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Health Care Claim Status Request (X212)
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X12 276 Health Care Claim Status Request (X212)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Status Request Transaction Set (276) for use within the context of an Electronic Data Interchange (EDI) environment.
This transaction set can be used by a provider, recipient of health care products or services, or their authorized agent to request the status of a health care claim or encounter from a health care payer. This transaction set is not intended to replace the Health Care Claim Transaction Set (837), but rather to occur after the receipt of a claim or encounter information.
The request may occur at the summary or service line detail level.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    detail
    Information Source Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Information Receiver Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Service Provider Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Subscriber Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    DMG
    0400
    Subscriber Demographic Information
    Max use 1
    Optional
    Claim Status Tracking Number Loop
    SE
    1600
    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

    HR
    Health Care Claim Status Request (276)
    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

    005010X212
    ANSI ASC X12 Health Care Claim Status Request (276) and Health Care Information Status Notification (277) mandated under HIPAA through August 2006

    Heading

    ST
    0100

    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).
    276
    Health Care Claim Status Request
    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 Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there.
    ST-03
    1705
    Version, Release, or Industry Identifier
    Required

    Reference assigned to identify Implementation Convention

    • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
    Usage notes
    • This element must be populated with the implementation guide Version/Release/Industry Identifier Code named in Section 1.2.
    • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
    005010X212
    BHT
    0200

    Beginning of Hierarchical Transaction

    RequiredMax use 1

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

    Example
    BHT-01
    1005
    Hierarchical Structure Code
    Required

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

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

    Code identifying purpose of transaction set

    13
    Request
    BHT-03
    127
    Reference Identification
    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.
    BHT-04
    373
    Transaction Set Creation Date
    Required
    CCYYMMDD format

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

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

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

    • BHT05 is the time the transaction was created within the business application system.

    Detail

    2000A Information Source Level Loop
    RequiredMax >1
    HL
    0100

    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.
    2100A Payer Name Loop
    RequiredMax 1
    NM1
    0500

    Payer 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

    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

    Individual last name or organizational name

    SECURITY HEALTH PLAN
    SHP
    NM1-08
    66
    Identification Code Qualifier
    Required

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

    PI
    Payor Identification

    Payer identification number established through trading partner agreement.

    NM1-09
    67
    Payer Identifier
    Required

    Code identifying a party or other code

    SHP
    2000B Information Receiver Level Loop
    RequiredMax >1
    HL
    0100

    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.
    21
    Information Receiver
    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.
    2100B Information Receiver Name Loop
    RequiredMax 1
    NM1
    0500

    Information 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

    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
    Information Receiver Last or Organization Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Information Receiver First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Information Receiver Middle Name
    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)
    NM1-09
    67
    Information Receiver Identification Number
    Required
    Min 2Max 80

    Code identifying a party or other code

    Usage notes
    • The ETIN is established through Trading Partner agreement.
    2000C Service Provider Level Loop
    RequiredMax >1
    HL
    0100

    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.
    19
    Provider of Service
    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.
    2100C Provider Name Loop
    RequiredMax 2
    NM1
    0500

    Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Provider of Service is generic in that this could be the entity that originally submitted the claim (Billing Provider) or may be the entity that provided or participated in some aspect of the health care (Rendering Provider). The provider identified facilitates identification of the claim within a payer's system.
    • During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
    • After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop may be sent with the NPI reported in the NM109 and NM108=XX.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    1P
    Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

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

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

    NM1-09
    67
    Provider Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    2000D Subscriber Level Loop
    RequiredMax >1
    HL
    0100

    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.
    DMG
    0400

    Subscriber Demographic Information

    OptionalMax use 1

    To supply demographic information

    Usage notes
    • Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.
    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
    Optional

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    2100D Subscriber Name Loop
    RequiredMax 1
    NM1
    0500

    Subscriber 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

    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

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

    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

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    MI
    Member Identification Number
    NM1-09
    67
    Subscriber Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    Usage notes

