X12 837 Health Care Claim: Professional (X222A2)
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.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
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)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
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)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
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
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
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
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
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HC
- Health Care Claim (837)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
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)
Assigned number originated and maintained by the sender
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
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
- 005010X222A2
- ANSI ASC X12N 837 Health Care Claims (837) for professional claims and/or encounters through June 2014
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
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
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- 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.
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.
- 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.
- 005010X222A2
Beginning of Hierarchical Transaction
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
- The second example denotes the case where the entire transaction set contains ENCOUNTERS.
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
Code identifying purpose of transaction set
- 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.
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.
- 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.
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.
- This is the date that the original submitter created the claim file from their business application system.
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.
- This is the time that the original submitter created the claim file from their business application system.
Code specifying the type of transaction
- CH
- Chargeable
Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.
Submitter Name
To supply the full name of an individual or organizational entity
- The submitter is the entity responsible for the creation and formatting of this transaction.
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Established by trading partner agreement
Code identifying a party or other code
Federal Tax ID of the submitter. This number should be identical to the ISA06 and GS02 Federal Tax ID.
Submitter EDI Contact Information
To identify a person or office to whom administrative communications should be directed
- 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.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Receiver Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- 40
- Receiver
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Receiver Name (Organization)
UNITEDHEALTHCARE
- UNITEDHEALTHCARE
Code designating the system/method of code structure used for Identification Code (67)
ETIN Code
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
- 87726
- UnitedHealthcare Payer ID
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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
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.
Billing Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when the payer's adjudication is known to be impacted by the provider taxonomy code.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Foreign Currency Information
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code (Standard ISO) for country in whose currency the charges are specified
- 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.
Billing Provider Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Billing Provider Address
To specify the location of the named party
- 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.
Billing Provider City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
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.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Billing Provider Tax Identification
To specify identifying information
- This is the tax identification number (TIN) of the entity to be paid for the submitted services.
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.
- 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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider UPIN/License Information
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- 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.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Pay-to Address Name
To supply the full name of an individual or organizational entity
- 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.
Pay-To Address City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
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.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Pay-To Plan Name
To supply the full name of an individual or organizational entity
- Required when willing trading partners agree to use this implementation for their subrogation payment requests.
- This loop may only be used when BHT06 = 31.
Code identifying an organizational entity, a physical location, property or an individual
- PE
- Payee
PE is used to indicate the subrogated payee.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- Use code value "PI" when reporting Payor Identification.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:
- Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
OR - Follow an early implementation approach in which the HPID or OEID is sent in NM109.
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Pay-To Plan City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
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.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Pay-to Plan Secondary Identification
To specify identifying information
- Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
This code is only allowed when the qualifier XV is reported in NM108 of this loop.
- FY
- Claim Office Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pay-To Plan Tax Identification Number
To specify identifying information
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
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.
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.
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
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.
Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- 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.
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
- 18
- Self
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
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
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.
Patient Information
To supply patient information
- Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- PAT06 is the date of death.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- 01
- Actual Pounds
Code indicating a Yes or No condition or response
- PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant.
- For this implementation, the listed value takes precedence over the semantic note.
- Y
- Yes
Subscriber Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
Code designating the system/method of code structure used for Identification Code (67)
MI is the only valid value at this time. Claims received with value II will be rejected.
- 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.
Subscriber Address
To specify the location of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
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.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Demographic Information
To supply demographic information
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Subscriber Secondary Identification
To specify identifying information
- 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.
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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Property and Casualty Claim Number
To specify identifying information
- 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.
Property and Casualty Subscriber Contact Information
To identify a person or office to whom administrative communications should be directed
- Required for Property and Casualty claims when this information is deemed necessary by the submitter. 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-".
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EX
- Telephone Extension
Complete communications number including country or area code when applicable
Payer Name
To supply the full name of an individual or organizational entity
- 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.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- Use code value "PI" when reporting Payor Identification.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:
- Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
OR - Follow an early implementation approach in which the HPID or OEID is sent in NM109.
- PI
- Payor Identification
Payer Address
To specify the location of the named party
- 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.
Payer City, State, ZIP Code
To specify the geographic place of the named party
- 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.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
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.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Payer Secondary Identification
To specify identifying information
- Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
This code is only allowed when the qualifier XV is reported in NM108 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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Secondary Identification
To specify identifying information
- 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.
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
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Information
To specify basic data about the claim
- 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.
Identifier used to track a claim from creation by the health care provider through payment
- 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.
Monetary amount
- CLM02 is the total amount of all submitted charges of service segments for this claim.
- 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 Professional Service (SV1) segments for this claim.
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.
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
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
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
Code indicating whether the provider accepts assignment
- 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. - B
- Assignment Accepted on Clinical Lab Services Only
Required when the provider accepts assignment for Clinical Lab Services only.
