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Health Care Claim: Professional (X222A2)
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X12 837 Health Care Claim: Professional (X222A2)

X12 Release 5010

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

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

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    ST
    0050
    Transaction Set Header
    Max use 1
    Required
    BHT
    0100
    Beginning of Hierarchical Transaction
    Max use 1
    Required
    Receiver Name Loop
    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
    PAT
    0070
    Patient Information
    Max use 1
    Optional
    Claim Information Loop
    CLM
    1300
    Claim Information
    Max use 1
    Required
    DTP
    1350
    Date - Accident
    Max use 1
    Optional
    DTP
    1350
    Date - Acute Manifestation
    Max use 1
    Optional
    DTP
    1350
    Date - Admission
    Max use 1
    Optional
    DTP
    1350
    Date - Assumed and Relinquished Care Dates
    Max use 2
    Optional
    DTP
    1350
    Date - Authorized Return to Work
    Max use 1
    Optional
    DTP
    1350
    Date - Disability Dates
    Max use 1
    Optional
    DTP
    1350
    Date - Discharge
    Max use 1
    Optional
    DTP
    1350
    Date - Hearing and Vision Prescription Date
    Max use 1
    Optional
    DTP
    1350
    Date - Initial Treatment Date
    Max use 1
    Optional
    DTP
    1350
    Date - Last Menstrual Period
    Max use 1
    Optional
    DTP
    1350
    Date - Last Seen Date
    Max use 1
    Optional
    DTP
    1350
    Date - Last Worked
    Max use 1
    Optional
    DTP
    1350
    Date - Last X-ray Date
    Max use 1
    Optional
    DTP
    1350
    Date - Onset of Current Illness or Symptom
    Max use 1
    Optional
    DTP
    1350
    Date - Property and Casualty Date of First Contact
    Max use 1
    Optional
    DTP
    1350
    Date - Repricer Received Date
    Max use 1
    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
    Care Plan Oversight
    Max use 1
    Optional
    REF
    1800
    Claim Identifier For Transmission Intermediaries
    Max use 1
    Optional
    REF
    1800
    Clinical Laboratory Improvement Amendment (CLIA) Number
    Max use 1
    Optional
    REF
    1800
    Demonstration Project Identifier
    Max use 1
    Optional
    REF
    1800
    Investigational Device Exemption Number
    Max use 1
    Optional
    REF
    1800
    Mammography Certification Number
    Max use 1
    Optional
    REF
    1800
    Mandatory Medicare (Section 4081) Crossover Indicator
    Max use 1
    Optional
    REF
    1800
    Medical Record Number
    Max use 1
    Optional
    REF
    1800
    Payer Claim Control Number
    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 1
    Optional
    CR1
    1950
    Ambulance Transport Information
    Max use 1
    Optional
    CR2
    2000
    Spinal Manipulation Service Information
    Max use 1
    Optional
    CRC
    2200
    Ambulance Certification
    Max use 3
    Optional
    CRC
    2200
    EPSDT Referral
    Max use 1
    Optional
    CRC
    2200
    Homebound Indicator
    Max use 1
    Optional
    CRC
    2200
    Patient Condition Information: Vision
    Max use 3
    Optional
    HI
    2310
    Anesthesia Related Procedure
    Max use 1
    Optional
    HI
    2310
    Condition Information
    Max use 2
    Optional
    HI
    2310
    Health Care Diagnosis Code
    Max use 1
    Required
    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
    SV1
    3700
    Professional Service
    Max use 1
    Required
    SV5
    4000
    Durable Medical Equipment Service
    Max use 1
    Optional
    PWK
    4200
    Durable Medical Equipment Certificate of Medical Necessity Indicator
    Max use 1
    Optional
    PWK
    4200
    Line Supplemental Information
    Max use 10
    Optional
    CR1
    4250
    Ambulance Transport Information
    Max use 1
    Optional
    CR3
    4350
    Durable Medical Equipment Certification
    Max use 1
    Optional
