United Healthcare
/
Health Care Claim: Dental (X224A3)
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X12 837 Health Care Claim: Dental (X224A3)

X12 Release 5010
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
Submitter Name Loop
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
CUR
0100
Foreign Currency Information
Max use 1
Optional
Pay-to Address Name Loop
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
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
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
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
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
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
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
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
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
Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)
00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10
ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)
00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10
ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 15
ISA-07
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 15
ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format
ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format
ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1
^
Repetition Separator
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)
00501
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA-13
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9
ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
Min 1Max 1
0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1
I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1
>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1
Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)
HC
Health Care Claim (837)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15
GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15
GS-04
373
Date
Required
Date (DT)
CCYYMMDD format
GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9
GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 2
T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)
005010X224A3

Heading

ST
0050
Heading > ST

Transaction Set Header

RequiredMax use 1
Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)
837
Health Care Claim
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9
Usage notes
ST-03
1705
Implementation Guide Version Name
Required
String (AN)
Usage notes
005010X224A3
BHT
0100
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1
Usage notes
Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)
0019
Information Source, Subscriber, Dependent
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)
Usage notes
00
Original
18
Reissue
BHT-03
127
Originator Application Transaction Identifier
Required
String (AN)
Min 1Max 50
Usage notes
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format
Usage notes
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
Usage notes
BHT-06
640
Claim or Encounter Identifier
Required
Identifier (ID)
31
Subrogation Demand
1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name Loop
NM1
0200
Heading > Submitter Name Loop > NM1

Submitter Name

RequiredMax use 1
Usage notes
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
41
Submitter
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
2
Non-Person Entity
NM1-03
1035
Submitter Last or Organization Name
Required
String (AN)
Min 1Max 60
NM1-04
1036
Submitter First Name
Optional
String (AN)
Min 1Max 35
NM1-05
1037
Submitter Middle Name or Initial
Optional
String (AN)
Min 1Max 25
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
46
Electronic Transmitter Identification Number (ETIN)
NM1-09
67
Submitter Identifier
Required
String (AN)
Min 2Max 80
PER
0450
Heading > Submitter Name Loop > PER

Submitter EDI Contact Information

RequiredMax use 2
Usage notes
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
Identifier (ID)
IC
Information Contact
PER-02
93
Submitter Contact Name
Optional
String (AN)
Min 1Max 60
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
1000A Submitter Name Loop end
1000B Receiver Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Name Loop
NM1
0200
Heading > Receiver Name Loop > NM1

Receiver Name

RequiredMax use 1
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
40
Receiver
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
2
Non-Person Entity
NM1-03
1035
Receiver Name
Required
String (AN)
Min 1Max 60
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
46
Electronic Transmitter Identification Number (ETIN)
NM1-09
67
Receiver Primary Identifier
Required
String (AN)
Min 2Max 80
1000B Receiver Name Loop end
Heading end

Detail

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

Hierarchical Level

RequiredMax use 1
Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)
20
Information Source
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV

Billing Provider Specialty Information

OptionalMax use 1
Usage notes
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
BI
Billing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR

Foreign Currency Information

OptionalMax use 1
Usage notes
Example
CUR-01
98
Entity Identifier Code
Required
Identifier (ID)
85
Billing Provider
CUR-02
100
Currency Code
Required
Identifier (ID)
Min 3Max 3
Usage notes
2010AA Billing Provider Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1

Billing Provider Name

RequiredMax use 1
Usage notes
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
Identifier (ID)
85
Billing Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
2
Non-Person Entity
NM1-03
1035
Billing Provider Last or Organizational Name
Required
String (AN)
Min 1Max 60
NM1-04
1036
Billing Provider First Name
Optional
String (AN)
Min 1Max 35
NM1-05
1037
Billing Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
NM1-07
1039
Billing Provider Name Suffix
Optional
String (AN)
Min 1Max 10
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Billing Provider Identifier
Optional
String (AN)
Min 2Max 80
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3

Billing Provider Address

RequiredMax use 1
Usage notes
Example
N3-01
166
Billing Provider Address Line
Required
String (AN)
Min 1Max 55
Usage notes
N3-02
166
Billing Provider Address Line
Optional
String (AN)
Min 1Max 55
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4

Billing Provider City, State, ZIP Code

RequiredMax use 1
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
String (AN)
Min 2Max 30
N4-02
156
Billing Provider State or Province Code
Optional
Identifier (ID)
Min 2Max 2
N4-03
116
Billing Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
Usage notes
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
Usage notes
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
Usage notes
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider Tax Identification

RequiredMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
EI
Employer's Identification Number
REF-02
127
Billing Provider Tax Identification Number
Required
String (AN)
Min 1Max 50
Usage notes
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF

Billing Provider UPIN/License Information

OptionalMax use 2
Usage notes
Example
Variants (all may be used)
REFBilling Provider Tax Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
0B
State License Number
1G
Provider UPIN Number
REF-02
127
Billing Provider License and/or UPIN Information
Required
String (AN)
Min 1Max 50
PER
0400
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER

Billing Provider Contact Information

OptionalMax use 2
Usage notes
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
Identifier (ID)
IC
Information Contact
PER-02
93
Billing Provider Contact Name
Optional
String (AN)
Min 1Max 60
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
EM
Electronic Mail
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
2010AA Billing Provider Name Loop end
2010AB Pay-to Address Name Loop
OptionalMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1

Pay-to Address Name

RequiredMax use 1
Usage notes
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
87
Pay-to Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
2
Non-Person Entity
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3

Pay-to Address - ADDRESS

RequiredMax use 1
Example
N3-01
166
Pay-To Address Line
Required
String (AN)
Min 1Max 55
Usage notes
N3-02
166
Pay-To Address Line
Optional
String (AN)
Min 1Max 55
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4

Pay-To Address City, State, ZIP Code

RequiredMax use 1
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
String (AN)
Min 2Max 30
N4-02
156
Pay-To Address State or Province Code
Optional
Identifier (ID)
Min 2Max 2
N4-03
116
Pay-to Address Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
Usage notes
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
Usage notes
2010AB Pay-to Address Name Loop end
2010AC Pay-To Plan Name Loop
OptionalMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > NM1

Pay-To Plan Name

RequiredMax use 1
Usage notes
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
PE
Payee
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
2
Non-Person Entity
NM1-03
1035
Pay-To Plan Organizational Name
Required
String (AN)
Min 1Max 60
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
Usage notes
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Pay-To Plan Primary Identifier
Required
String (AN)
Min 2Max 80
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3

Pay-to Plan Address

RequiredMax use 1
Example
N3-01
166
Pay-To Plan Address Line
Required
String (AN)
Min 1Max 55
N3-02
166
Pay-To Plan Address Line
Optional
String (AN)
Min 1Max 55
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4

Pay-To Plan City, State, ZIP Code

RequiredMax use 1
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
String (AN)
Min 2Max 30
N4-02
156
Pay-To Plan State or Province Code
Optional
Identifier (ID)
Min 2Max 2
N4-03
116
Pay-To Plan Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
Usage notes
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
Usage notes
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-to Plan Secondary Identification

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
2U
Payer Identification Number
FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Pay-to Plan Secondary Identifier
Required
String (AN)
Min 1Max 50
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF

Pay-To Plan Tax Identification Number

RequiredMax use 1
Example
Variants (all may be used)
REFPay-to Plan Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
EI
Employer's Identification Number
REF-02
127
Pay-To Plan Tax Identification Number
Required
String (AN)
Min 1Max 50
2010AC Pay-To Plan Name Loop end
2000B Subscriber Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL

Hierarchical Level

RequiredMax use 1
Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)
22
Subscriber
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR

Subscriber Information

RequiredMax use 1
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)
Usage notes
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
SBR-02
1069
Individual Relationship Code
Optional
Identifier (ID)
18
Self
SBR-03
127
Subscriber Group or Policy Number
Optional
String (AN)
Min 1Max 50
Usage notes
SBR-04
93
Subscriber Group Name
Optional
String (AN)
Min 1Max 60
SBR-05
1336
Insurance Type Code
Optional
Identifier (ID)
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
Identifier (ID)
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
TV
Title V
VA
Veterans Affairs Plan
WC
Workers' Compensation Health Claim
ZZ
Mutually Defined
2010BA Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Payer Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1
Usage notes
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
Identifier (ID)
IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
2
Non-Person Entity
NM1-03
1035
Subscriber Last Name
Required
String (AN)
Min 1Max 60
NM1-04
1036
Subscriber First Name
Optional
String (AN)
Min 1Max 35
NM1-05
1037
Subscriber Middle Name or Initial
Optional
String (AN)
Min 1Max 25
NM1-07
1039
Subscriber Name Suffix
Optional
String (AN)
Min 1Max 10
Usage notes
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
II
Standard Unique Health Identifier for each Individual in the United States
MI
Member Identification Number
NM1-09
67
Subscriber Primary Identifier
Optional
String (AN)
Min 2Max 80
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1
Usage notes
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55
N3-02
166
Subscriber Address Line
Optional
String (AN)
Min 1Max 55
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1
Usage notes
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
String (AN)
Min 2Max 30
N4-02
156
Subscriber State Code
Optional
Identifier (ID)
Min 2Max 2
N4-03
116
Subscriber Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
Usage notes
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
Usage notes
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1
Usage notes
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Subscriber Birth Date
Required
String (AN)
Min 1Max 35
DMG-03
1068
Subscriber Gender Code
Required
Identifier (ID)
F
Female
M
Male
U
Unknown
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Property and Casualty Claim Number

OptionalMax use 1
Usage notes
Example
Variants (all may be used)
REFSubscriber Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
Y4
Agency Claim Number
REF-02
127
Property Casualty Claim Number
Required
String (AN)
Min 1Max 50
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF

Subscriber Secondary Identification

OptionalMax use 1
Usage notes
Example
Variants (all may be used)
REFProperty and Casualty Claim Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
SY
Social Security Number
REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50
2010BA Subscriber Name Loop end
2010BB Payer Name Loop
RequiredMax 1
Variants (all may be used)
Subscriber Name Loop
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1

Payer Name

RequiredMax use 1
Usage notes
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
PR
Payer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
2
Non-Person Entity
NM1-03
1035
Payer Name
Required
String (AN)
Min 1Max 60
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
Usage notes
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM1-09
67
Payer Identifier
Required
String (AN)
Min 2Max 80
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3

Payer Address

OptionalMax use 1
Usage notes
Example
N3-01
166
Payer Address Line
Required
String (AN)
Min 1Max 55
N3-02
166
Payer Address Line
Optional
String (AN)
Min 1Max 55
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4

Payer City, State, ZIP Code

OptionalMax use 1
Usage notes
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
String (AN)
Min 2Max 30
N4-02
156
Payer State Code
Optional
Identifier (ID)
Min 2Max 2
N4-03
116
Payer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
Usage notes
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
Usage notes
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Billing Provider Secondary Identification

OptionalMax use 1
Usage notes
Example
Variants (all may be used)
REFPayer Secondary Identification
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
G2
Provider Commercial Number
LU
Location Number
REF-02
127
Billing Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF

Payer Secondary Identification

OptionalMax use 3
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
2U
Payer Identification Number
EI
Employer's Identification Number
FY
Claim Office Number
NF
National Association of Insurance Commissioners (NAIC) Code
REF-02
127
Payer Secondary Identifier
Required
String (AN)
Min 1Max 50
2010BB Payer Name Loop end
2300 Claim Information Loop
OptionalMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM

Claim Information

RequiredMax use 1
Usage notes
Example
CLM-01
1028
Patient Control Number
Required
String (AN)
Min 1Max 38
Usage notes
CLM-02
782
Total Claim Charge Amount
Required
Decimal number (R)
Min 1Max 15
Usage notes
CLM-05
C023
Health Care Service Location Information
RequiredMax use 1
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
String (AN)
Min 1Max 2
C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)
B
Place of Service Codes for Professional or Dental Services
C023-03
1325
Claim Frequency Code
Required
Identifier (ID)
Min 1Max 1
CLM-06
1073
Provider or Supplier Signature Indicator
Required
Identifier (ID)
N
No
Y
Yes
CLM-07
1359
Assignment or Plan Participation Code
Required
Identifier (ID)
Usage notes
A
Assigned
C
Not Assigned
CLM-08
1073
Benefits Assignment Certification Indicator
Required
Identifier (ID)
Usage notes
N
No
W
Not Applicable
Y
Yes
CLM-09
1363
Release of Information Code
Required
Identifier (ID)
Usage notes
I
Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
CLM-11
C024
Related Causes Information
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
C024-01
1362
Related Causes Code
Required
Identifier (ID)
AA
Auto Accident
EM
Employment
OA
Other Accident
C024-02
1362
Related Causes Code
Optional
Identifier (ID)
Min 2Max 3
C024-04
156
Auto Accident State or Province Code
Optional
Identifier (ID)
Min 2Max 2
C024-05
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
CLM-12
1366
Special Program Indicator
Optional
Identifier (ID)
01
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
02
Physically Handicapped Children's Program
03
Special Federal Funding
05
Disability
CLM-19
1383
Predetermination of Benefits Code
Optional
Identifier (ID)
PB
Predetermination of Dental Benefits
CLM-20
1514
Delay Reason Code
Optional
Identifier (ID)
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
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Accident

OptionalMax use 1
Usage notes
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Accident Date
Required
String (AN)
Min 1Max 35
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Appliance Placement

OptionalMax use 1
Usage notes
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
452
Appliance Placement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Orthodontic Banding Date
Required
String (AN)
Min 1Max 35
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Repricer Received Date

OptionalMax use 1
Usage notes
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
050
Received
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Repricer Received Date
Required
String (AN)
Min 1Max 35
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP

Date - Service Date

OptionalMax use 1
Usage notes
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
472
Service
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Service Date
Required
String (AN)
Min 1Max 35
DN1
1450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DN1

Orthodontic Total Months of Treatment

OptionalMax use 1
Usage notes
Example
DN1-01
380
Orthodontic Treatment Months Count
Optional
Decimal number (R)
Min 1Max 15
DN1-02
380
Orthodontic Treatment Months Remaining Count
Optional
Decimal number (R)
Min 1Max 15
DN1-04
352
Orthodontic Treatment Indicator
Optional
String (AN)
Min 1Max 80
Usage notes
DN2
1500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DN2

Tooth Status

OptionalMax use 35
Usage notes
Example
DN2-01
127
Tooth Number
Required
String (AN)
Min 1Max 50
Usage notes
DN2-02
1368
Tooth Status Code
Required
Identifier (ID)
E
To Be Extracted
M
Missing
DN2-06
1270
Code List Qualifier Code
Required
Identifier (ID)
JP
Universal National Tooth Designation System
PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK

Claim Supplemental Information

OptionalMax use 10
Usage notes
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
Identifier (ID)
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
Identifier (ID)
AA
Available on Request at Provider Site
BM
By Mail
EL
Electronically Only
EM
E-Mail
FT
File Transfer
FX
By Fax
PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)
AC
Attachment Control Number
PWK-06
67
Attachment Control Number
Optional
String (AN)
Min 2Max 80
Usage notes
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1

Contract Information

OptionalMax use 1
Usage notes
Example
CN1-01
1166
Contract Type Code
Required
Identifier (ID)
02
Per Diem
03
Variable Per Diem
04
Flat
05
Capitated
06
Percent
09
Other
CN1-02
782
Contract Amount
Optional
Decimal number (R)
Min 1Max 15
CN1-03
332
Contract Percentage
Optional
Decimal number (R)
Min 1Max 6
CN1-04
127
Contract Code
Optional
String (AN)
Min 1Max 50
CN1-05
338
Terms Discount Percentage
Optional
Decimal number (R)
Min 1Max 6
CN1-06
799
Contract Version Identifier
Optional
String (AN)
Min 1Max 30
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT

Patient Amount Paid

OptionalMax use 1
Usage notes
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
F5
Patient Amount Paid
AMT-02
782
Patient Amount Paid
Required
Decimal number (R)
Min 1Max 15
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Adjusted Repriced Claim Number

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
9C
Adjusted Repriced Claim Reference Number
REF-02
127
Adjusted Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Claim Identifier For Transmission Intermediaries

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
Usage notes
D9
Claim Number
REF-02
127
Value Added Network Trace Number
Required
String (AN)
Min 1Max 50
Usage notes
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Payer Claim Control Number

