaction Set Purpose Code
    Required

    Code identifying purpose of transaction set

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

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

    18
    Reissue

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

    BHT-03
    127
    Originator Application Transaction Identifier
    Required
    Min 1Max 50

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

    • BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
    Usage notes
    • The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
    • This field is limited to 30 characters.
    BHT-04
    373
    Transaction Set Creation Date
    Required
    CCYYMMDD format

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

    • BHT04 is the date the transaction was created within the business application system.
    Usage notes
    • This is the date that the original submitter created the claim file from their business application system.
    BHT-05
    337
    Transaction Set Creation Time
    Required
    HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

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

    • BHT05 is the time the transaction was created within the business application system.
    Usage notes
    • This is the time that the original submitter created the claim file from their business application system.
    BHT-06
    640
    Claim Identifier
    Required

    Code specifying the type of transaction

    31
    Subrogation Demand

    The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners.
    NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction.

    CH
    Chargeable

    Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.

    RP
    Reporting

    Use RP when the entire ST-SE envelope contains only capitated encounters.
    Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes.

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

    Receiver Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    40
    Receiver
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

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

    Code identifying a party or other code

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

    Submitter Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    41
    Submitter
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    46
    Electronic Transmitter Identification Number (ETIN)

    Established by trading partner agreement

    NM1-09
    67
    Submitter Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    PER
    0450

    Submitter EDI Contact Information

    RequiredMax use 2

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

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

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    Detail

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

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

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

    Billing Provider Specialty Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
    Example
    PRV-01
    1221
    Provider Code
    Required

    Code identifying the type of provider

    BI
    Billing
    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    CUR
    0100

    Foreign Currency Information

    OptionalMax use 1

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

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

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

    85
    Billing Provider
    CUR-02
    100
    Currency Code
    Required
    Min 3Max 3

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

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

    Billing Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
    • Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
    • The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
    • When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
    Example
    If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    85
    Billing Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

    XX
    Centers for Medicare and Medicaid Services National Provider Identifier
    NM1-09
    67
    Billing Provider Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    Billing Provider Address

    RequiredMax use 1

    To specify the location of the named party

    Usage notes
    • The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
    Example
    N3-01
    166
    Billing Provider Address Line
    Required
    Min 1Max 55

    Address information

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

    Address information

    N4
    0300

    Billing Provider City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

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

    Code identifying the country

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

    Code identifying the country subdivision

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

    Billing Provider Tax Identification

    RequiredMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    EI
    Employer's Identification Number

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

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

    REF-02
    127
    Billing Provider Tax Identification Number
    Required
    Min 1Max 50

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

    PER
    0400

    Billing Provider Contact Information

    OptionalMax use 2

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

    Usage notes
    • Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;
    • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
    • There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
    Example
    If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    2010AB Pay-to Address Name Loop
    OptionalMax 1
    NM1
    0150

    Pay-to Address Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
    • The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    87
    Pay-to Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    N3
    0250

    Pay-to Address - ADDRESS

    RequiredMax use 1

    To specify the location of the named party

    Example
    N3-01
    166
    Pay-To Address Line
    Required
    Min 1Max 55

    Address information

    N3-02
    166
    Pay-To Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    0300

    Pay-To Address City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

    Example
    Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Pay-to Address City Name
    Required
    Min 2Max 30

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    2010AC Pay-To Plan Name Loop
    OptionalMax 1
    NM1
    0150

    Pay-To Plan Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when willing trading partners agree to use this implementation for their subrogation payment requests.
    • This loop may only be used when BHT06 = 31.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    PE
    Payee

    PE is used to indicate the subrogated payee.

    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Pay-To Plan Organizational Name
    Required
    Min 1Max 60

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes
    • Use code value "PI" when reporting Payor Identification.
      Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

    Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:

    1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
      OR
    2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.
    PI
    Payor Identification
    XV
    Centers for Medicare and Medicaid Services PlanID
    NM1-09
    67
    Pay-To Plan Primary Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    Pay-to Plan Address

    RequiredMax use 1

    To specify the location of the named party

    Example
    N3-01
    166
    Pay-To Plan Address Line
    Required
    Min 1Max 55

    Address information

    N3-02
    166
    Pay-To Plan Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    0300

    Pay-To Plan City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Pay-To Plan State or Province Code
    Optional
    Min 2Max 2

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Pay-to Plan Secondary Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    2U
    Payer Identification Number

    This code is only allowed when the qualifier XV is reported in NM108 of this loop.

