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Health Care Claim Status Request (X212)
  • Specification
  • EDI Inspector
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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
EDI samples
  • Example 1: Claim Level Status
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
Information Source Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Information Receiver Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
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
Identifier (ID)

Code identifying the type of information in the Authorization Information

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

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

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

Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

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

Date of the interchange

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

Time of the interchange

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

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

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

Code specifying the version number of the interchange control segments

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

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

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

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

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

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

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

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

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

Code identifying a group of application related transaction sets

HR
Health Care Claim Status Request (276)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

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

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

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

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

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

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

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

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

Assigned number originated and maintained by the sender

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

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

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

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

005010X212

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

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

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

Code uniquely identifying a Transaction Set

  • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
276
Health Care Claim Status Request
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

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

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

Reference assigned to identify Implementation Convention

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

Beginning of Hierarchical Transaction

RequiredMax use 1

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

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

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

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

Code identifying purpose of transaction set

13
Request
BHT-03
127
Reference Identification
Required
String (AN)
Min 1Max 50

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

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

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

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

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

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

Detail

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

Hierarchical Level

RequiredMax use 1

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

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

Payer Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

SECURITY HEALTH PLAN
SHP
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

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

PI
Payor Identification

Payer identification number established through trading partner agreement.

NM1-09
67
Payer Identifier
Required
String (AN)

Code identifying a party or other code

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

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

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

Information Receiver Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

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

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

Code identifying a party or other code

Usage notes
  • The ETIN is established through Trading Partner agreement.
2100B Information Receiver Name Loop end
2000C Service Provider Level Loop
RequiredMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
2100C Provider Name Loop
RequiredMax 2
NM1
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider Name Loop > NM1

Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • 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
Identifier (ID)

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

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

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

Code identifying a party or other code

2100C Provider Name Loop end
2000D Subscriber Level Loop
RequiredMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
DMG
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > DMG

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
Identifier (ID)

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

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

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

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

Code indicating the sex of the individual

F
Female
M
Male
2100D Subscriber Name Loop
RequiredMax 1
NM1
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

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

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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

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

Code identifying a party or other code

Usage notes

Medicaid ID
Subscriber ID

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

Claim Status Tracking Number

RequiredMax use 1

To uniquely identify a transaction to an application

Usage notes
  • This 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
Identifier (ID)

Code identifying which transaction is being referenced

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

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

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

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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when 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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

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
Identifier (ID)

Code qualifying the Reference Identification

6P
Group Number
REF-02
127
Group Number
Required
String (AN)
Min 1Max 50

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Institutional Bill Type Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required 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
Identifier (ID)

Code qualifying the Reference Identification

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

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

Usage notes
  • Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
    Code Source 236: Uniform Billing Claim Form Bill Type
    Code Source 235: Claim Frequency Type Code
REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Patient Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Patient Control Number 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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Payer Claim Control Number

OptionalMax use 1

To specify identifying information

Usage notes
  • 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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

Pharmacy Prescription Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the Pharmacy Prescription Number 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
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

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
Identifier (ID)

Code to qualify amount

T3
Total Submitted Charges
AMT-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

Claim Service Date

OptionalMax use 1

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

Usage notes
  • For professional claims, this date is derived from the service level dates.
  • 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
Identifier (ID)

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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
String (AN)
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
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

Service Line Information

RequiredMax use 1

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

Usage notes
  • 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
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

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

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

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

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

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

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

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

This code is the NUBC Revenue Code.

