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Health Care Services Review Information - Response (X217)
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X12 278 Health Care Services Review Information - Response (X217)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.

Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
  • Example 1: Response to the Request for Review
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
Utilization Management Organization (UMO) Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
AAA
0300
Request Validation
Max use 9
Optional
Requester Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Subscriber Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Dependent Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Patient Event Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Patient Event Tracking Number
Max use 3
Optional
AAA
0300
Patient Event Request Validation
Max use 9
Optional
UM
0400
Health Care Services Review Information
Max use 1
Required
HCR
0500
Health Care Services Review
Max use 1
Optional
REF
0600
Administrative Reference Number
Max use 1
Optional
REF
0600
Previous Review Authorization Number
Max use 1
Optional
DTP
0700
Accident Date
Max use 1
Optional
DTP
0700
Admission Date
Max use 1
Optional
DTP
0700
Certification Effective Date
Max use 1
Optional
DTP
0700
Certification Expiration Date
Max use 1
Optional
DTP
0700
Certification Issue Date
Max use 1
Optional
DTP
0700
Discharge Date
Max use 1
Optional
DTP
0700
Estimated Date of Birth
Max use 1
Optional
DTP
0700
Event Date
Max use 1
Optional
DTP
0700
Last Menstrual Period Date
Max use 1
Optional
DTP
0700
Onset of Current Symptoms or Illness Date
Max use 1
Optional
HI
0800
Patient Diagnosis
Max use 1
Optional
HSD
0900
Health Care Services Delivery
Max use 1
Optional
CL1
1100
Institutional Claim Code
Max use 1
Optional
CR1
1200
Ambulance Transport Information
Max use 1
Optional
CR2
1300
Spinal Manipulation Service Information
Max use 1
Optional
CR5
1400
Home Oxygen Therapy Information
Max use 1
Optional
CR6
1500
Home Health Care Information
Max use 1
Optional
PWK
1550
Additional Patient Information
Max use 10
Optional
MSG
1600
Message Text
Max use 1
Optional
Service Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Service Trace Number
Max use 3
Optional
AAA
0300
Service Request Validation
Max use 9
Optional
UM
0400
Health Care Services Review Information
Max use 1
Optional
HCR
0500
Health Care Services Review
Max use 1
Optional
REF
0600
Administrative Reference Number
Max use 1
Optional
REF
0600
Previous Review Authorization Number
Max use 1
Optional
DTP
0700
Certification Effective Date
Max use 1
Optional
DTP
0700
Certification Expiration Date
Max use 1
Optional
DTP
0700
Certification Issue Date
Max use 1
Optional
DTP
0700
Service Date
Max use 1
Optional
HI
0800
Request For Additional Information
Max use 1
Optional
SV1
0810
Professional Service
Max use 1
Optional
SV2
0820
Institutional Service Line
Max use 1
Optional
SV3
0830
Dental Service
Max use 1
Optional
TOO
0840
Tooth Information
Max use 32
Optional
HSD
0900
Health Care Services Delivery
Max use 1
Optional
PWK
1550
Additional Service Information
Max use 10
Optional
MSG
1600
Message Text
Max use 1
Optional
SE
2800
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
Identifier (ID)

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
String (AN)
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
Identifier (ID)

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
String (AN)
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
Identifier (ID)
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
String (AN)
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
Identifier (ID)
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
String (AN)
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
Date (DT)
YYMMDD format

Date of the interchange

ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format

Time of the interchange

ISA-11
I65
Repetition Separator
Required
String (AN)
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
Identifier (ID)

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
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
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
Identifier (ID)
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
String (AN)
Min 1Max 1

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

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

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

Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)

Code identifying a group of application related transaction sets

HI
Health Care Services Review Information (278)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

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

GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15

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

GS-04
373
Date
Required
Date (DT)
CCYYMMDD format

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

GS-05
337
Time
Required
Time (TM)
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
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

GS-07
455
Responsible Agency Code
Required
Identifier (ID)
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
String (AN)

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

005010X217

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

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

Usage notes
  • This segment indicates the start of a health care services review information response transaction set with all the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management response.
Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)

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).
278
Health Care Services Review Information
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

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

Usage notes
  • The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research. Use the corresponding value in SE02 for this transaction set.
ST-03
1705
Implementation Guide Version Name
Required
String (AN)

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 (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
005010X217
BHT
0200
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

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

Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)

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

0007
Information Source, Information Receiver, Subscriber, Dependent, Event, Services
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

11
Response
BHT-03
127
Submitter Transaction Identifier
Required
String (AN)
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
  • Return the transaction identifier entered in BHT03 on the 278 request.
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

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

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

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

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

Code specifying the type of transaction

18
Response - No Further Updates to Follow

Use this code to indicate that this is a final response. This indicates that no additional EDI responses are necessary or forthcoming from the UMO in relation to the original request.