- C
- Not Assigned
Required when neither codes
A' norB' apply.
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.
- 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
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- 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
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
- P
- Signature generated by provider because the patient was not physically present for services
Signature generated by an entity other than the patient according to State or Federal law.
Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.
Code identifying an accompanying cause of an illness, injury or an accident
- AA
- Auto Accident
- EM
- Employment
- OA
- Other Accident
Code identifying an accompanying cause of an illness, injury or an accident
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".
Code indicating the Special Program under which the services rendered to the patient were performed
- 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.
- 09
- Second Opinion or Surgery
This code is used for Medicaid claims only.
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
Date - Onset of Current Illness or Symptom
To specify any or all of a date, a time, or a time period
- Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send.
- This date is the onset of acute symptoms for the current illness or condition.
Code specifying type of date or time, or both date and time
- 431
- Onset of Current Symptoms or Illness
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Initial Treatment Date
To specify any or all of a date, a time, or a time period
- Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. 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.
Code specifying type of date or time, or both date and time
- 454
- Initial Treatment
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Last Seen Date
To specify any or all of a date, a time, or a time period
- Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.
- This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed.
- 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.
Code specifying type of date or time, or both date and time
- 304
- Latest Visit or Consultation
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Acute Manifestation
To specify any or all of a date, a time, or a time period
- Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 453
- Acute Manifestation of a Chronic Condition
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Accident
To specify any or all of a date, a time, or a time period
- Required when CLM11-1 or CLM11-2 has a value of
AA' orOA'.
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.
Code specifying type of date or time, or both date and time
- 439
- Accident
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Last Menstrual Period
To specify any or all of a date, a time, or a time period
- Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 484
- Last Menstrual Period
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Last X-ray Date
To specify any or all of a date, a time, or a time period
- Required when claim involves spinal manipulation and an x-ray was taken. 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.
Code specifying type of date or time, or both date and time
- 455
- Last X-Ray
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Hearing and Vision Prescription Date
To specify any or all of a date, a time, or a time period
- Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 471
- Prescription
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Disability Dates
To specify any or all of a date, a time, or a time period
- Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work.
OR
Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 314
- Disability
Use code 314 when both disability start and end date are being reported.
- 360
- Initial Disability Period Start
Use code 360 if patient is currently disabled and disability end date is unknown.
- 361
- Initial Disability Period End
Use code 361 if patient is no longer disabled and the start date is unknown.
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
Use code D8 when DTP01 is 360 or 361.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use code RD8 when DTP01 is 314.
Expression of a date, a time, or range of dates, times or dates and times
Date - Last Worked
To specify any or all of a date, a time, or a time period
- Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 297
- Initial Disability Period Last Day Worked
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Authorized Return to Work
To specify any or all of a date, a time, or a time period
- Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 296
- Initial Disability Period Return To Work
This is the date the provider has authorized the patient to return to work.
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Admission
To specify any or all of a date, a time, or a time period
- Required on all ambulance claims when the patient was known to be admitted to the hospital.
OR
Required on all claims involving inpatient medical visits.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 435
- Admission
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Discharge
To specify any or all of a date, a time, or a time period
- Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 096
- Discharge
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Assumed and Relinquished Care Dates
To specify any or all of a date, a time, or a time period
- Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send.
- Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates.
Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A".
Code specifying type of date or time, or both date and time
- 090
- Report Start
Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care.
- 091
- Report End
Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider.
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Property and Casualty Date of First Contact
To specify any or all of a date, a time, or a time period
- Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send.
- This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.
Code specifying type of date or time, or both date and time
- 444
- First Visit or Consultation
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
Expression of a date, a time, or range of dates, times or dates and times
Date - Repricer Received Date
To specify any or all of a date, a time, or a time period
- Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 050
- Received
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
Expression of a date, a time, or range of dates, times or dates and times
Claim Supplemental Information
To identify the type or transmission or both of paperwork or supporting information
- 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.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
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
- FT
- File Transfer
Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- FX
- By Fax
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
Code identifying a party or other code
- 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.
Contract Information
To specify basic data about the contract or contract line item
- 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.
Code identifying a contract type
- 01
- Diagnosis Related Group (DRG)
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
- CN103 is the allowance or charge percent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CN104 is the contract code.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
Revision level of a particular format, program, technique or algorithm
- CN106 is an additional identifying number for the contract.
Patient Amount Paid
To indicate the total monetary amount
- 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).
Service Authorization Exception Code
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 4N
- Special Payment Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- 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
Mandatory Medicare (Section 4081) Crossover Indicator
To specify identifying information
- Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- F5
- Medicare Version Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The allowed values for this element are:
Y 4081
N Regular crossover
Mammography Certification Number
To specify identifying information
- Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EW
- Mammography Certification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- 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.
Prior Authorization
To specify identifying information
- 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.
- 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.
- 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.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier