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Health Care Claim: Dental (X224A3)
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X12 837 Health Care Claim: Dental (X224A3)

X12 Release 5010

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

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

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    ST
    0050
    Transaction Set Header
    Max use 1
    Required
    BHT
    0100
    Beginning of Hierarchical Transaction
    Max use 1
    Required
    Receiver Name Loop
    NM1
    0200
    Receiver Name
    Max use 1
    Required
    Submitter Name Loop
    NM1
    0200
    Submitter Name
    Max use 1
    Required
    PER
    0450
    Submitter EDI Contact Information
    Max use 2
    Required
    detail
    Billing Provider Hierarchical Level Loop
    HL
    0010
    Hierarchical Level
    Max use 1
    Required
    PRV
    0030
    Billing Provider Specialty Information
    Max use 1
    Optional
    CUR
    0100
    Foreign Currency Information
    Max use 1
    Optional
    Billing Provider Name Loop
    NM1
    0150
    Billing Provider Name
    Max use 1
    Required
    N3
    0250
    Billing Provider Address
    Max use 1
    Required
    N4
    0300
    Billing Provider City, State, ZIP Code
    Max use 1
    Required
    REF
    0350
    Billing Provider Tax Identification
    Max use 1
    Required
    REF
    0350
    Billing Provider UPIN/License Information
    Max use 2
    Optional
    PER
    0400
    Billing Provider Contact Information
    Max use 2
    Optional
    Pay-to Address Name Loop
    NM1
    0150
    Pay-to Address Name
    Max use 1
    Required
    N3
    0250
    Pay-to Address - ADDRESS
    Max use 1
    Required
    N4
    0300
    Pay-To Address City, State, ZIP Code
    Max use 1
    Required
    Pay-To Plan Name Loop
    NM1
    0150
    Pay-To Plan Name
    Max use 1
    Required
    N3
    0250
    Pay-to Plan Address
    Max use 1
    Required
    N4
    0300
    Pay-To Plan City, State, ZIP Code
    Max use 1
    Required
    REF
    0350
    Pay-to Plan Secondary Identification
    Max use 1
    Optional
    REF
    0350
    Pay-To Plan Tax Identification Number
    Max use 1
    Required
    Subscriber Hierarchical Level Loop
    HL
    0010
    Hierarchical Level
    Max use 1
    Required
    SBR
    0050
    Subscriber Information
    Max use 1
    Required
    Payer Name Loop
    NM1
    0150
    Payer Name
    Max use 1
    Required
    N3
    0250
    Payer Address
    Max use 1
    Optional
    N4
    0300
    Payer City, State, ZIP Code
    Max use 1
    Optional
    REF
    0350
    Billing Provider Secondary Identification
    Max use 1
    Optional
    REF
    0350
    Payer Secondary Identification
    Max use 3
    Optional
    Subscriber Name Loop
    NM1
    0150
    Subscriber Name
    Max use 1
    Required
    N3
    0250
    Subscriber Address
    Max use 1
    Optional
    N4
    0300
    Subscriber City, State, ZIP Code
    Max use 1
    Optional
    DMG
    0320
    Subscriber Demographic Information
    Max use 1
    Optional
    REF
    0350
    Property and Casualty Claim Number
    Max use 1
    Optional
    REF
    0350
    Subscriber Secondary Identification
    Max use 1
    Optional
    Claim Information Loop
    CLM
    1300
    Claim Information
    Max use 1
    Required
    DTP
    1350
    Date - Accident
    Max use 1
    Optional
    DTP
    1350
    Date - Appliance Placement
    Max use 1
    Optional
    DTP
    1350
    Date - Repricer Received Date
    Max use 1
    Optional
    DTP
    1350
    Date - Service Date
    Max use 1
    Optional
    DN1
    1450
    Orthodontic Total Months of Treatment
    Max use 1
    Optional
    DN2
    1500
    Tooth Status
    Max use 35
    Optional
    PWK
    1550
    Claim Supplemental Information
    Max use 10
    Optional
    CN1
    1600
    Contract Information
    Max use 1
    Optional
    AMT
    1750
    Patient Amount Paid
    Max use 1
    Optional
    REF
    1800
    Adjusted Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Claim Identifier For Transmission Intermediaries
    Max use 1
    Optional
    REF
    1800
    Payer Claim Control Number
    Max use 1
    Optional
    REF
    1800
    Predetermination Identification
    Max use 1
    Optional
    REF
    1800
    Prior Authorization
    Max use 1
    Optional
    REF
    1800
    Referral Number
    Max use 1
    Optional
    REF
    1800
    Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Service Authorization Exception Code
    Max use 1
    Optional
    K3
    1850
    File Information
    Max use 10
    Optional
    NTE
    1900
    Claim Note
    Max use 5
    Optional
    HI
    2310
    Health Care Diagnosis Code
    Max use 1
    Optional
    HCP
    2410
    Claim Pricing/Repricing Information
    Max use 1
    Optional
    Assistant Surgeon Name Loop
    NM1
    2500
    Assistant Surgeon Name
    Max use 1
    Required
    PRV
    2550
    Assistant Surgeon Specialty Information
    Max use 1
    Required
    REF
    2710
    Assistant Surgeon Secondary Identification
    Max use 4
    Optional
    Referring Provider Name Loop
    NM1
    2500
    Referring Provider Name
    Max use 1
    Required
    PRV
    2550
    Referring Provider Specialty Information
    Max use 1
    Optional
    REF
    2710
    Referring Provider Secondary Identification
    Max use 3
    Optional
    Rendering Provider Name Loop
    NM1
    2500
    Rendering Provider Name
    Max use 1
    Required
    PRV
    2550
    Rendering Provider Specialty Information
    Max use 1
    Required
    REF
    2710
    Rendering Provider Secondary Identification
    Max use 4
    Optional
    Service Facility Location Name Loop
    NM1
    2500
    Service Facility Location Name
    Max use 1
    Required
    N3
    2650
    Service Facility Location Address
    Max use 1
    Required
    N4
    2700
    Service Facility Location City, State, ZIP Code
    Max use 1
    Required
    REF
    2710
    Service Facility Location Secondary Identification
    Max use 3
    Optional
    Supervising Provider Name Loop
    NM1
    2500
    Supervising Provider Name
    Max use 1
    Required
    REF
    2710
    Supervising Provider Secondary Identification
    Max use 4
    Optional
    Other Subscriber Information Loop
    SBR
    2900
    Other Subscriber Information
    Max use 1
    Required
    CAS
    2950
    Claim Level Adjustments
    Max use 5
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Payer Paid Amount
    Max use 1
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Total Non-Covered Amount
    Max use 1
    Optional
    AMT
    3000
    Remaining Patient Liability
    Max use 1
    Optional
    OI
    3100
    Other Insurance Coverage Information
    Max use 1
    Required
    MOA
    3200
    Outpatient Adjudication Information
    Max use 1
    Optional
    Other Payer Assistant Surgeon Loop
    NM1
    3250
    Other Payer Assistant Surgeon
    Max use 1
    Required
    REF
    3550
    Other Payer Assistant Surgeon Secondary Identifier
    Max use 3
    Required
    Other Payer Billing Provider Loop
    NM1
    3250
    Other Payer Billing Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Billing Provider Secondary Identification
    Max use 2
    Required
    Other Payer Name Loop
    NM1