    FY
    Claim Office Number
    NF
    National Association of Insurance Commissioners (NAIC) Code
    REF-02
    127
    Pay-to Plan Secondary Identifier
    Required
    Min 1Max 50

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

    REF
    0350

    Pay-To Plan Tax Identification Number

    RequiredMax use 1

    To specify identifying information

    Example
    Variants (all may be used)
    REFPay-to Plan Secondary Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EI
    Employer's Identification Number

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

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

    REF-02
    127
    Pay-To Plan Tax Identification Number
    Required
    Min 1Max 50

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

    2000B Subscriber Hierarchical Level Loop
    RequiredMax >1
    HL
    0010

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

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

    Subscriber Information

    RequiredMax use 1

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

    Example
    SBR-01
    1138
    Payer Responsibility Sequence Number Code
    Required

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

    Usage notes
    • Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
    A
    Payer Responsibility Four
    B
    Payer Responsibility Five
    C
    Payer Responsibility Six
    D
    Payer Responsibility Seven
    E
    Payer Responsibility Eight
    F
    Payer Responsibility Nine
    G
    Payer Responsibility Ten
    H
    Payer Responsibility Eleven
    P
    Primary
    S
    Secondary
    T
    Tertiary
    U
    Unknown

    This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.

    SBR-02
    1069
    Individual Relationship Code
    Optional

    Code indicating the relationship between two individuals or entities

    • SBR02 specifies the relationship to the person insured.
    18
    Self
    SBR-03
    127
    Subscriber Group or Policy Number
    Optional
    Min 1Max 50

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

    • SBR03 is policy or group number.
    Usage notes
    • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
    SBR-04
    93
    Subscriber Group Name
    Optional
    Min 1Max 60

    Free-form name

    • SBR04 is plan name.
    SBR-09
    1032
    Claim Filing Indicator Code
    Required

    Code identifying type of claim

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

    Use code OF when submitting Medicare Part D claims.

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

    Use Code ZZ when Type of Insurance is not known.

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

    Payer Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This is the destination payer.
    • For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    PR
    Payer
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes
    • Use code value "PI" when reporting Payor Identification.
      Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

    Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:

    1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
      OR
    2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.
    PI
    Payor Identification
    XV
    Centers for Medicare and Medicaid Services PlanID
    NM1-09
    67
    Payer Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    Payer Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
    Example
    N3-01
    166
    Payer Address Line
    Required
    Min 1Max 55

    Address information

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

    Address information

    N4
    0300

    Payer City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
    Example
    Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Payer City Name
    Required
    Min 2Max 30

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Billing Provider Secondary Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider.
      OR
      Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
      If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFPayer Secondary Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    G2
    Provider Commercial Number

    This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.

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

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

    REF
    0350

    Payer Secondary Identification

    OptionalMax use 3

    To specify identifying information

    Usage notes
    • Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    2U
    Payer Identification Number

    This code is only allowed when the qualifier XV is reported in NM108 of this loop.

    EI
    Employer's Identification Number

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

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

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

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

    2010BA Subscriber Name Loop
    RequiredMax 1
    Variants (all may be used)
    2010BBPayer Name Loop
    NM1
    0150

    Subscriber Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
    Example
    If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

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

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

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

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

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

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

    MI
    Member Identification Number

    The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

    MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.

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

    NM1-09
    67
    Subscriber Primary Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    Subscriber Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
    Example
    N3-01
    166
    Subscriber Address Line
    Required
    Min 1Max 55

    Address information

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

    Address information

    N4
    0300

    Subscriber City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
    Example
    Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Subscriber City Name
    Required
    Min 2Max 30

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Subscriber Demographic Information

    OptionalMax use 1

    To supply demographic information

    Usage notes
    • Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
    Example
    DMG-01
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

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

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    REF
    0350

    Property and Casualty Claim Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
    • This segment is not a HIPAA requirement as of this writing.
    • Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFSubscriber Secondary Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    0350

    Subscriber Secondary Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFProperty and Casualty Claim Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    SY
    Social Security Number

