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Health Care Information Status Notification (X212)
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X12 277 Health Care Information Status Notification (X212)

X12 Release 5010

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

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

    Interchange Control Header

    RequiredMax use 1

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

    Example
    ISA-01
    I01
    Authorization Information Qualifier
    Required

    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

    HN
    Health Care Information Status Notification (277)
    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).
    277
    Health Care Information Status Notification
    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

    08
    Status
    BHT-03
    127
    Originator Application Transaction Identifier
    Required
    Min 1Max 50

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

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

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

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

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

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

    Code specifying the type of transaction

    DG
    Response

    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
    PER
    0800

    Payer Contact Information

    OptionalMax use 1

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

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

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

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

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    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.
    0
    No Subordinate HL Segment in This Hierarchical Structure.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    2100B Information Receiver Name Loop
    RequiredMax 1
    NM1
    0500

    Information Receiver Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

    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.
    2200B Information Receiver Trace Identifier Loop
    OptionalMax 1
    TRN
    0900

    Information Receiver Trace Identifier

    RequiredMax use 1

    To uniquely identify a transaction to an application

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

    Code identifying which transaction is being referenced

    2
    Referenced Transaction Trace Numbers
    TRN-02
    127
    Claim Transaction Batch 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.
    Usage notes
    • This value must be the BHT03 data element value from the 276 Claim Status Request being rejected.
    STC
    1000

    Information Receiver Status Information

    RequiredMax use >1

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

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

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid values.
    2000C Service Provider 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.
    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.
    0
    No Subordinate HL Segment in This Hierarchical Structure.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    2100C Provider Name Loop
    RequiredMax 2
    NM1
    0500

    Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

    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

    2200C Provider of Service Trace Identifier Loop
    OptionalMax 1
    TRN
    0900

    Provider of Service Trace Identifier

    RequiredMax use 1

    To uniquely identify a transaction to an application

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

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers
    TRN-02
    127
    Provider of Service Information Trace Identifier
    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.
    STC
    1000

    Provider Status Information

    RequiredMax use >1

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

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

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

    • C043-03 identifies the entity associated with the Health Care Claim Status Code.
    Usage notes
    • See STC01-3 for valid value.
    2000D Subscriber 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.
    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.
    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)

    24
    Employer's Identification Number

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

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

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

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

    Code identifying a party or other code

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

    Code identifying which transaction is being referenced

    2
    Referenced Transaction Trace Numbers
    TRN-02
    127
    Referenced 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.
    STC
    1000

    Claim Level Status Information

    RequiredMax use >1

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

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

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

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

    Code identifying a specific industry code list

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

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

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

    Monetary amount

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

    Monetary amount

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

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

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

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

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

    Check identification number

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

    • C043-04 is used to identify the Code Source referenced in C043-02.
    RX
    National Council for Prescription Drug Programs Reject/Payment Codes
    REF
    1100

    Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Institutional Bill Type Identification

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Patient Control Number

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Payer Claim Control Number

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Pharmacy Prescription Number

    OptionalMax use 1

    To specify identifying information

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

    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

    REF
    1100

    Voucher Identifier

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    VV
    Voucher
    REF-02
    127
    Voucher Identifier
    Required
    Min 1Max 50

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

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

    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
    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

    2220D Service Line Information Loop
    OptionalMax >1
    SVC
    1800

    Service Line Information

    RequiredMax use 1

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

    Usage notes
    • Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
    • For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
    Example
    SVC-01
    C003
    Composite Medical Procedure Identifier
    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 is the line item total on the current claim service status.
    SVC-03
    782
    Line Item Payment Amount
    Required
    Min 1Max 15

    Monetary amount

    • SVC03 is the amount paid this service.
    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.
    STC
    1900

    Service Line Status Information

    RequiredMax use >1

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

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

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

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

    Code identifying a specific industry code list

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

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

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

    • C043-04 is used to identify the Code Source referenced in C043-02.
    RX
    National Council for Prescription Drug Programs Reject/Payment Codes
    REF
    2000

    Service Line Item Identification

    OptionalMax use 1

    To specify identifying information

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

    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
    2100

    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
    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.
    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 is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    2
    Referenced Transaction Trace Numbers
    TRN-02
    127
    Referenced 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.
    STC
    1000

    Claim Level Status Information

    RequiredMax use >1

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

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

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

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

    Code identifying a specific industry code list

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

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

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

    Monetary amount

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

    Monetary amount

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

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

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

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

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

    Check identification number

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

    • C043-04 is used to identify the Code Source referenced in C043-02.
    RX
    National Council for Prescription Drug Programs Reject/Payment Codes
    REF
    1100

    Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Institutional Bill Type Identification

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Patient Control Number

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Payer Claim Control Number

    OptionalMax use 1

    To specify identifying information

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

    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
    1100

    Pharmacy Prescription Number

    OptionalMax use 1

    To specify identifying information

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

    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

    REF
    1100

    Voucher Identifier

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    VV
    Voucher
    REF-02
    127
    Voucher Identifier
    Required
    Min 1Max 50

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

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

    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
    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

    2220E Service Line Information Loop
    OptionalMax >1
    SVC
    1800

    Service Line Information

    RequiredMax use 1

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

    Usage notes
    • Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
    • For Institutional claims, when both an NUBC revenue code and a HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
    Example
    SVC-01
    C003
    Composite Medical Procedure Identifier
    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 is the line item total on the current claim service status.
    SVC-03
    782
    Line Item Payment Amount
    Required
    Min 1Max 15

    Monetary amount

    • SVC03 is the amount paid this service.
    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.
    STC
    1900

    Service Line Status Information

    RequiredMax use >1

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

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

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

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

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

    Code identifying a specific industry code list

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

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

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

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

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

    C043-01
    1271
    Health Care Claim Status Category Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    Code indicating a code from a specific industry code list

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

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

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

    Code identifying a specific industry code list

    • C043-04 is used to identify the Code Source referenced in C043-02.
    RX
    National Council for Prescription Drug Programs Reject/Payment Codes
    REF
    2000

    Service Line Item Identification

    OptionalMax use 1

    To specify identifying information

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

    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
    2100

    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
    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
    2700

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

    Example 2: Provider Level Status

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

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