    Medicaid ID
    Subscriber ID

    2200D Claim Status Tracking Number Loop
    OptionalMax >1
    TRN
    0900

    Claim Status Tracking Number

    RequiredMax use 1

    To uniquely identify a transaction to an application

    Usage notes
    • This segment conveys a unique trace or reference number for each 2200D loop. This number will be returned in the 277 response.
    • Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.
    • When the patient is not the subscriber or a dependent with a unique identification number, the Loop 2200E TRN and subsequent segments will be used to reflect the claim status information.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers
    TRN-02
    127
    Current Transaction Trace Number
    Required
    Min 1Max 50

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

    • TRN02 provides unique identification for the transaction.
    REF
    1000

    Application or Location System Identifier

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the application or location system identifier is known. If not required by this implementation guide, do not send.
    • This identifier will be provided to the Information Receiver by the Information Source through a companion document or other trading partner document. If a payer has multiple adjudication systems processing the same type of claim (e.g. professional or institutional), this identifier can be used to improve status routing and response time.
    Example
    Variants (all may be used)
    REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFGroup NumberREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    LU
    Location Number
    REF-02
    127
    Application or Location System Identifier
    Required
    Min 1Max 50

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

    REF
    1000

    Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when a Clearinghouse or other transmission intermediary needs to attach their own unique claim number. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    D9
    Claim Number
    REF-02
    127
    Clearinghouse Trace Number
    Required
    Min 1Max 50

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

    REF
    1000

    Group Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    6P
    Group Number
    REF-02
    127
    Group Number
    Required
    Min 1Max 50

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

    REF
    1000

    Institutional Bill Type Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when needed to refine the search criteria on Institutional claims. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    BLT
    Billing Type
    REF-02
    127
    Bill Type Identifier
    Required
    Min 1Max 50

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

    Usage notes
    • Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
      Code Source 236: Uniform Billing Claim Form Bill Type
      Code Source 235: Claim Frequency Type Code
    REF
    1000

    Patient Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.
    • The maximum number of characters supported for the Patient Control Number is `20'.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EJ
    Patient Account Number
    REF-02
    127
    Patient Control Number
    Required
    Min 1Max 50

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

    REF
    1000

    Payer Claim Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
    • Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    1K
    Payor's Claim 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
    1000

    Pharmacy Prescription Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    XZ
    Pharmacy Prescription Number
    REF-02
    127
    Pharmacy Prescription Number
    Required
    Min 1Max 50

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

    AMT
    1100

    Claim Submitted Charges

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.
    • Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.
    Example
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    T3
    Total Submitted Charges
    AMT-02
    782
    Total Claim Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    DTP
    1200

    Claim Service Date

    OptionalMax use 1

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

    Usage notes
    • For professional claims, this date is derived from the service level dates.
    • Required for institutional claims or for professional and dental claims when the service date (Loop 2210) is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    472
    Service
    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
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

    RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.

    DTP-03
    1251
    Claim Service Period
    Required
    Min 1Max 35

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

    2210D Service Line Information Loop
    OptionalMax >1
    SVC
    1300

    Service Line Information

    RequiredMax use 1

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

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

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

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

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

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

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

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

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

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

    This code is the NUBC Revenue Code.

    WK
    Advanced Billing Concepts (ABC) Codes

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

    C003-02
    234
    Procedure Code
    Required
    Min 1Max 48

    Identifying number for a product or service

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

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

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

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

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

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

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

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

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

    Monetary amount

    • SVC02 is the submitted service charge.
    Usage notes
    • This amount is the original submitted charge.
    SVC-04
    234
    Revenue Code
    Optional
    Min 1Max 48

    Identifying number for a product or service

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

    Numeric value of quantity

    • SVC07 is the original submitted units of service.
    REF
    1400

    Service Line Item Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    FJ
    Line Item Control Number
    REF-02
    127
    Line Item Control Number
    Required
    Min 1Max 50

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

    DTP
    1500

    Service Line Date

    RequiredMax use 1

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

    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    472
    Service
    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
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

    RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.