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

    REF-02
    127
    Subscriber Supplemental Identifier
    Required
    Min 1Max 50

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

    2300 Claim Information Loop
    OptionalMax 100
    CLM
    1300

    Claim Information

    RequiredMax use 1

    To specify basic data about the claim

    Usage notes
    • The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
    • For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
    Example
    CLM-01
    1028
    Patient Control Number
    Required
    Min 1Max 38

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

    Usage notes
    • The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
    • When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
    • The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
    CLM-02
    782
    Total Claim Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    • CLM02 is the total amount of all submitted charges of service segments for this claim.
    Usage notes
    • The Total Claim Charge Amount must be greater than or equal to zero.
    • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim.
    CLM-05
    C023
    Health Care Service Location Information
    To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
    C023-01
    1331
    Facility Type Code
    Required
    Min 1Max 2

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

    C023-02
    1332
    Facility Code Qualifier
    Required

    Code identifying the type of facility referenced

    • C023-02 qualifies C023-01 and C023-03.
    A
    Uniform Billing Claim Form Bill Type
    C023-03
    1325
    Claim Frequency Code
    Required
    Min 1Max 1

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

    Usage notes

    Must contain a value for the National UB Data Element Specification Type List Type of Bill Position 3

    CLM-07
    1359
    Assignment or Plan Participation Code
    Required

    Code indicating whether the provider accepts assignment

    Usage notes
    • Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
    A
    Assigned

    Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
    OR
    Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans.

    B
    Assignment Accepted on Clinical Lab Services Only

    Required when the provider accepts assignment for Clinical Lab Services only.

    C
    Not Assigned

    Required when neither codes A' nor B' apply.

    CLM-08
    1073
    Benefits Assignment Certification Indicator
    Required

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes
    CLM-09
    1363
    Release of Information Code
    Required

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

    Usage notes
    • The Release of Information response is limited to the information carried in this claim.
    I
    Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

    Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

    Y
    Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

    Required when the provider has collected a signature.
    OR
    Required when state or federal laws require a signature be collected.

    CLM-20
    1514
    Delay Reason Code
    Optional

    Code indicating the reason why a request was delayed

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

    Admission Date/Hour

    OptionalMax use 1

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

    Usage notes
    • Required on inpatient claims.
      If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

    • DTP02 is the date or time or period format that will appear in DTP03.
    Usage notes
    • Selection of the appropriate qualifier is designated by the NUBC Billing Manual.
    D8
    Date Expressed in Format CCYYMMDD
    DT
    Date and Time Expressed in Format CCYYMMDDHHMM
    DTP-03
    1251
    Admission Date and Hour
    Required
    Min 1Max 35

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

    DTP
    1350

    Date - Repricer Received Date

    OptionalMax use 1

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

    Usage notes
    • Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    DTP
    1350

    Discharge Hour

    OptionalMax use 1

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

    Usage notes
    • Required on all final inpatient claims. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

    • DTP02 is the date or time or period format that will appear in DTP03.
    TM
    Time Expressed in Format HHMM
    DTP-03
    1251
    Discharge Time
    Required
    Min 1Max 35

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

    DTP
    1350

    Statement Dates

    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

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

    434
    Statement
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

    • DTP02 is the date or time or period format that will appear in DTP03.
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

    Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same.

    DTP-03
    1251
    Statement From and To Date
    Required
    Min 1Max 35

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

    CL1
    1400

    Institutional Claim Code

    RequiredMax use 1

    To supply information specific to hospital claims

    Example
    CL1-01
    1315
    Admission Type Code
    Required
    Min 1Max 1

    Code indicating the priority of this admission

    CL1-02
    1314
    Admission Source Code
    Optional
    Min 1Max 1

    Code indicating the source of this admission

    CL1-03
    1352
    Patient Status Code
    Required
    Min 1Max 2

    Code indicating patient status as of the "statement covers through date"

    PWK
    1550

    Claim Supplemental Information

    OptionalMax use 10

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

    Usage notes
    • Required when there is a paper attachment following this claim.
      OR
      Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
      OR
      Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
      If not required by this implementation guide, do not send.
    Example
    If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
    PWK-01
    755
    Attachment Report Type Code
    Required

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

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

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

    AA
    Available on Request at Provider Site

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

    BM
    By Mail
    EL
    Electronically Only

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

    EM
    E-Mail
    FT
    File Transfer

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

    FX
    By Fax
    PWK-05
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

    Usage notes
    • PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
    • For the purpose of this implementation, the maximum field length is 50.
    CN1
    1600

    Contract Information

    OptionalMax use 1

    To specify basic data about the contract or contract line item

    Usage notes
    • Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
    • The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
    Example
    CN1-01
    1166
    Contract Type Code
    Required

    Code identifying a contract type

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

    Monetary amount

    • CN102 is the contract amount.
    CN1-03
    332
    Contract Percentage
    Optional
    Min 1Max 6

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

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

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

    • CN104 is the contract code.
    CN1-05
    338
    Terms Discount Percentage
    Optional
    Min 1Max 6

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

    CN1-06
    799
    Contract Version Identifier
    Optional
    Min 1Max 30

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

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

    Patient Estimated Amount Due

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when the Patient Responsibility Amount is applicable to this claim.
      If not required by this implementation guide, do not send.
    Example
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    F3
    Patient Responsibility - Estimated
    AMT-02
    782
    Patient Responsibility Amount
    Required
    Min 1Max 15

    Monetary amount

    REF
    1800

    Adjusted Repriced Claim Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Auto Accident State

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code named in code source 22. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    LU
    Location Number
    REF-02
    127
    Auto Accident State or Province Code
    Required
    Min 1Max 50

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

    Usage notes
    • Values in this field must be valid codes found in code source 22.
    REF
    1800

    Claim Identifier For Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
    • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    Usage notes
    • The value carried in this element is limited to a maximum of 20 positions.
    REF
    1800

    Demonstration Project Identifier

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    P4
    Project Code
    REF-02
    127
    Demonstration Project Identifier
    Required
    Min 1Max 50

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

    REF
    1800

    Investigational Device Exemption Number

    OptionalMax use 5

    To specify identifying information

    Usage notes
    • Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Medical Record Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Payer Claim Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Peer Review Organization (PRO) Approval Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    G4
    Peer Review Organization (PRO) Approval Number
    REF-02
    127
    Peer Review Authorization Number
    Required
    Min 1Max 50

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

    REF
    1800

    Prior Authorization

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
    • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
    • Required when an authorization number is assigned by the payer or UMO
      AND
      the services on this claim were preauthorized.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Referral Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
      AND
      a referral is involved.
      If not required by this implementation guide, do not send.
    • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Repriced Claim Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Service Authorization Exception Code

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

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

    File Information

    OptionalMax use 10

    To transmit a fixed-format record or matrix contents

    Usage notes
    • Required when ALL of the following conditions are met:
    • A regulatory agency concludes it must use the K3 to meet an emergency
      legislative requirement;
    • The administering regulatory agency or other state organization has
      completed each one of the following steps:
      contacted the X12N workgroup,
      requested a review of the K3 data requirement to ensure there is not
      an existing method within the implementation guide to meet this
      requirement
    • X12N determines that there is no method to meet the requirement.
      If not required by this implementation guide, do not send.
    • At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
    • The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
    • The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
      Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations.
    • Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
    • X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
    Example
    K3-01
    449
    Fixed Format Information
    Required
    Min 1Max 80

    Data in fixed format agreed upon by sender and receiver

    NTE
    1900

    Billing Note

    OptionalMax use 1

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

    Usage notes
    • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
      If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    NTEClaim Note
    NTE-01
    363
    Note Reference Code
    Required

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

    ADD
    Additional Information
    NTE-02
    352
    Billing Note Text
    Required
    Min 1Max 80

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

    NTE
    1900

    Claim Note

    OptionalMax use 10

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

    Usage notes
    • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
      OR
      Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services.
      If not required by this implementation guide, do not send.
    • The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
    Example
    Variants (all may be used)
    NTEBilling Note
    NTE-01
    363
    Note Reference Code
    Required