    CRC
    4500
    Ambulance Certification
    Max use 3
    Optional
    CRC
    4500
    Condition Indicator/Durable Medical Equipment
    Max use 1
    Optional
    CRC
    4500
    Hospice Employee Indicator
    Max use 1
    Optional
    DTP
    4550
    Date - Begin Therapy Date
    Max use 1
    Optional
    DTP
    4550
    DATE - Certification Revision/Recertification Date
    Max use 1
    Optional
    DTP
    4550
    Date - Initial Treatment Date
    Max use 1
    Optional
    DTP
    4550
    Date - Last Certification Date
    Max use 1
    Optional
    DTP
    4550
    Date - Last Seen Date
    Max use 1
    Optional
    DTP
    4550
    Date - Last X-ray Date
    Max use 1
    Optional
    DTP
    4550
    Date - Prescription Date
    Max use 1
    Optional
    DTP
    4550
    Date - Service Date
    Max use 1
    Required
    DTP
    4550
    Date - Shipped Date
    Max use 1
    Optional
    DTP
    4550
    Date - Test Date
    Max use 2
    Optional
    QTY
    4600
    Ambulance Patient Count
    Max use 1
    Optional
    QTY
    4600
    Obstetric Anesthesia Additional Units
    Max use 1
    Optional
    MEA
    4620
    Test Result
    Max use 5
    Optional
    CN1
    4650
    Contract Information
    Max use 1
    Optional
    REF
    4700
    Adjusted Repriced Line Item Reference Number
    Max use 1
    Optional
    REF
    4700
    Clinical Laboratory Improvement Amendment (CLIA) Number
    Max use 1
    Optional
    REF
    4700
    Immunization Batch Number
    Max use 1
    Optional
    REF
    4700
    Line Item Control Number
    Max use 1
    Optional
    REF
    4700
    Mammography Certification Number
    Max use 1
    Optional
    REF
    4700
    Prior Authorization
    Max use 5
    Optional
    REF
    4700
    Referral Number
    Max use 5
    Optional
    REF
    4700
    Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
    Max use 1
    Optional
    REF
    4700
    Repriced Line Item Reference Number
    Max use 1
    Optional
    AMT
    4750
    Postage Claimed Amount
    Max use 1
    Optional
    AMT
    4750
    Sales Tax Amount
    Max use 1
    Optional
    K3
    4800
    File Information
    Max use 10
    Optional
    NTE
    4850
    Line Note
    Max use 1
    Optional
    NTE
    4850
    Third Party Organization Notes
    Max use 1
    Optional
    PS1
    4880
    Purchased Service Information
    Max use 1
    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 - Acute Manifestation
    Max use 1
    Optional
    DTP
    1350
    Date - Admission
    Max use 1
    Optional
    DTP
    1350
    Date - Assumed and Relinquished Care Dates
    Max use 2
    Optional
    DTP
    1350
    Date - Authorized Return to Work
    Max use 1
    Optional
    DTP
    1350
    Date - Disability Dates
    Max use 1
    Optional
    DTP
    1350
    Date - Discharge
    Max use 1
    Optional
    DTP
    1350
    Date - Hearing and Vision Prescription Date
    Max use 1
    Optional
    DTP
    1350
    Date - Initial Treatment Date
    Max use 1
    Optional
    DTP
    1350
    Date - Last Menstrual Period
    Max use 1
    Optional
    DTP
    1350
    Date - Last Seen Date
    Max use 1
    Optional
    DTP
    1350
    Date - Last Worked
    Max use 1
    Optional
    DTP
    1350
    Date - Last X-ray Date
    Max use 1
    Optional
    DTP
    1350
    Date - Onset of Current Illness or Symptom
    Max use 1
    Optional
    DTP
    1350
    Date - Property and Casualty Date of First Contact
    Max use 1
    Optional
    DTP
    1350
    Date - Repricer Received Date
    Max use 1
    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
    Care Plan Oversight
    Max use 1
    Optional
    REF
    1800
    Claim Identifier For Transmission Intermediaries
    Max use 1
    Optional
    REF
    1800
    Clinical Laboratory Improvement Amendment (CLIA) Number
    Max use 1
    Optional
    REF
    1800
    Demonstration Project Identifier
    Max use 1
    Optional
    REF
    1800
    Investigational Device Exemption Number
    Max use 1
    Optional