WK
Advanced Billing Concepts (ABC) Codes

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

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

Identifying number for a product or service

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

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

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

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

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

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

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

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

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

Monetary amount

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

Identifying number for a product or service

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

Numeric value of quantity

  • SVC07 is the original submitted units of service.
REF
1400
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

Service Line Item Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when 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
Identifier (ID)

Code qualifying the Reference Identification

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

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

DTP
1500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

Service Line Date

RequiredMax use 1

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

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

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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
String (AN)
Min 1Max 35

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

2210D Service Line Information Loop end
2200D Claim Status Tracking Number Loop end
2000E Dependent Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

Hierarchical Level

RequiredMax use 1

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

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

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

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

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

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

Code defining the characteristic of a level in a hierarchical structure

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

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

  • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0
No Subordinate HL Segment in This Hierarchical Structure.
DMG
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > DMG

Dependent Demographic Information

RequiredMax use 1

To supply demographic information

Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

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

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

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

Code indicating the sex of the individual

F
Female
M
Male
2100E Dependent Name Loop
RequiredMax 1
NM1
0500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

Dependent Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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

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

Code qualifying the type of entity

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

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

Claim Status Tracking Number

RequiredMax use 1

To uniquely identify a transaction to an application

Usage notes
  • This 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
Identifier (ID)

Code identifying which transaction is being referenced

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

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

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

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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

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
Identifier (ID)

Code qualifying the Reference Identification

6P
Group Number
REF-02
127
Group Number
Required
String (AN)
Min 1Max 50

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

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
Identifier (ID)

Code qualifying the Reference Identification

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

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

Usage notes
  • Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values.
    Code Source 236: Uniform Billing Claim Form Bill Type
    Code Source 235: Claim Frequency Type Code
REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

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
Identifier (ID)

Code qualifying the Reference Identification

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

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

REF
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > REF

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
Identifier (ID)

Code qualifying the Reference Identification

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

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

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

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
Identifier (ID)

Code to qualify amount

T3
Total Submitted Charges
AMT-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

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

Claim Service Date

OptionalMax use 1

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

Usage notes
  • For professional claims, this date is derived from the service level dates.
  • 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
Identifier (ID)

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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
String (AN)
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
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

Service Line Information

RequiredMax use 1

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

Usage notes
  • 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
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

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

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

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

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

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

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

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

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

This code is the NUBC Revenue Code.

WK
Advanced Billing Concepts (ABC) Codes

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

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

Identifying number for a product or service

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

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

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

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

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

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

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

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

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

Monetary amount

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

Identifying number for a product or service

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

Numeric value of quantity

  • SVC07 is the original submitted units of service.
REF
1400
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

Service Line Item Identification

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when 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
Identifier (ID)

Code qualifying the Reference Identification

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

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

DTP
1500
Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Dependent Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

Service Line Date

RequiredMax use 1

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

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

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

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

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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
String (AN)
Min 1Max 35

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

2210E Service Line Information Loop end
2200E Claim Status Tracking Number Loop end
2000E Dependent Level Loop end
2000D Subscriber Level Loop end
2000C Service Provider Level Loop end
2000B Information Receiver Level Loop end
2000A Information Source Level Loop end
SE
1600
Detail > SE

Transaction Set Trailer

RequiredMax use 1

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

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

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

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

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

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

Functional Group Trailer

RequiredMax use 1

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

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

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

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

Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

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

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

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

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

A control number assigned by the interchange sender

EDI Samples

Example 1: Claim Level Status

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0215*^*00501*000000001*0*T*>~
GS*HR*SENDERGS*RECEIVERGS*20231103*021550*000000001*X*005010X212~
ST*276*0001*005010X212~
BHT*0010*13*ABC276XXX*20050915*1425~
HL*1**20*1~
NM1*PR*2*SECURITY HEALTH PLAN*****PI*SHP~
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~
GE*1*000000001~
IEA*1*000000001~

Example 2: Provider Level Status

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231103*0216*^*00501*000000001*0*T*>~
GS*HR*SENDERGS*RECEIVERGS*20231103*021611*000000001*X*005010X212~
ST*276*0001*005010X212~
BHT*0010*13*ABC276XXX*20050915*1425~
HL*1**20*1~
NM1*PR*2*SECURITY HEALTH PLAN*****PI*SHP~
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~
GE*1*000000001~
IEA*1*000000001~

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