    DTP-03
    1251
    Service Line Date
    Required
    Min 1Max 35

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

    2000E Dependent Level Loop
    OptionalMax >1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    0
    No Subordinate HL Segment in This Hierarchical Structure.
    DMG
    0400

    Dependent Demographic Information

    RequiredMax use 1

    To supply demographic information

    Example
    DMG-01
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    • DMG02 is the date of birth.
    DMG-03
    1068
    Patient Gender Code
    Optional

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    2100E Dependent Name Loop
    RequiredMax 1
    NM1
    0500

    Dependent 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

    QC
    Patient
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    2200E Claim Status Tracking Number Loop
    RequiredMax >1
    TRN
    0900

    Claim Status Tracking Number

    RequiredMax use 1

    To uniquely identify a transaction to an application

    Usage notes
    • This segment conveys a unique trace or reference for each 2200E Loop. This number will be returned in the 277 response.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers
    TRN-02
    127
    Current Transaction Trace Number
    Required
    Min 1Max 50

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

    • TRN02 provides unique identification for the transaction.
    REF
    1000

    Application or Location System Identifier

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the application or location system identifier is known. If not required by this implementation guide, do not send.
    • This identifier will be provided to the Information Receiver by the Information Source through a companion document or other trading partner document. If a payer has multiple adjudication systems processing the same type of claim (e.g. professional or institutional), this identifier can be used to improve status routing and response time.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    LU
    Location Number
    REF-02
    127
    Application or Location System Identifier
    Required
    Min 1Max 50

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

    REF
    1000

    Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when a Clearinghouse or other transmission intermediary needs to attach their own unique claim number. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    D9
    Claim Number
    REF-02
    127
    Clearinghouse Trace Number
    Required
    Min 1Max 50

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

    REF
    1000

    Group Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    6P
    Group Number
    REF-02
    127
    Group Number
    Required
    Min 1Max 50

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

    REF
    1000

    Institutional Bill Type Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when needed to refine the search criteria on Institutional claims. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    BLT
    Billing Type
    REF-02
    127
    Bill Type Identifier
    Required
    Min 1Max 50

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

    Usage notes
    • Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
      Code Source 236: Uniform Billing Claim Form Bill Type
      Code Source 235: Claim Frequency Type Code
    REF
    1000

    Patient Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.
    • The maximum number of characters supported for the Patient Control Number is `20'.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EJ
    Patient Account Number
    REF-02
    127
    Patient Control Number
    Required
    Min 1Max 50

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

    REF
    1000

    Payer Claim Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
    • Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    1K
    Payor's Claim 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
    1000

    Pharmacy Prescription Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    XZ
    Pharmacy Prescription Number
    REF-02
    127
    Pharmacy Prescription Number
    Required
    Min 1Max 50

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

    AMT
    1100

    Claim Submitted Charges

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.
    • Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.
    Example
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    T3
    Total Submitted Charges
    AMT-02
    782
    Total Claim Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    DTP
    1200

    Claim Service Date

    OptionalMax use 1

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

    Usage notes
    • For professional claims, this date is derived from the service level dates.
    • Required for institutional claims or for professional and dental claims when the service date (Loop 2210) is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    472
    Service
    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
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

    RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.

    DTP-03
    1251
    Claim Service Period
    Required
    Min 1Max 35

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

    2210E Service Line Information Loop
    OptionalMax >1
    SVC
    1300

    Service Line Information

    RequiredMax use 1

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

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

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

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

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

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

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

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

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

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

    This code is the NUBC Revenue Code.

    WK
    Advanced Billing Concepts (ABC) Codes

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

    C003-02
    234
    Procedure Code
    Required
    Min 1Max 48

    Identifying number for a product or service

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

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

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

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

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

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

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

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

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

    Monetary amount

    • SVC02 is the submitted service charge.
    Usage notes
    • This amount is the original submitted charge.
    SVC-04
    234
    Revenue Code
    Optional
    Min 1Max 48

    Identifying number for a product or service

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

    Numeric value of quantity

    • SVC07 is the original submitted units of service.
    REF
    1400

    Service Line Item Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    FJ
    Line Item Control Number
    REF-02
    127
    Line Item Control Number
    Required
    Min 1Max 50

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

    DTP
    1500

    Service Line Date

    RequiredMax use 1

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

    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    472
    Service
    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
    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

    RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.

    DTP-03
    1251
    Service Line Date
    Required
    Min 1Max 35

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

    SE
    1600

    Transaction Set Trailer

    RequiredMax use 1

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

    Example
    SE-01
    96
    Transaction Segment Count
    Required
    Min 1Max 10

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

    SE-02
    329
    Transaction Set Control Number
    Required
    Min 4Max 9

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

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

    Functional Group Trailer

    RequiredMax use 1

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

    Example
    GE-01
    97
    Number of Transaction Sets Included
    Required
    Min 1Max 6

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

    GE-02
    28
    Group Control Number
    Required
    Min 1Max 9

    Assigned number originated and maintained by the sender

    Interchange Control Trailer

    RequiredMax use 1

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

    Example
    IEA-01
    I16
    Number of Included Functional Groups
    Required
    Min 1Max 5

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

    IEA-02
    I12
    Interchange Control Number
    Required
    Min 9Max 9

    A control number assigned by the interchange sender

    EDI Samples

    Example 1: Claim Level Status

    ST*276*0001*005010X212~
    BHT*0010*13*ABC276XXX*20050915*1425~
    HL*1**20*1~
    NM1*PR*2*ABC INSURANCE*****PI*12345~
    HL*2*1*21*1~
    NM1*41*2*XYZ SERVICE*****46*X67E~
    HL*3*2*19*1~
    NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
    HL*4*3*22*0~
    DMG*D8*19301210*M~
    NM1*IL*1*SMITH*FRED****MI*123456789A~
    TRN*1*ABCXYZ1~
    REF*BLT*111~
    REF*EJ*SM123456~
    AMT*T3*8513.88~
    DTP*472*RD8*20050831-20050906~
    HL*5*3*22*0~
    DMG*D8*19301115*F~
    NM1*IL*1*JONES*MARY****MI*234567890A~
    TRN*1*ABCXYZ2~
    REF*BLT*111~
    REF*EJ*JO234567~
    AMT*T3*7599~
    DTP*472*RD8*20050731-20050809~
    HL*6*2*19*1~
    NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~
    HL*7*6*22*1~
    NM1*IL*1*MANN*JOHN****MI*345678901~
    HL*8*7*23~
    DMG*D8*19951101*M~
    NM1*QC*1*MANN*JOSEPH~
    TRN*1*ABCXYZ3~
    REF*EJ*MA345678~
    SVC*HC>99203*150*****1~
    DTP*472*D8*20050501~
    SE*36*0001~

    Example 2: Provider Level Status

    ST*276*0001*005010X212~
    BHT*0010*13*ABC276XXX*20050915*1425~
    HL*1**20*1~
    NM1*PR*2*ABC INSURANCE*****PI*12345~
    HL*2*1*21*1~
    NM1*41*2*XYZ SERVICE*****46*X67E~
    HL*3*2*19*1~
    NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
    HL*4*3*22*0~
    DMG*D8*19301210*M~
    NM1*IL*1*SMITH*FRED****MI*123456789A~
    TRN*1*ABCXYZ1~
    REF*BLT*111~
    REF*EJ*SM123456~
    AMT*T3*8513.88~
    DTP*472*RD8*20050831-20050906~
    HL*5*2*19*1~
    NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*6166666666~
    HL*6*5*22*1~
    NM1*IL*1*MANN*JOHN****MI*345678901~
    HL*7*6*23~
    DMG*D8*19951101*M~
    NM1*QC*1*MANN*JOSEPH~
    TRN*1*ABCXYZ3~
    REF*EJ*MA345678~
    SVC*HC>99203*150*****1~
    DTP*472*D8*20050501~
    SE*28*0001~

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