    3250
    Other Payer Name
    Max use 1
    Required
    N3
    3320
    Other Payer Address
    Max use 1
    Optional
    N4
    3400
    Other Payer City, State, ZIP Code
    Max use 1
    Optional
    DTP
    3500
    Claim Check or Remittance Date
    Max use 1
    Optional
    REF
    3550
    Other Payer Claim Adjustment Indicator
    Max use 1
    Optional
    REF
    3550
    Other Payer Claim Control Number
    Max use 1
    Optional
    REF
    3550
    Other Payer Predetermination Identification
    Max use 1
    Optional
    REF
    3550
    Other Payer Prior Authorization Number
    Max use 1
    Optional
    REF
    3550
    Other Payer Referral Number
    Max use 1
    Optional
    REF
    3550
    Other Payer Secondary Identifier
    Max use 3
    Optional
    Other Payer Referring Provider Loop
    NM1
    3250
    Other Payer Referring Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Referring Provider Secondary Identification
    Max use 3
    Required
    Other Payer Rendering Provider Loop
    NM1
    3250
    Other Payer Rendering Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Rendering Provider Secondary Identification
    Max use 3
    Required
    Other Payer Service Facility Location Loop
    NM1
    3250
    Other Payer Service Facility Location
    Max use 1
    Required
    REF
    3550
    Other Payer Service Facility Location Secondary Identification
    Max use 3
    Required
    Other Payer Supervising Provider Loop
    NM1
    3250
    Other Payer Supervising Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Supervising Provider Secondary Identification
    Max use 3
    Required
    Other Subscriber Name Loop
    NM1
    3250
    Other Subscriber Name
    Max use 1
    Required
    N3
    3320
    Other Subscriber Address
    Max use 1
    Optional
    N4
    3400
    Other Subscriber City, State, ZIP Code
    Max use 1
    Optional
    REF
    3550
    Other Subscriber Secondary Identification
    Max use 2
    Optional
    Service Line Number Loop
    LX
    3650
    Service Line Number
    Max use 1
    Required
    SV3
    3800
    Dental Service
    Max use 1
    Required
    TOO
    3820
    Tooth Information
    Max use 32
    Optional
    DTP
    4550
    Date - Appliance Placement
    Max use 1
    Optional
    DTP
    4550
    Date - Prior Placement
    Max use 1
    Optional
    DTP
    4550
    Date - Replacement
    Max use 1
    Optional
    DTP
    4550
    Date - Service Date
    Max use 1
    Optional
    DTP
    4550
    Date - Treatment Completion
    Max use 1
    Optional
    DTP
    4550
    Date - Treatment Start
    Max use 1
    Optional
    CN1
    4650
    Contract Information
    Max use 1
    Optional
    REF
    4700
    Adjusted Repriced Claim Number
    Max use 1
    Optional
    REF
    4700
    Line Item Control Number
    Max use 1
    Optional
    REF
    4700
    Prior Authorization
    Max use 5
    Optional
    REF
    4700
    Referral Number
    Max use 5
    Optional
    REF
    4700
    Repriced Claim Number
    Max use 1
    Optional
    REF
    4700
    Service Predetermination Identification
    Max use 5
    Optional
    AMT
    4750
    Sales Tax Amount
    Max use 1
    Optional
    K3
    4800
    File Information
    Max use 10
    Optional
    HCP
    4920
    Line Pricing/Repricing Information
    Max use 1
    Optional
    Assistant Surgeon Name Loop
    NM1
    5000
    Assistant Surgeon Name
    Max use 1
    Required
    PRV
    5050
    Assistant Surgeon Specialty Information
    Max use 1
    Optional
    REF
    5250
    Assistant Surgeon Secondary Identification
    Max use 20
    Optional
    Rendering Provider Name Loop
    NM1
    5000
    Rendering Provider Name
    Max use 1
    Required
    PRV
    5050
    Rendering Provider Specialty Information
    Max use 1
    Required
    REF
    5250
    Rendering Provider Secondary Identification
    Max use 20
    Optional
    Service Facility Location Name Loop
    NM1
    5000
    Service Facility Location Name
    Max use 1
    Required
    N3
    5140
    Service Facility Location Address
    Max use 1
    Required
    N4
    5200
    Service Facility Location City, State, ZIP Code
    Max use 1
    Required
    REF
    5250
    Service Facility Location Secondary Identification
    Max use 20
    Optional
    Supervising Provider Name Loop
    NM1
    5000
    Supervising Provider Name
    Max use 1
    Required
    REF
    5250
    Supervising Provider Secondary Identification
    Max use 20
    Optional
    Line Adjudication Information Loop
    SVD
    5400
    Line Adjudication Information
    Max use 1
    Required
    CAS
    5450
    Line Adjustment
    Max use 5
    Optional
    DTP
    5500
    Line Check or Remittance Date
    Max use 1
    Required
    AMT
    5505
    Remaining Patient Liability
    Max use 1
    Optional
    Patient Hierarchical Level Loop
    HL
    0010
    Hierarchical Level
    Max use 1
    Required
    PAT
    0070
    Patient Information
    Max use 1
    Required
    Patient Name Loop
    NM1
    0150
    Patient Name
    Max use 1
    Required
    N3
    0250
    Patient Address
    Max use 1
    Required
    N4
    0300
    Patient City, State, ZIP Code
    Max use 1
    Required
    DMG
    0320
    Patient Demographic Information
    Max use 1
    Required
    REF
    0350
    Property and Casualty Claim Number
    Max use 1
    Optional
    REF
    0350
    Property and Casualty Patient Identifier
    Max use 1
    Optional
    Claim Information Loop
    CLM
    1300
    Claim Information
    Max use 1
    Required
    DTP
    1350
    Date - Accident
    Max use 1
    Optional
    DTP
    1350
    Date - Appliance Placement
    Max use 1
    Optional
    DTP
    1350
    Date - Repricer Received Date
    Max use 1
    Optional
    DTP
    1350
    Date - Service Date
    Max use 1
    Optional
    DN1
    1450
    Orthodontic Total Months of Treatment
    Max use 1
    Optional
    DN2
    1500
    Tooth Status
    Max use 35
    Optional
    PWK
    1550
    Claim Supplemental Information
    Max use 10
    Optional
    CN1
    1600
    Contract Information
    Max use 1
    Optional
    AMT
    1750
    Patient Amount Paid
    Max use 1
    Optional
    REF
    1800
    Adjusted Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Claim Identifier For Transmission Intermediaries
    Max use 1
    Optional
    REF
    1800
    Payer Claim Control Number
    Max use 1
    Optional
    REF
    1800
    Predetermination Identification
    Max use 1
    Optional
    REF
    1800
    Prior Authorization
    Max use 1
    Optional
    REF
    1800
    Referral Number
    Max use 1
    Optional
    REF
    1800
    Repriced Claim Number
    Max use 1
    Optional
    REF
    1800
    Service Authorization Exception Code
    Max use 1
    Optional
    K3
    1850
    File Information
    Max use 10
    Optional
    NTE
    1900
    Claim Note
    Max use 5
    Optional
    HI
    2310
    Health Care Diagnosis Code
    Max use 1
    Optional
    HCP
    2410
    Claim Pricing/Repricing Information
    Max use 1
    Optional
    Assistant Surgeon Name Loop
    NM1
    2500
    Assistant Surgeon Name
    Max use 1
    Required
    PRV
    2550
    Assistant Surgeon Specialty Information
    Max use 1
    Required
    REF
    2710
    Assistant Surgeon Secondary Identification
    Max use 4
    Optional
    Referring Provider Name Loop
    NM1
    2500
    Referring Provider Name
    Max use 1
    Required
    PRV
    2550
    Referring Provider Specialty Information
    Max use 1
    Optional
    REF
    2710
    Referring Provider Secondary Identification
    Max use 3
    Optional
    Rendering Provider Name Loop
    NM1
    2500
    Rendering Provider Name
    Max use 1
    Required
    PRV
    2550
    Rendering Provider Specialty Information
    Max use 1
    Required
    REF
    2710
    Rendering Provider Secondary Identification
    Max use 4
    Optional
    Service Facility Location Name Loop
    NM1
    2500
    Service Facility Location Name
    Max use 1
    Required
    N3
    2650
    Service Facility Location Address
    Max use 1
    Required
    N4
    2700
    Service Facility Location City, State, ZIP Code
    Max use 1
    Required
    REF
    2710
    Service Facility Location Secondary Identification
    Max use 3
    Optional
    Supervising Provider Name Loop
    NM1
    2500
    Supervising Provider Name
    Max use 1
    Required
    REF
    2710
    Supervising Provider Secondary Identification
    Max use 4
    Optional
    Other Subscriber Information Loop
    SBR
    2900
    Other Subscriber Information
    Max use 1
    Required
    CAS
    2950
    Claim Level Adjustments
    Max use 5
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Payer Paid Amount
    Max use 1
    Optional
    AMT
    3000
    Coordination of Benefits (COB) Total Non-Covered Amount
    Max use 1
    Optional
    AMT
    3000
    Remaining Patient Liability
    Max use 1
    Optional
    OI
    3100
    Other Insurance Coverage Information
    Max use 1
    Required
    MOA
    3200
    Outpatient Adjudication Information
    Max use 1
    Optional
    Other Payer Assistant Surgeon Loop
    NM1
    3250
    Other Payer Assistant Surgeon
    Max use 1
    Required
    REF
    3550
    Other Payer Assistant Surgeon Secondary Identifier
    Max use 3
    Required
    Other Payer Billing Provider Loop
    NM1
    3250
    Other Payer Billing Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Billing Provider Secondary Identification
    Max use 2
    Required
    Other Payer Name Loop
    NM1
    3250
    Other Payer Name
    Max use 1
    Required
    N3
    3320
    Other Payer Address
    Max use 1
    Optional
    N4
    3400
    Other Payer City, State, ZIP Code
    Max use 1
    Optional
    DTP
    3500
    Claim Check or Remittance Date
    Max use 1
    Optional
    REF
    3550
    Other Payer Claim Adjustment Indicator
    Max use 1
    Optional
    REF
    3550
    Other Payer Claim Control Number
    Max use 1
    Optional
    REF
    3550
    Other Payer Predetermination Identification
    Max use 1
    Optional
    REF
    3550
    Other Payer Prior Authorization Number
    Max use 1
    Optional
    REF
    3550
    Other Payer Referral Number
    Max use 1
    Optional
    REF
    3550
    Other Payer Secondary Identifier
    Max use 3
    Optional
    Other Payer Referring Provider Loop
    NM1
    3250
    Other Payer Referring Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Referring Provider Secondary Identification
    Max use 3
    Required
    Other Payer Rendering Provider Loop
    NM1
    3250
    Other Payer Rendering Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Rendering Provider Secondary Identification
    Max use 3
    Required
    Other Payer Service Facility Location Loop
    NM1
    3250
    Other Payer Service Facility Location
    Max use 1
    Required
    REF
    3550
    Other Payer Service Facility Location Secondary Identification
    Max use 3
    Required
    Other Payer Supervising Provider Loop
    NM1
    3250
    Other Payer Supervising Provider
    Max use 1
    Required
    REF
    3550
    Other Payer Supervising Provider Secondary Identification
    Max use 3
    Required
    Other Subscriber Name Loop
    NM1
    3250
    Other Subscriber Name
    Max use 1
    Required
    N3
    3320
    Other Subscriber Address
    Max use 1
    Optional
    N4
    3400
    Other Subscriber City, State, ZIP Code
    Max use 1
    Optional
    REF
    3550
    Other Subscriber Secondary Identification
    Max use 2
    Optional
    Service Line Number Loop
    LX
    3650
    Service Line Number
    Max use 1
    Required
    SV3
    3800
    Dental Service
    Max use 1
    Required
    TOO
    3820
    Tooth Information
    Max use 32
    Optional
    DTP
    4550
    Date - Appliance Placement
    Max use 1
    Optional
    DTP
    4550
    Date - Prior Placement
    Max use 1
    Optional
    DTP
    4550
    Date - Replacement
    Max use 1
    Optional
    DTP
    4550
    Date - Service Date
    Max use 1
    Optional
    DTP
    4550
    Date - Treatment Completion
    Max use 1
    Optional
    DTP
    4550
    Date - Treatment Start
    Max use 1
    Optional
    CN1
    4650
    Contract Information
    Max use 1
    Optional
    REF
    4700
    Adjusted Repriced Claim Number
    Max use 1
    Optional
    REF
    4700
    Line Item Control Number
    Max use 1
    Optional
    REF
    4700
    Prior Authorization
    Max use 5
    Optional
    REF
    4700
    Referral Number
    Max use 5
    Optional
    REF
    4700
    Repriced Claim Number
    Max use 1
    Optional
    REF
    4700
    Service Predetermination Identification
    Max use 5
    Optional
    AMT
    4750
    Sales Tax Amount
    Max use 1
    Optional
    K3
    4800
    File Information
    Max use 10
    Optional
    HCP
    4920
    Line Pricing/Repricing Information
    Max use 1
    Optional
    Assistant Surgeon Name Loop
    NM1
    5000
    Assistant Surgeon Name
    Max use 1
    Required
    PRV
    5050
    Assistant Surgeon Specialty Information
    Max use 1
    Optional
    REF
    5250
    Assistant Surgeon Secondary Identification
    Max use 20
    Optional
    Rendering Provider Name Loop
    NM1
    5000
    Rendering Provider Name
    Max use 1
    Required
    PRV
    5050
    Rendering Provider Specialty Information
    Max use 1
    Required
    REF
    5250
    Rendering Provider Secondary Identification
    Max use 20
    Optional
    Service Facility Location Name Loop
    NM1
    5000
    Service Facility Location Name
    Max use 1
    Required
    N3
    5140
    Service Facility Location Address
    Max use 1
    Required
    N4
    5200
    Service Facility Location City, State, ZIP Code
    Max use 1
    Required
    REF
    5250
    Service Facility Location Secondary Identification
    Max use 20
    Optional
    Supervising Provider Name Loop
    NM1
    5000
    Supervising Provider Name
    Max use 1
    Required
    REF
    5250
    Supervising Provider Secondary Identification
    Max use 20
    Optional
    Line Adjudication Information Loop
    SVD
    5400
    Line Adjudication Information
    Max use 1
    Required
    CAS
    5450
    Line Adjustment
    Max use 5
    Optional
    DTP
    5500
    Line Check or Remittance Date
    Max use 1
    Required
    AMT
    5505
    Remaining Patient Liability
    Max use 1
    Optional
    SE
    5550
    Transaction Set Trailer
    Max use 1
    Required
    GE
    -
    Functional Group Trailer
    Max use 1
    Required
    IEA
    -
    Interchange Control Trailer
    Max use 1
    Required
    ISA

    Interchange Control Header

    RequiredMax use 1

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

    Example
    ISA-01
    I01
    Authorization Information Qualifier
    Required

    Code identifying the type of information in the Authorization Information

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

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

    ISA-03
    I03
    Security Information Qualifier
    Required

    Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

    ISA-09
    I08
    Interchange Date
    Required
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    Min 1Max 1

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

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

    Code specifying the version number of the interchange control segments

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

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    Min 1Max 1

    Code indicating sender's request for an interchange acknowledgment

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

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

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

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

    >
    Component Element Separator
    GS

    Functional Group Header

    RequiredMax use 1

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

    Example
    GS-01
    479
    Functional Identifier Code
    Required

    Code identifying a group of application related transaction sets

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

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

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

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

    GS-04
    373
    Date
    Required
    CCYYMMDD format

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

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

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

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

    Assigned number originated and maintained by the sender

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

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

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

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

    005010X224A3
    ANSI ASC X12N Health Care Claims (837) for dental claims and/or encounters through June 2014

    Heading

    ST
    0050

    Transaction Set Header

    RequiredMax use 1

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

    Example
    ST-01
    143
    Transaction Set Identifier Code
    Required

    Code uniquely identifying a Transaction Set

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

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

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

    Reference assigned to identify Implementation Convention

    • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
    Usage notes
    • This element must be populated with the guide identifier named in Section 1.2.
    • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
    005010X224A3
    BHT
    0100

    Beginning of Hierarchical Transaction

    RequiredMax use 1

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

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

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

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

    Code identifying purpose of transaction set

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

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

    18
    Reissue

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

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

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

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

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

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

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

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

    Code specifying the type of transaction

    31
    Subrogation Demand

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

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

    Receiver Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    40
    Receiver
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

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

    Code identifying a party or other code

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

    Submitter Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    41
    Submitter
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    46
    Electronic Transmitter Identification Number (ETIN)

    Established by trading partner agreement

    NM1-09
    67
    Submitter Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    PER
    0450

    Submitter EDI Contact Information

    RequiredMax use 2

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

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

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    Detail

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

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

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

    Billing Provider Specialty Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Required when the Billing Provider is also the Rendering Provider for at least one of the claims in this transaction.
      If not required by this implementation guide, do not send.
    Example
    PRV-01
    1221
    Provider Code
    Required

    Code identifying the type of provider

    BI
    Billing
    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    CUR
    0100

    Foreign Currency Information

    OptionalMax use 1

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

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

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

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

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

    Usage notes
    • The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.
    2010AA Billing Provider Name Loop
    RequiredMax 1
    Variants (all may be used)
    2010ABPay-to Address Name Loop2010ACPay-To Plan Name Loop
    NM1
    0150

    Billing Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
    • Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
    • The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
    • The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration).
    • When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
    Example
    If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    85
    Billing Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

    N3
    0250

    Billing Provider Address

    RequiredMax use 1

    To specify the location of the named party

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

    Address information

    Usage notes

    Follow the 5010 Implementation Guide; Dental recommends sending the full street address.

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

    Address information

    N4
    0300

    Billing Provider City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

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

    Code identifying the country

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

    Code identifying the country subdivision

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

    Billing Provider Tax Identification

    RequiredMax use 1

    To specify identifying information

    Usage notes
    • This is the tax identification number (TIN) of the entity to be paid for the submitted services.
    Example
    Variants (all may be used)
    REFBilling Provider UPIN/License Information
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EI
    Employer's Identification Number

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

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

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

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

    Usage notes

    This segment must contain tax identification 2010ABnumber of the billing provider.

    REF
    0350

    Billing Provider UPIN/License Information

    OptionalMax use 2

    To specify identifying information

    Usage notes
    • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider.
      OR
      Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider.
      If not required by this implementation guide, do not send.
    • Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification.
    Example
    Variants (all may be used)
    REFBilling Provider Tax Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1G
    Provider UPIN Number

    UPINs must be formatted as either X99999 or XXX999.

    REF-02
    127
    Billing Provider License and/or UPIN Information
    Required
    Min 1Max 50

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

    PER
    0400

    Billing Provider Contact Information

    OptionalMax use 2

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

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

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    2010AB Pay-to Address Name Loop
    OptionalMax 1
    Variants (all may be used)
    2010AABilling Provider Name Loop2010ACPay-To Plan Name Loop
    NM1
    0150

    Pay-to Address Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

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

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    N3
    0250

    Pay-to Address - ADDRESS

    RequiredMax use 1

    To specify the location of the named party

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

    Address information

    Usage notes

    Follow the 5010 Implementation Guide. Dental recommends sending the full street address rather than a PO Box address.

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

    Address information

    N4
    0300

    Pay-To Address City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    2010AC Pay-To Plan Name Loop
    OptionalMax 1
    Variants (all may be used)
    2010AABilling Provider Name Loop2010ABPay-to Address Name Loop
    NM1
    0150

    Pay-To Plan Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    PE
    Payee

    PE is used to indicate the subrogated payee.

    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes
    • On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

    Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

    If a phase-in period is designated, PI must be sent unless:

    1. Both the sender and receiver agree to use the National Plan ID,
    2. The receiver has a National Plan ID, and
    3. The sender has the capability to send the National Plan ID.

    If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

    PI
    Payor Identification
    XV
    Centers for Medicare and Medicaid Services PlanID
    NM1-09
    67
    Pay-To Plan Primary Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    Pay-to Plan Address

    RequiredMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Pay-To Plan City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Pay-to Plan Secondary Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFPay-To Plan Tax Identification Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    2U
    Payer Identification Number

    This code is only allowed when the National Plan Identifier is reported in NM109 of this loop.

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

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

    REF
    0350

    Pay-To Plan Tax Identification Number

    RequiredMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    EI
    Employer's Identification Number

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

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

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

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

    2000B Subscriber Hierarchical Level Loop
    RequiredMax >1
    HL
    0010

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

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

    Subscriber Information

    RequiredMax use 1

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

    Example
    SBR-01
    1138
    Payer Responsibility Sequence Number Code
    Required

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

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

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

    SBR-02
    1069
    Individual Relationship Code
    Optional

    Code indicating the relationship between two individuals or entities

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

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

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

    Free-form name

    • SBR04 is plan name.
    SBR-05
    1336
    Insurance Type Code
    Optional

    Code identifying the type of insurance policy within a specific insurance program

    12
    Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
    13
    Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
    14
    Medicare Secondary, No-fault Insurance including Auto is Primary
    15
    Medicare Secondary Worker's Compensation
    16
    Medicare Secondary Public Health Service (PHS)or Other Federal Agency
    41
    Medicare Secondary Black Lung
    42
    Medicare Secondary Veteran's Administration
    43
    Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
    47
    Medicare Secondary, Other Liability Insurance is Primary
    SBR-09
    1032
    Claim Filing Indicator Code
    Optional

    Code identifying type of claim

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

    Use code OF when submitting Medicare Part D claims.

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

    Use Code ZZ when Type of Insurance is not known.

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

    Payer Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    PR
    Payer
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes
    • On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.

    Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

    If a phase-in period is designated, PI must be sent unless:

    1. Both the sender and receiver agree to use the National Plan ID,
    2. The receiver has a National Plan ID, and
    3. The sender has the capability to send the National Plan ID.

    If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.

    PI
    Payor Identification
    XV
    Centers for Medicare and Medicaid Services PlanID
    NM1-09
    67
    Payer Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    Payer Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Payer City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Billing Provider Secondary Identification

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    G2
    Provider Commercial Number

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

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

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

    REF
    0350

    Payer Secondary Identification

    OptionalMax use 3

    To specify identifying information

    Usage notes
    • Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFBilling Provider Secondary Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    2U
    Payer Identification Number

    This code is only allowed when the National Plan Identifier is reported in NM109 of this loop.

    EI
    Employer's Identification Number

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

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

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

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

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

    Subscriber Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

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

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

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

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

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

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

    MI
    Member Identification Number

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

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

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

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

    Code identifying a party or other code

    N3
    0250

    Subscriber Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Subscriber City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Subscriber Demographic Information

    OptionalMax use 1

    To supply demographic information

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

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

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

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

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

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    REF
    0350

    Property and Casualty Claim Number

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

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

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

    REF
    0350

    Subscriber Secondary Identification

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    SY
    Social Security Number

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

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

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

    2300 Claim Information Loop
    OptionalMax 100
    CLM
    1300

    Claim Information

    RequiredMax use 1

    To specify basic data about the claim

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

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

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

    Monetary amount

    • CLM02 is the total amount of all submitted charges of service segments for this claim.
    Usage notes
    • The Total Claim Charge Amount must be greater than or equal to zero.
    • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.
    CLM-05
    C023
    Health Care Service Location Information
    To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
    C023-01
    1331
    Place of Service Code
    Required
    Min 1Max 2

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

    C023-02
    1332
    Facility Code Qualifier
    Required

    Code identifying the type of facility referenced

    • C023-02 qualifies C023-01 and C023-03.
    B
    Place of Service Codes for Professional or Dental Services
    C023-03
    1325
    Claim Frequency Code
    Required
    Min 1Max 1

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

    CLM-06
    1073
    Provider or Supplier Signature Indicator
    Required

    Code indicating a Yes or No condition or response

    • CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
    N
    No
    Y
    Yes
    CLM-07
    1359
    Assignment or Plan Participation Code
    Required

    Code indicating whether the provider accepts assignment

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

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

    C
    Not Assigned

    Required when code `A' does not apply.

    CLM-08
    1073
    Benefits Assignment Certification Indicator
    Required

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes
    CLM-09
    1363
    Release of Information Code
    Required

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

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

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

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

    For this Implementation Guide, this also applies to dental billing data related to a claim.

    CLM-11
    C024
    Related Causes Information
    To identify one or more related causes and associated state or country information
    Usage notes

    Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.

    C024-01
    1362
    Related Causes Code
    Required

    Code identifying an accompanying cause of an illness, injury or an accident

    AA
    Auto Accident
    EM
    Employment
    OA
    Other Accident
    C024-02
    1362
    Related Causes Code
    Optional
    Min 2Max 3

    Code identifying an accompanying cause of an illness, injury or an accident

    C024-04
    156
    Auto Accident State or Province Code
    Optional
    Min 2Max 2

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

    • C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
    C024-05
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

    CLM-12
    1366
    Special Program Indicator
    Optional

    Code indicating the Special Program under which the services rendered to the patient were performed

    01
    Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
    02
    Physically Handicapped Children's Program

    This code is used for Medicaid claims only.

    03
    Special Federal Funding

    This code is used for Medicaid claims only.

    05
    Disability

    This code is used for Medicaid claims only.

    CLM-19
    1383
    Predetermination of Benefits Code
    Optional

    Code identifying reason for claim submission

    PB
    Predetermination of Dental Benefits
    CLM-20
    1514
    Delay Reason Code
    Optional

    Code indicating the reason why a request was delayed

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

    Date - Accident

    OptionalMax use 1

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

    Usage notes
    • Required when CLM11-1 or CLM11-2 has a value of AA' or OA'.
      OR
      Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
      If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    DTPDate - Appliance PlacementDTPDate - Repricer Received DateDTPDate - Service Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    439
    Accident
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Appliance Placement

    OptionalMax use 1

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

    Usage notes
    • Required when reporting the date orthodontic appliances were placed. If not required by this implementation guide, do not send.
    • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
    Example
    Variants (all may be used)
    DTPDate - AccidentDTPDate - Repricer Received DateDTPDate - Service Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

    452
    Appliance Placement
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Repricer Received Date

    OptionalMax use 1

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

    Usage notes
    • Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Service Date
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    DTP
    1350

    Date - Service Date

    OptionalMax use 1

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

    Usage notes
    • Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. If not required by this implementation guide, do not send.
    • Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
    Example
    Variants (all may be used)
    DTPDate - AccidentDTPDate - Appliance PlacementDTPDate - Repricer Received Date
    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 Date
    Required
    Min 1Max 35

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

    DN1
    1450

    Orthodontic Total Months of Treatment

    OptionalMax use 1

    To supply orthodontic information

    Usage notes
    • Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
    • When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
    Example
    DN1-01
    380
    Orthodontic Treatment Months Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • DN101 is the estimated number of treatment months.
    DN1-02
    380
    Orthodontic Treatment Months Remaining Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • DN102 is the number of treatment months remaining.
    DN1-04
    352
    Orthodontic Treatment Indicator
    Optional
    Min 1Max 80

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

    • DN104 is the appliance description.
    Usage notes
    • The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.
    DN2
    1500

    Tooth Status

    OptionalMax use 35

    To specify the status of individual teeth

    Usage notes
    • Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.
    Example
    DN2-01
    127
    Tooth Number
    Required
    Min 1Max 50

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

    • DN201 is the tooth number.
    Usage notes
    • The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
    DN2-02
    1368
    Tooth Status Code
    Required

    Code specifying the status of the tooth

    E
    To Be Extracted
    M
    Missing
    DN2-06
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    • DN206 designates the code set used to identify the tooth in DN201.
    JP
    Universal National Tooth Designation System
    PWK
    1550

    Claim Supplemental Information

    OptionalMax use 10

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

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

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

    B4
    Referral Form
    DA
    Dental Models
    DG
    Diagnostic Report
    EB
    Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
    OZ
    Support Data for Claim
    P6
    Periodontal Charts
    RB
    Radiology Films
    RR
    Radiology Reports
    PWK-02
    756
    Attachment Transmission Code
    Required

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

    AA
    Available on Request at Provider Site

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

    BM
    By Mail
    EL
    Electronically Only

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

    EM
    E-Mail
    FT
    File Transfer

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

    FX
    By Fax
    PWK-05
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

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

    Contract Information

    OptionalMax use 1

    To specify basic data about the contract or contract line item

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

    Code identifying a contract type

    02
    Per Diem
    03
    Variable Per Diem
    04
    Flat
    05
    Capitated
    06
    Percent
    09
    Other
    CN1-02
    782
    Contract Amount
    Optional
    Min 1Max 15

    Monetary amount

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

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

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

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

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

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

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

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

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

    Patient Amount Paid

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
    • Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
    Example
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    F5
    Patient Amount Paid
    AMT-02
    782
    Patient Amount Paid
    Required
    Min 1Max 15

    Monetary amount

    REF
    1800

    Adjusted Repriced Claim Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    Example
    Variants (all may be used)
    REFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Claim Identifier For Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
    • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
    Example
    Variants (all may be used)
    REFAdjusted Repriced Claim NumberREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

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

    Payer Claim Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    Example
    Variants (all may be used)
    REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Predetermination Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
    • Reference numbers at this position apply to the entire claim.
    Example
    Variants (all may be used)
    REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception Code
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    G3
    Predetermination of Benefits Identification Number
    REF-02
    127
    Predetermination of Benefits Identifier
    Required
    Min 1Max 50

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

    REF
    1800

    Prior Authorization

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Referral Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
      AND
      a referral is involved.
      If not required by this implementation guide, do not send.
    • Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
    • This segment must not be used to report the Predetermination of Benefits Identification Number.
    Example
    Variants (all may be used)
    REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFRepriced Claim NumberREFService Authorization Exception Code
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Repriced Claim Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    Example
    Variants (all may be used)
    REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFService Authorization Exception Code
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Service Authorization Exception Code

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFPayer Claim Control NumberREFPredetermination IdentificationREFPrior AuthorizationREFReferral NumberREFRepriced Claim Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

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

    File Information

    OptionalMax use 10

    To transmit a fixed-format record or matrix contents

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

    Data in fixed format agreed upon by sender and receiver

    NTE
    1900

    Claim Note

    OptionalMax use 5

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

    Usage notes
    • Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
      If not required by this implementation guide, do not send.
    • The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
    Example
    NTE-01
    363
    Note Reference Code
    Required

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

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

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

    HI
    2310

    Health Care Diagnosis Code

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • Do not transmit the decimal point for ICD codes. The decimal point is implied.
    • Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
    If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
    OR
    The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
    OR
    For claims which are not covered under HIPAA.

    BK
    International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
    TQ
    Systemized Nomenclature of Dentistry (SNODENT)

    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 SNODENT codes as an allowable code set under HIPAA,
    OR
    the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

    C022-02
    1271
    Principal Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

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

    C022-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

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

    This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
    If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
    OR
    The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
    OR
    For claims which are not covered under HIPAA.

    BF
    International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
    TQ
    Systemized Nomenclature of Dentistry (SNODENT)

    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 SNODENT codes as an allowable code set under HIPAA,
    OR
    the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.