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

    ALG
    Allergies
    DCP
    Goals, Rehabilitation Potential, or Discharge Plans
    DGN
    Diagnosis Description
    DME
    Durable Medical Equipment (DME) and Supplies
    MED
    Medications
    NTR
    Nutritional Requirements
    ODT
    Orders for Disciplines and Treatments
    RHB
    Functional Limitations, Reason Homebound, or Both
    RLH
    Reasons Patient Leaves Home
    RNH
    Times and Reasons Patient Not at Home
    SET
    Unusual Home, Social Environment, or Both
    SFM
    Safety Measures
    SPT
    Supplementary Plan of Treatment
    UPI
    Updated Information
    NTE-02
    352
    Claim Note Text
    Required
    Min 1Max 80

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

    CRC
    2200

    EPSDT Referral

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Qualifier
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    ZZ
    Mutually Defined

    EPSDT Screening referral information.

    CRC-02
    1073
    Certification Condition Code Applies Indicator
    Required

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes
    CRC-03
    1321
    Condition Indicator
    Required

    Code indicating a condition

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

    Patient refused referral.

    NU
    Not Used

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

    S2
    Under Treatment

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

    ST
    New Services Requested

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

    CRC-04
    1321
    Condition Indicator
    Optional
    Min 2Max 3

    Code indicating a condition

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

    Code indicating a condition

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

    Admitting Diagnosis

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • Required when claim involves an inpatient admission.
      If not required by this implementation guide, do not send.;
    • Do not transmit the decimal point for ICD codes. The decimal point is implied.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    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 ICD-10-CM 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.

    BJ
    International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
    C022-02
    1271
    Admitting Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    HI
    2310

    Condition Information

    OptionalMax use 2

    To supply information related to the delivery of health care

    Usage notes
    • Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

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

    Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    HI
    2310

    Diagnosis Related Group (DRG) Information

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    DR
    Diagnosis Related Group (DRG)
    C022-02
    1271
    Diagnosis Related Group (DRG) Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    HI
    2310

    External Cause of Injury

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send.
    • Do not transmit the decimal point for ICD codes. The decimal point is implied.
    • In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-02
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-03
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-04
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-05
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-06
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-07
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-08
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-09
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-10
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-11
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI-12
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    ABN
    International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury 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 ICD-10-CM 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.

    BN
    International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
    C022-02
    1271
    External Cause of Injury Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-09
    1073
    Present on Admission Indicator
    Optional

    Code indicating a Yes or No condition or response

    • C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not.
    • C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08.
    N
    No
    U
    Unknown
    W
    Not Applicable
    Y
    Yes
    HI
    2310

    Occurrence Information

    OptionalMax use 2

    To supply information related to the delivery of health care

    Usage notes
    • Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    BH
    Occurrence
    C022-02
    1271
    Occurrence Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-03
    1250
    Date Time Period Format Qualifier
    Required

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

    • C022-03 is the date format that will appear in C022-04.
    D8
    Date Expressed in Format CCYYMMDD
    C022-04
    1251
    Occurrence Code Date
    Required
    Min 1Max 35

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

    HI-02
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    BH
    Occurrence
    C022-02
    1271
    Occurrence Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-03
    1250
    Date Time Period Format Qualifier
    Required

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

    • C022-03 is the date format that will appear in C022-04.
    D8
    Date Expressed in Format CCYYMMDD
    C022-04
    1251
    Occurrence Code Date
    Required
    Min 1Max 35

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

    HI-03
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    BH
    Occurrence
    C022-02
    1271
    Occurrence Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-03
    1250
    Date Time Period Format Qualifier
    Required

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

    • C022-03 is the date format that will appear in C022-04.
    D8
    Date Expressed in Format CCYYMMDD
    C022-04
    1251
    Occurrence Code Date
    Required
    Min 1Max 35

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

    HI-04
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    BH
    Occurrence
    C022-02
    1271
    Occurrence Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-03
    1250
    Date Time Period Format Qualifier
    Required

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

    • C022-03 is the date format that will appear in C022-04.
    D8
    Date Expressed in Format CCYYMMDD
    C022-04
    1251
    Occurrence Code Date
    Required
    Min 1Max 35

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

    HI-05
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send.

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    BH
    Occurrence
    C022-02
    1271
    Occurrence Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    C022-03
    1250
    Date Time Period Format Qualifier
    Required

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

    • C022-03 is the date format that will appear in C022-04.
    D8
    Date Expressed in Format CCYYMMDD