    REF
    1800
    Mammography Certification Number
    Max use 1
    Optional
    REF
    1800
    Mandatory Medicare (Section 4081) Crossover Indicator
    Max use 1
    Optional
    REF
    1800
    Medical Record Number
    Max use 1
    Optional
    REF
    1800
    Payer Claim Control Number
    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 1
    Optional
    CR1
    1950
    Ambulance Transport Information
    Max use 1
    Optional
    CR2
    2000
    Spinal Manipulation Service Information
    Max use 1
    Optional
    CRC
    2200
    Ambulance Certification
    Max use 3
    Optional
    CRC
    2200
    EPSDT Referral
    Max use 1
    Optional
    CRC
    2200
    Homebound Indicator
    Max use 1
    Optional
    CRC
    2200
    Patient Condition Information: Vision
    Max use 3
    Optional
    HI
    2310
    Anesthesia Related Procedure
    Max use 1
    Optional
    HI
    2310
    Condition Information
    Max use 2
    Optional
    HI
    2310
    Health Care Diagnosis Code
    Max use 1
    Required
    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
    SV1
    3700
    Professional Service
    Max use 1
    Required
    SV5
    4000
    Durable Medical Equipment Service
    Max use 1
    Optional
    PWK
    4200
    Durable Medical Equipment Certificate of Medical Necessity Indicator
    Max use 1
    Optional
    PWK
    4200
    Line Supplemental Information
    Max use 10
    Optional
    CR1
    4250
    Ambulance Transport Information
    Max use 1
    Optional
    CR3
    4350
    Durable Medical Equipment Certification
    Max use 1
    Optional
    CRC
    4500
    Ambulance Certification
    Max use 3
    Optional
    CRC
    4500
    Condition Indicator/Durable Medical Equipment
    Max use 1
    Optional
    CRC
    4500
    Hospice Employee Indicator
    Max use 1
    Optional
    DTP
    4550
    Date - Begin Therapy Date
    Max use 1
    Optional
    DTP
    4550
    DATE - Certification Revision/Recertification Date
    Max use 1
    Optional
    DTP
    4550
    Date - Initial Treatment Date
    Max use 1
    Optional
    DTP
    4550
    Date - Last Certification Date
    Max use 1
    Optional
    DTP
    4550
    Date - Last Seen Date
    Max use 1
    Optional
    DTP
    4550
    Date - Last X-ray Date
    Max use 1
    Optional
    DTP
    4550
    Date - Prescription Date
    Max use 1
    Optional
    DTP
    4550
    Date - Service Date
    Max use 1
    Required
    DTP
    4550
    Date - Shipped Date
    Max use 1
    Optional
    DTP
    4550
    Date - Test Date
    Max use 2
    Optional
    QTY
    4600
    Ambulance Patient Count
    Max use 1
    Optional
    QTY
    4600
    Obstetric Anesthesia Additional Units
    Max use 1
    Optional
    MEA
    4620
    Test Result
    Max use 5
    Optional
    CN1
    4650
    Contract Information
    Max use 1
    Optional
    REF
    4700
    Adjusted Repriced Line Item Reference Number
    Max use 1
    Optional
    REF
    4700
    Clinical Laboratory Improvement Amendment (CLIA) Number
    Max use 1
    Optional
    REF
    4700
    Immunization Batch Number
    Max use 1
    Optional
    REF
    4700
    Line Item Control Number
    Max use 1
    Optional
    REF
    4700
    Mammography Certification Number
    Max use 1
    Optional
    REF
    4700
    Prior Authorization
    Max use 5
    Optional
    REF
    4700
    Referral Number
    Max use 5
    Optional
    REF
    4700
    Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
    Max use 1
    Optional
    REF
    4700
    Repriced Line Item Reference Number
    Max use 1
    Optional
    AMT
    4750
    Postage Claimed Amount
    Max use 1
    Optional
    AMT
    4750
    Sales Tax Amount
    Max use 1
    Optional
    K3
    4800
    File Information
    Max use 10
    Optional
    NTE
    4850
    Line Note
    Max use 1
    Optional
    NTE
    4850
    Third Party Organization Notes
    Max use 1
    Optional
    PS1
    4880
    Purchased Service Information
    Max use 1
    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

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

    Example
    ISA-01
    I01
    Authorization Information Qualifier
    Required

    Code identifying the type of information in the Authorization Information

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

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

    ISA-03
    I03
    Security Information Qualifier
    Required

    Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

    ISA-09
    I08
    Interchange Date
    Required
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    Min 1Max 1

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

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

    Code specifying the version number of the interchange control segments

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

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    Min 1Max 1

    Code indicating sender's request for an interchange acknowledgment

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

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

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

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

    >
    Component Element Separator

    Functional Group Header

    RequiredMax use 1

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

    Example
    GS-01
    479
    Functional Identifier Code
    Required

    Code identifying a group of application related transaction sets

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

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

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

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

    GS-04
    373
    Date
    Required
    CCYYMMDD format

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

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

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

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

    Assigned number originated and maintained by the sender

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

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

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

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

    005010X222A2
    ANSI ASC X12N 837 Health Care Claims (837) for professional claims and/or encounters through June 2014

    Heading

    ST
    0050

    Transaction Set Header

    RequiredMax use 1

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

    Example
    ST-01
    143
    Transaction Set Identifier Code
    Required

    Code uniquely identifying a Transaction Set

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

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

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

    Reference assigned to identify Implementation Convention

    • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
    Usage notes
    • This element must be populated with the guide identifier named in Section 1.2.
    • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
    005010X222A2
    BHT
    0100

    Beginning of Hierarchical Transaction

    RequiredMax use 1

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

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

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

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

    Code identifying purpose of transaction set

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

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

    18
    Reissue

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

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

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

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

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

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

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

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

    Code specifying the type of transaction

    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.

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

    Receiver Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    40
    Receiver
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    Usage notes

    Receiver Name (Organization)

    UNITEDHEALTHCARE

    UNITEDHEALTHCARE
    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes

    ETIN Code

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

    Code identifying a party or other code

    87726
    UnitedHealthcare Payer ID
    1000A Submitter Name Loop
    RequiredMax 1
    Variants (all may be used)
    1000BReceiver Name Loop
    NM1
    0200

    Submitter Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    41
    Submitter
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    46
    Electronic Transmitter Identification Number (ETIN)

    Established by trading partner agreement

    NM1-09
    67
    Submitter Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    Usage notes

    Federal Tax ID of the submitter. This number should be identical to the ISA06 and GS02 Federal Tax ID.

    PER
    0450

    Submitter EDI Contact Information

    RequiredMax use 2

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

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

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    Detail

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

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

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

    Billing Provider Specialty Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

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

    Code identifying the type of provider

    BI
    Billing
    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    CUR
    0100

    Foreign Currency Information

    OptionalMax use 1

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

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

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

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

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

    Usage notes
    • The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.
    2010AA Billing Provider Name Loop
    RequiredMax 1
    NM1
    0150

    Billing Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    85
    Billing Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

    N3
    0250

    Billing Provider Address

    RequiredMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Billing Provider City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

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

    Code identifying the country

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

    Code identifying the country subdivision

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

    Billing Provider Tax Identification

    RequiredMax use 1

    To specify identifying information

    Usage notes
    • This is the tax identification number (TIN) of the entity to be paid for the submitted services.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EI
    Employer's Identification Number

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

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

    SY
    Social Security Number

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

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

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

    REF
    0350

    Billing Provider UPIN/License Information

    OptionalMax use 2

    To specify identifying information

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

    Code qualifying the Reference Identification

    0B
    State License Number
    1G
    Provider UPIN Number

    UPINs must be formatted as either X99999 or XXX999.

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

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

    PER
    0400

    Billing Provider Contact Information

    OptionalMax use 2

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

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

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

    Complete communications number including country or area code when applicable

    2010AB Pay-to Address Name Loop
    OptionalMax 1
    NM1
    0150

    Pay-to Address Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

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

    Code qualifying the type of entity

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

    Pay-to Address - ADDRESS

    RequiredMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Pay-To Address City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    2010AC Pay-To Plan Name Loop
    OptionalMax 1
    NM1
    0150

    Pay-To Plan Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    PE
    Payee

    PE is used to indicate the subrogated payee.

    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes
    • 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:

    1. 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
    2. 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
    NM1-09
    67
    Pay-To Plan Primary Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    N3
    0250

    Pay-to Plan Address

    RequiredMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Pay-To Plan City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Pay-to Plan Secondary Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required 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.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    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
    REF-02
    127
    Pay-to Plan Secondary Identifier
    Required
    Min 1Max 50

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

    REF
    0350

    Pay-To Plan Tax Identification Number

    RequiredMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    EI
    Employer's Identification Number

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

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

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

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

    2000B Subscriber Hierarchical Level Loop
    RequiredMax >1
    HL
    0010

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

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

    Subscriber Information

    RequiredMax use 1

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

    Example
    SBR-01
    1138
    Payer Responsibility Sequence Number Code
    Required

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

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

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

    SBR-02
    1069
    Individual Relationship Code
    Optional

    Code indicating the relationship between two individuals or entities

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

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

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

    Free-form name

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

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

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

    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.

    PAT
    0070

    Patient Information

    OptionalMax use 1

    To supply patient information

    Usage notes
    • 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.
    Example
    If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required
    If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required
    PAT-05
    1250
    Date Time Period Format Qualifier
    Optional

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

    D8
    Date Expressed in Format CCYYMMDD
    PAT-06
    1251
    Patient Death Date
    Optional
    Min 1Max 35

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

    • PAT06 is the date of death.
    PAT-07
    355
    Unit or Basis for Measurement Code
    Optional

    Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

    01
    Actual Pounds
    PAT-08
    81
    Patient Weight
    Optional
    Min 1Max 10

    Numeric value of weight

    • PAT08 is the patient's weight.
    PAT-09
    1073
    Pregnancy Indicator
    Optional

    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.
    Usage notes
    • For this implementation, the listed value takes precedence over the semantic note.
    Y
    Yes
    2010BB Payer Name Loop
    RequiredMax 1
    Variants (all may be used)
    2010BASubscriber Name Loop
    NM1
    0150

    Payer Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

    PR
    Payer
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    UNITEDHEALTHCARE
    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes
    • 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:

    1. 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
    2. Follow an early implementation approach in which the HPID or OEID is sent in NM109.
    PI
    Payor Identification
    NM1-09
    67
    Payer Identifier
    Required

    Code identifying a party or other code

    87726
    Claims
    N3
    0250

    Payer Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Payer City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
    Example
    Only one of Payer State 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
    Payer City Name
    Required
    Min 2Max 30

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Billing Provider Secondary Identification

    RequiredMax use 2

    To specify identifying information

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

    Code qualifying the Reference Identification

    G2
    Provider Commercial Number

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

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

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

    REF
    0350

    Payer Secondary Identification

    OptionalMax use 3

    To specify identifying information

    Usage notes
    • Required 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.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    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
    REF-02
    127
    Payer Secondary Identifier
    Required
    Min 1Max 50

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

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

    Subscriber Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

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

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

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

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

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

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

    Usage notes

    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.

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

    Code identifying a party or other code

    N3
    0250

    Subscriber Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    0300

    Subscriber City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

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

    Subscriber Demographic Information

    OptionalMax use 1

    To supply demographic information

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

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

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

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

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

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    REF
    0350

    Property and Casualty Claim Number

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

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

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

    REF
    0350

    Subscriber Secondary Identification

    OptionalMax use 1

    To specify identifying information

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

    Code qualifying the Reference Identification

    SY
    Social Security Number

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

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

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

    PER
    0400

    Property and Casualty Subscriber Contact Information

    OptionalMax use 1

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

    Usage notes
    • 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-".
    Example
    If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

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

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

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

    TE
    Telephone
    PER-04
    364
    Communication Number
    Required
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EX
    Telephone Extension
    PER-06
    364
    Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    2300 Claim Information Loop
    OptionalMax 100
    CLM
    1300

    Claim Information

    RequiredMax use 1

    To specify basic data about the claim

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

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

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

    Monetary amount

    • CLM02 is the total amount of all submitted charges of service segments for this claim.
    Usage notes
    • The Total Claim Charge Amount must be greater than or equal to zero.
    • The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim.
    CLM-05
    C023
    Health Care Service Location Information
    To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
    C023-01
    1331
    Place of Service Code
    Required
    Min 1Max 2

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

    C023-02
    1332
    Facility Code Qualifier
    Required

    Code identifying the type of facility referenced

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

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

    CLM-06
    1073
    Provider or Supplier Signature Indicator
    Required

    Code indicating a Yes or No condition or response

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

    Code indicating whether the provider accepts assignment

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

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

    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' nor B' apply.

    CLM-08
    1073
    Benefits Assignment Certification Indicator
    Required

    Code indicating a Yes or No condition or response

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

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

    Y
    Yes
    CLM-09
    1363
    Release of Information Code
    Required

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

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

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

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

    Required when the provider has collected a signature.
    OR
    Required when state or federal laws require a signature be collected.

    CLM-10
    1351
    Patient Signature Source Code
    Optional

    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.

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

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

    C024-01
    1362
    Related Causes Code
    Required

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

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

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

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

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

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

    Code identifying the country

    CLM-12
    1366
    Special Program Indicator
    Optional

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

    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.

    CLM-20
    1514
    Delay Reason Code
    Optional

    Code indicating the reason why a request was delayed

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

    Date - Accident

    OptionalMax use 1

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

    Usage notes
    • Required when CLM11-1 or CLM11-2 has a value of AA' or OA'.
      OR
      Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
      If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    DTP
    1350

    Date - Acute Manifestation

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    453
    Acute Manifestation of a Chronic Condition
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Admission

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    435
    Admission
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Assumed and Relinquished Care Dates

    OptionalMax use 2

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

    Usage notes
    • 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".

    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    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.

    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Authorized Return to Work

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    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.

    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Disability Dates

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    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.

    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

    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.

    DTP-03
    1251
    Disability From Date
    Required
    Min 1Max 35

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

    DTP-01
    374
    Date Time Qualifier
    Required

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

    096
    Discharge
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Hearing and Vision Prescription Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    471
    Prescription
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Initial Treatment Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    454
    Initial Treatment
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Last Menstrual Period

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    484
    Last Menstrual Period
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Last Seen Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    304
    Latest Visit or Consultation
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Last Worked

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    297
    Initial Disability Period Last Day Worked
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Last X-ray Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    455
    Last X-Ray
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Onset of Current Illness or Symptom

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    431
    Onset of Current Symptoms or Illness
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    1350

    Date - Property and Casualty Date of First Contact

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    444
    First Visit or Consultation
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    PWK
    1550

    Claim Supplemental Information

    OptionalMax use 10

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

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

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

    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
    PWK-02
    756
    Attachment Transmission Code
    Required

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

    AA
    Available on Request at Provider Site

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

    BM
    By Mail
    EL
    Electronically Only

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

    EM
    E-Mail
    FT
    File Transfer

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

    FX
    By Fax
    PWK-05
    66
    Identification Code Qualifier
    Optional

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

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

    Code identifying a party or other code

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

    Contract Information

    OptionalMax use 1

    To specify basic data about the contract or contract line item

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

    Code identifying a contract type

    01
    Diagnosis Related Group (DRG)
    02
    Per Diem
    03
    Variable Per Diem
    04
    Flat
    05
    Capitated
    06
    Percent
    09
    Other
    CN1-02
    782
    Contract Amount
    Optional
    Min 1Max 15

    Monetary amount

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

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

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

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

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

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

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

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

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

    Patient Amount Paid

    OptionalMax use 1

    To indicate the total monetary amount

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

    Code to qualify amount

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

    Monetary amount

    REF
    1800

    Adjusted Repriced Claim Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
    • This information is specific to the destination payer reported in Loop ID-2010BB.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    REF
    1800

    Care Plan Oversight

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send.
    • This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished.
      Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number.
      On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    1J
    Facility ID Number
    REF-02
    127
    Care Plan Oversight Number
    Required
    Min 1Max 50

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

    REF
    1800

    Claim Identifier For Transmission Intermediaries

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
    • Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

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

    Clinical Laboratory Improvement Amendment (CLIA) Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send.
    • If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
    • In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    X4
    Clinical Laboratory Improvement Amendment Number
    REF-02
    127
    Clinical Laboratory Improvement Amendment Number
    Required
    Min 1Max 50

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

    REF
    1800

    Demonstration Project Identifier

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    P4
    Project Code
    REF-02