    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

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

    C022-01
    1270
    Code List Qualifier Code
    Required
    Min 1Max 3

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    Usage notes
    • See element HI02-1 for a list of valid values.
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

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

    C022-01
    1270
    Code List Qualifier Code
    Required
    Min 1Max 3

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    Usage notes
    • See element HI02-1 for a list of valid values.
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
    HCP
    2410

    Claim Pricing/Repricing Information

    OptionalMax use 1

    To specify pricing or repricing information about a health care claim or line item

    Usage notes
    • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    • For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
    Example
    At least one of Pricing Methodology (HCP-01) or Reject Reason Code (HCP-13) is required
    HCP-01
    1473
    Pricing Methodology
    Required

    Code specifying pricing methodology at which the claim or line item has been priced or repriced

    Usage notes
    • Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
    00
    Zero Pricing (Not Covered Under Contract)
    01
    Priced as Billed at 100%
    02
    Priced at the Standard Fee Schedule
    03
    Priced at a Contractual Percentage
    04
    Bundled Pricing
    05
    Peer Review Pricing
    07
    Flat Rate Pricing
    08
    Combination Pricing
    09
    Maternity Pricing
    10
    Other Pricing
    11
    Lower of Cost
    12
    Ratio of Cost
    13
    Cost Reimbursed
    14
    Adjustment Pricing
    HCP-02
    782
    Repriced Allowed Amount
    Required
    Min 1Max 15

    Monetary amount

    • HCP02 is the allowed amount.
    HCP-03
    782
    Repriced Saving Amount
    Optional
    Min 1Max 15

    Monetary amount

    • HCP03 is the savings amount.
    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    HCP-04
    127
    Repricing Organization Identifier
    Optional
    Min 1Max 50

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

    • HCP04 is the repricing organization identification number.
    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    HCP-05
    118
    Repricing Per Diem or Flat Rate Amount
    Optional
    Min 1Max 9

    Rate expressed in the standard monetary denomination for the currency specified

    • HCP05 is the pricing rate associated with per diem or flat rate repricing.
    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    HCP-06
    127
    Repriced Approved Ambulatory Patient Group Code
    Optional
    Min 1Max 50

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

    • HCP06 is the approved DRG code.
    • HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    HCP-13
    901
    Reject Reason Code
    Optional

    Code assigned by issuer to identify reason for rejection

    • HCP13 is the rejection message returned from the third party organization.
    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    T1
    Cannot Identify Provider as TPO (Third Party Organization) Participant
    T2
    Cannot Identify Payer as TPO (Third Party Organization) Participant
    T3
    Cannot Identify Insured as TPO (Third Party Organization) Participant
    T4
    Payer Name or Identifier Missing
    T5
    Certification Information Missing
    T6
    Claim does not contain enough information for re-pricing
    HCP-14
    1526
    Policy Compliance Code
    Optional

    Code specifying policy compliance

    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    1
    Procedure Followed (Compliance)
    2
    Not Followed - Call Not Made (Non-Compliance Call Not Made)
    3
    Not Medically Necessary (Non-Compliance Non-Medically Necessary)
    4
    Not Followed Other (Non-Compliance Other)
    5
    Emergency Admit to Non-Network Hospital
    HCP-15
    1527
    Exception Code
    Optional

    Code specifying the exception reason for consideration of out-of-network health care services

    • HCP15 is the exception reason generated by a third party organization.
    Usage notes
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    1
    Non-Network Professional Provider in Network Hospital
    2
    Emergency Care
    3
    Services or Specialist not in Network
    4
    Out-of-Service Area
    5
    State Mandates
    6
    Other
    2310D Assistant Surgeon Name Loop
    OptionalMax 1
    Variants (all may be used)
    2310AReferring Provider Name Loop2310BRendering Provider Name Loop2310CService Facility Location Name Loop2310ESupervising Provider Name Loop
    NM1
    2500

    Assistant Surgeon Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when the Rendering Provider provided these services in the role of the Assisting Surgeon.
      If not required by this implementation guide, do not send.
    • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
    Example
    If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    DD
    Assistant Surgeon
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-04
    1036
    Assistant Surgeon First Name
    Optional
    Min 1Max 35

    Individual first name

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

    Individual middle name or initial

    NM1-07
    1039
    Assistant Surgeon Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

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

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

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

    Code identifying a party or other code

    PRV
    2550

    Assistant Surgeon Specialty Information

    RequiredMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
    Example
    PRV-01
    1221
    Provider Code
    Required

    Code identifying the type of provider

    AS
    Assistant Surgeon
    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    2710

    Assistant Surgeon Secondary Identification

    OptionalMax use 4

    To specify identifying information

    Usage notes
    • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
      OR
      Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1G
    Provider UPIN Number

    UPINs must be formatted as either X99999 or XXX999.

    G2
    Provider Commercial Number

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

    LU
    Location Number
    REF-02
    127
    Assistant Surgeon Secondary Identifier
    Required
    Min 1Max 50

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

    2310A Referring Provider Name Loop
    OptionalMax 2
    Variants (all may be used)
    2310DAssistant Surgeon Name Loop2310BRendering Provider Name Loop2310CService Facility Location Name Loop2310ESupervising Provider Name Loop
    NM1
    2500

    Referring Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when this claim involves a referral. If not required by this implementation guide, do not send.
    • When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
    • When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
    Example
    If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    DN
    Referring Provider

    Use on the first iteration of this loop. Use if loop is used only once.

    P3
    Primary Care Provider

    Use only if loop is used twice. Use only on second iteration of this loop.

    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

    PRV
    2550

    Referring Provider Specialty Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

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

    Code identifying the type of provider

    RF
    Referring
    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    2710

    Referring Provider Secondary Identification

    OptionalMax use 3

    To specify identifying information

    Usage notes
    • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
    • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
      OR
      Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1G
    Provider UPIN Number

    UPINs must be formatted as either X99999 or XXX999.

    G2
    Provider Commercial Number

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

    REF-02
    127
    Referring Provider Secondary Identifier
    Required
    Min 1Max 50

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

    2310B Rendering Provider Name Loop
    OptionalMax 1
    Variants (all may be used)
    2310DAssistant Surgeon Name Loop2310AReferring Provider Name Loop2310CService Facility Location Name Loop2310ESupervising Provider Name Loop
    NM1
    2500

    Rendering Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. If not required by this implementation guide, do not send.
    • Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
    • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
    Example
    If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    82
    Rendering 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
    Rendering Provider Last or Organization Name
    Required
    Min 1Max 60

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

    PRV
    2550

    Rendering Provider Specialty Information

    RequiredMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
    Example
    PRV-01
    1221
    Provider Code
    Required

    Code identifying the type of provider

    PE
    Performing
    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    2710

    Rendering Provider Secondary Identification

    OptionalMax use 4

    To specify identifying information

    Usage notes
    • The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
    • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
      OR
      Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1G
    Provider UPIN Number

    UPINs must be formatted as either X99999 or XXX999.