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
F8
Original Reference Number
REF-02
127
Payer Claim Control Number
Required
String (AN)
Min 1Max 50
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Predetermination Identification

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
G3
Predetermination of Benefits Identification Number
REF-02
127
Predetermination of Benefits Identifier
Required
String (AN)
Min 1Max 50
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Prior Authorization

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
G1
Prior Authorization Number
REF-02
127
Prior Authorization Number
Required
String (AN)
Min 1Max 50
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Referral Number

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
9F
Referral Number
REF-02
127
Referral Number
Required
String (AN)
Min 1Max 50
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Repriced Claim Number

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
9A
Repriced Claim Reference Number
REF-02
127
Repriced Claim Reference Number
Required
String (AN)
Min 1Max 50
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF

Service Authorization Exception Code

OptionalMax use 1
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
4N
Special Payment Reference Number
REF-02
127
Service Authorization Exception Code
Required
String (AN)
Min 1Max 50
Usage notes
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3

File Information

OptionalMax use 10
Usage notes
Example
K3-01
449
Fixed Format Information
Required
String (AN)
Min 1Max 80
NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE

Claim Note

OptionalMax use 5
Usage notes
Example
NTE-01
363
Note Reference Code
Required
Identifier (ID)
ADD
Additional Information
NTE-02
352
Claim Note Text
Required
String (AN)
Min 1Max 80
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI

Health Care Diagnosis Code

OptionalMax use 1
Usage notes
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)
C022-02
1271
Principal Diagnosis Code
Required
String (AN)
Min 1Max 30
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
TQ
Systemized Nomenclature of Dentistry (SNODENT)
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3
Usage notes
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
C022-01
1270
Code List Qualifier Code
Required
Identifier (ID)
Min 1Max 3
Usage notes
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30
HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP

Claim Pricing/Repricing Information

OptionalMax use 1
Usage notes
Example
HCP-01
1473
Pricing Methodology
Required
Identifier (ID)
Usage notes
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
Decimal number (R)
Min 1Max 15
HCP-03
782
Repriced Saving Amount
Optional
Decimal number (R)
Min 1Max 15
Usage notes
HCP-04
127
Repricing Organization Identifier
Optional
String (AN)
Min 1Max 50
Usage notes
HCP-05
118
Repricing Per Diem or Flat Rate Amount
Optional
Decimal number (R)
Min 1Max 9
Usage notes
HCP-06
127
Repriced Approved Ambulatory Patient Group Code
Optional
String (AN)
Min 1Max 50
Usage notes
HCP-13
901
Reject Reason Code
Optional
Identifier (ID)
Usage notes
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
Identifier (ID)
Usage notes
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
Identifier (ID)
Usage notes
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
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1

Referring Provider Name

RequiredMax use 1
Usage notes
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
Identifier (ID)
DN
Referring Provider
P3
Primary Care Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
NM1-03
1035
Referring Provider Last Name
Required
String (AN)
Min 1Max 60
NM1-04
1036
Referring Provider First Name
Optional
String (AN)
Min 1Max 35
NM1-05
1037
Referring Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
NM1-07
1039
Referring Provider Name Suffix
Optional
String (AN)
Min 1Max 10
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Referring Provider Identifier
Optional
String (AN)
Min 2Max 80
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > PRV

Referring Provider Specialty Information

OptionalMax use 1
Usage notes
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
RF
Referring
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF

Referring Provider Secondary Identification

OptionalMax use 3
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
0B
State License Number
1G
Provider UPIN Number
G2
Provider Commercial Number
REF-02
127
Referring Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
2310A Referring Provider Name Loop end
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1

Rendering Provider Name

RequiredMax use 1
Usage notes
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
Identifier (ID)
82
Rendering Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
2
Non-Person Entity
NM1-03
1035
Rendering Provider Last or Organization Name
Required
String (AN)
Min 1Max 60
NM1-04
1036
Rendering Provider First Name
Optional
String (AN)
Min 1Max 35
NM1-05
1037
Rendering Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
NM1-07
1039
Rendering Provider Name Suffix
Optional
String (AN)
Min 1Max 10
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Rendering Provider Identifier
Optional
String (AN)
Min 2Max 80
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV

Rendering Provider Specialty Information

RequiredMax use 1
Usage notes
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
PE
Performing
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF

Rendering Provider Secondary Identification

OptionalMax use 4
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
0B
State License Number
1G
Provider UPIN Number
G2
Provider Commercial Number
LU
Location Number
REF-02
127
Rendering Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
2310B Rendering Provider Name Loop end
2310C Service Facility Location Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1

Service Facility Location Name

RequiredMax use 1
Usage notes
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
Identifier (ID)
Usage notes
77
Service Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
2
Non-Person Entity
NM1-03
1035
Laboratory or Facility Name
Required
String (AN)
Min 1Max 60
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Laboratory or Facility Primary Identifier
Optional
String (AN)
Min 2Max 80
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3

Service Facility Location Address

RequiredMax use 1
Usage notes
Example
N3-01
166
Laboratory or Facility Address Line
Required
String (AN)
Min 1Max 55
Usage notes
N3-02
166
Laboratory or Facility Address Line
Optional
String (AN)
Min 1Max 55
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4

Service Facility Location City, State, ZIP Code

RequiredMax use 1
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
String (AN)
Min 2Max 30
N4-02
156
Laboratory or Facility State or Province Code
Optional
Identifier (ID)
Min 2Max 2
N4-03
116
Laboratory or Facility Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
Usage notes
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
Usage notes
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
Usage notes
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF

Service Facility Location Secondary Identification

OptionalMax use 3
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
0B
State License Number
G2
Provider Commercial Number
LU
Location Number
REF-02
127
Laboratory or Facility Secondary Identifier
Required
String (AN)
Min 1Max 50
2310C Service Facility Location Name Loop end
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > NM1

Assistant Surgeon Name

RequiredMax use 1
Usage notes
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
Identifier (ID)
DD
Assistant Surgeon
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
NM1-03
1035
Assistant Surgeon Last Name
Required
String (AN)
Min 1Max 60
NM1-04
1036
Assistant Surgeon First Name
Optional
String (AN)
Min 1Max 35
NM1-05
1037
Assistant Surgeon Middle Name or Initial
Optional
String (AN)
Min 1Max 25
NM1-07
1039
Assistant Surgeon Name Suffix
Optional
String (AN)
Min 1Max 10
Usage notes
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Assistant Surgeon Primary Identifier
Optional
String (AN)
Min 2Max 80
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > PRV

Assistant Surgeon Specialty Information

RequiredMax use 1
Usage notes
Example
PRV-01
1221
Provider Code
Required
Identifier (ID)
AS
Assistant Surgeon
PRV-02
128
Reference Identification Qualifier
Required
Identifier (ID)
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Required
String (AN)
Min 1Max 50
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > REF

Assistant Surgeon Secondary Identification

OptionalMax use 4
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
0B
State License Number
1G
Provider UPIN Number
G2
Provider Commercial Number
LU
Location Number
REF-02
127
Assistant Surgeon Secondary Identifier
Required
String (AN)
Min 1Max 50
2310D Assistant Surgeon Name Loop end
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1

Supervising Provider Name

RequiredMax use 1
Usage notes
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
Identifier (ID)
DQ
Supervising Physician
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
1
Person
NM1-03
1035
Supervising Provider Last Name
Required
String (AN)
Min 1Max 60
NM1-04
1036
Supervising Provider First Name
Optional
String (AN)
Min 1Max 35
NM1-05
1037
Supervising Provider Middle Name or Initial
Optional
String (AN)
Min 1Max 25
NM1-07
1039
Supervising Provider Name Suffix
Optional
String (AN)
Min 1Max 10
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Supervising Provider Identifier
Optional
String (AN)
Min 2Max 80
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF

Supervising Provider Secondary Identification

OptionalMax use 4
Usage notes
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
0B
State License Number
1G
Provider UPIN Number
G2
Provider Commercial Number
LU
Location Number
REF-02
127
Supervising Provider Secondary Identifier
Required
String (AN)
Min 1Max 50
2310E Supervising Provider Name Loop end
2320 Other Subscriber Information Loop
OptionalMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR

Other Subscriber Information

RequiredMax use 1
Usage notes
Example
SBR-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)
Usage notes
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