    G2
    Provider Commercial Number

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

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

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

    2310C Service Facility Location Name Loop
    OptionalMax 1
    Variants (all may be used)
    2310DAssistant Surgeon Name Loop2310AReferring Provider Name Loop2310BRendering Provider Name Loop2310ESupervising Provider Name Loop
    NM1
    2500

    Service Facility Location Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
      If not required by this implementation guide, do not send.
    • When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
    • When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
    • The purpose of this loop is to identify specifically where the service was rendered.
    • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
    Example
    If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    Usage notes

    UnitedHealthcare Dental will use the code 77

    77
    Service Location
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

    XX
    Centers for Medicare and Medicaid Services National Provider Identifier
    NM1-09
    67
    Laboratory or Facility Primary Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    N3
    2650

    Service Facility Location Address

    RequiredMax use 1

    To specify the location of the named party

    Usage notes
    • If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
    Example
    N3-01
    166
    Laboratory or Facility Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes

    Follow the 5010 Implementation Guide. Dental recommends sending the full street address rather than a PO Box address.

    N3-02
    166
    Laboratory or Facility Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2700

    Service Facility Location City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

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

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    REF
    2710

    Service Facility Location Secondary Identification

    OptionalMax use 3

    To specify identifying information

    Usage notes
    • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
      OR
      Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    G2
    Provider Commercial Number

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

    LU
    Location Number
    REF-02
    127
    Laboratory or Facility Secondary Identifier
    Required
    Min 1Max 50

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

    2310E Supervising Provider Name Loop
    OptionalMax 1
    Variants (all may be used)
    2310DAssistant Surgeon Name Loop2310AReferring Provider Name Loop2310BRendering Provider Name Loop2310CService Facility Location Name Loop
    NM1
    2500

    Supervising Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when the rendering provider is supervised by a physician or dentist. If not required by this implementation guide, do not send.
    • Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
    Example
    If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

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

    DQ
    Supervising Physician

    Use this code for the supervising dentist or physician.

    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

    REF
    2710

    Supervising Provider Secondary Identification

    OptionalMax use 4

    To specify identifying information

    Usage notes
    • Required when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop;
      OR
      Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider;
      OR
      Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1G
    Provider UPIN Number

    UPINs must be formatted as either X99999 or XXX999.

    G2
    Provider Commercial Number

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

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

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

    2320 Other Subscriber Information Loop
    OptionalMax 10
    SBR
    2900

    Other Subscriber Information

    RequiredMax use 1

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

    Usage notes
    • Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
    • All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
    • See Crosswalking COB Data Elements section for more information on handling COB in the 837.
    Example
    SBR-01
    1138
    Payer Responsibility Sequence Number Code
    Required

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

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

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

    SBR-02
    1069
    Individual Relationship Code
    Required

    Code indicating the relationship between two individuals or entities

    • SBR02 specifies the relationship to the person insured.
    01
    Spouse
    18
    Self
    19
    Child
    20
    Employee
    21
    Unknown
    39
    Organ Donor
    40
    Cadaver Donor
    53
    Life Partner
    G8
    Other Relationship
    SBR-03
    127
    Insured Group or Policy Number
    Optional
    Min 1Max 50

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

    • SBR03 is policy or group number.
    Usage notes
    • This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
    SBR-04
    93
    Other Insured Group Name
    Optional
    Min 1Max 60

    Free-form name

    • SBR04 is plan name.
    SBR-05
    1336
    Insurance Type Code
    Optional

    Code identifying the type of insurance policy within a specific insurance program

    12
    Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
    13
    Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
    14
    Medicare Secondary, No-fault Insurance including Auto is Primary
    15
    Medicare Secondary Worker's Compensation
    16
    Medicare Secondary Public Health Service (PHS)or Other Federal Agency
    41
    Medicare Secondary Black Lung
    42
    Medicare Secondary Veteran's Administration
    43
    Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
    47
    Medicare Secondary, Other Liability Insurance is Primary
    SBR-09
    1032
    Claim Filing Indicator Code
    Optional

    Code identifying type of claim

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

    Use code OF when submitting Medicare Part D claims.

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

    Use Code ZZ when Type of Insurance is not known.

    CAS
    2950

    Claim Level Adjustments

    OptionalMax use 5

    To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

    Usage notes
    • Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
    • Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
    • Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
    • Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
    • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
    Example
    If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
    If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
    If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
    If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
    If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
    If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
    If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
    If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
    If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
    If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
    If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
    If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
    If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
    If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
    If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
    CAS-01
    1033
    Claim Adjustment Group Code
    Required

    Code identifying the general category of payment adjustment

    CO
    Contractual Obligations
    CR
    Correction and Reversals
    OA
    Other adjustments
    PI
    Payor Initiated Reductions
    PR
    Patient Responsibility
    CAS-02
    1034
    Adjustment Reason Code
    Required
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-03
    782
    Adjustment Amount
    Required
    Min 1Max 15

    Monetary amount

    • CAS03 is the amount of adjustment.
    CAS-04
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS04 is the units of service being adjusted.
    CAS-05
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-06
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS06 is the amount of the adjustment.
    CAS-07
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS07 is the units of service being adjusted.
    CAS-08
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-09
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS09 is the amount of the adjustment.
    CAS-10
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS10 is the units of service being adjusted.
    CAS-11
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-12
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS12 is the amount of the adjustment.
    CAS-13
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS13 is the units of service being adjusted.
    CAS-14
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-15
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS15 is the amount of the adjustment.
    CAS-16
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS16 is the units of service being adjusted.
    CAS-17
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-18
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS18 is the amount of the adjustment.
    CAS-19
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS19 is the units of service being adjusted.
    AMT
    3000

    Coordination of Benefits (COB) Payer Paid Amount

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
      OR
      Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
      If not required by this implementation guide, do not send.;
    Example
    Variants (all may be used)
    AMTCoordination of Benefits (COB) Total Non-Covered AmountAMTRemaining Patient Liability
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    D
    Payor Amount Paid
    AMT-02
    782
    Payer Paid Amount
    Required
    Min 1Max 15

    Monetary amount

    Usage notes
    • It is acceptable to show "0" as the amount paid.
    • When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
    AMT
    3000

    Coordination of Benefits (COB) Total Non-Covered Amount

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
    • When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
    Example
    Variants (all may be used)
    AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient Liability
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    A8
    Noncovered Charges - Actual
    AMT-02
    782
    Non-Covered Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    AMT
    3000

    Remaining Patient Liability

    OptionalMax use 1

    To indicate the total monetary amount

    Usage notes
    • Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
      OR
      Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
      If not required by this implementation guide, do not send.
    • In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
    • This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
    • This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
    Example
    Variants (all may be used)
    AMTCoordination of Benefits (COB) Payer Paid AmountAMTCoordination of Benefits (COB) Total Non-Covered Amount
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    EAF
    Amount Owed
    AMT-02
    782
    Remaining Patient Liability
    Required
    Min 1Max 15

    Monetary amount

    OI
    3100

    Other Insurance Coverage Information