19
Response - Further Updates to Follow

Use this code to indicate that one or more of the services requested are pending further review and an EDI response will be delivered later.

AT
Administrative Action

BHT06 must be valued with "AT" if this 278 response contains a request for additional information.

Delivery of follow-up response(s) is as mutually agreed by trading partners.

RU
Medical Services Reservation

Use this code to respond to a request for medical services reservations.

Heading end

Detail

2000A Utilization Management Organization (UMO) Level Loop
RequiredMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > HL

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
String (AN)
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
Identifier (ID)

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
Identifier (ID)

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.
AAA
0300
Detail > Utilization Management Organization (UMO) Level Loop > AAA

Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Y
Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

04
Authorized Quantity Exceeded

Use this code to indicate that the functional group exceeds the maximum number of transactions as specified by agreement between the application sender GS02 and application receiver GS03.

41
Authorization/Access Restrictions

Use this code to indicate that the application sender (GS02) and application receiver (GS03) do not have a trading partner agreement for the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02. The 278 transaction set has three different implementations. The transaction set purpose, as identified in BHT02, specifies the implementation.

42
Unable to Respond at Current Time

Use this code to indicate that the entity responsible for forwarding the request to the information source (Loop 2010A) is unable to process the transaction at the current time. This indicates a problem in the system forwarding the request and not in the information source's (UMO) system.

79
Invalid Participant Identification

Use this code to indicate that the identifier used in GS02 or GS03 is invalid or unknown.

AA
Authorization Number Not Found
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
P
Please Resubmit Original Transaction
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2010A Utilization Management Organization (UMO) Name Loop
RequiredMax 1
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Utilization Management Organization (UMO) Name Loop > NM1

Utilization Management Organization (UMO) Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment identifies the source of information. In the case of a response to a request transaction, the information source would normally be the payer or utilization review organization who is the source of the decision regarding the request.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

2B
Third-Party Administrator
36
Employer
PR
Payer
X3
Utilization Management Organization
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Utilization Management Organization (UMO) Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Utilization Management Organization (UMO) First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Utilization Management Organization (UMO) Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Utilization Management Organization (UMO) Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

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

24
Employer's Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
PI
Payor Identification

Use when UMO is a payer and XV is not used.

XV
Centers for Medicare and Medicaid Services PlanID

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

NM1-09
67
Utilization Management Organization (UMO) Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
2200
Detail > Utilization Management Organization (UMO) Level Loop > Utilization Management Organization (UMO) Name Loop > PER

Utilization Management Organization (UMO) Contact Information

OptionalMax use 1

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

Usage notes
  • Use this segment to identify a contact name and/or communications number for the UMO.
  • Required when the requester must direct requests for follow-up to a specific UMO contact, email, facsimile, or telephone. 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 should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
Example
If either Communication Number Qualifier (PER-03) or Utilization Management Organization (UMO) Contact Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Utilization Management Organization (UMO) Contact Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Utilization Management Organization (UMO) Contact Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

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

IC
Information Contact
PER-02
93
Utilization Management Organization (UMO) Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

PER-04
364
Utilization Management Organization (UMO) Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

PER-06
364
Utilization Management Organization (UMO) Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)

Must not contain any characters used as delimiters in this transaction.

PER-08
364
Utilization Management Organization (UMO) Contact Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

AAA
2300
Detail > Utilization Management Organization (UMO) Level Loop > Utilization Management Organization (UMO) Name Loop > AAA

Utilization Management Organization (UMO) Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request cannot be processed at the system or application level based on the Utilization Management Organization (information source) identified in Loop 2010A. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

42
Unable to Respond at Current Time

Use this code to indicate that the information source (UMO) identified in Loop 2010A is unable to process the transaction at the current time.

79
Invalid Participant Identification

Use this code to indicate that the code used in Loop 2010A to identify the information source (UMO) is invalid.

80
No Response received - Transaction Terminated

Use this code to indicate that the trading partner/application system responsible for sending the request to the information source (UMO) has not received a response in the expected timeframe and therefore has terminated the request.

T4
Payer Name or Identifier Missing

Use this code to indicate that either the name or identifier for the information source (UMO) identified in Loop 2010A is missing.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

N
Resubmission Not Allowed
P
Please Resubmit Original Transaction
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2010A Utilization Management Organization (UMO) Name Loop end
2000B Requester Level Loop
OptionalMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > HL

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
String (AN)
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
String (AN)
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
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
21
Information Receiver
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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.
2010B Requester Name Loop
RequiredMax 2
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > NM1

Requester Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This loop identifies the receiver of information. In the case of a response to a request transaction, the receiver would normally be the provider who is receiving the decision.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

1P
Provider
FA
Facility
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Requester Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Requester First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Requester Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Requester Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

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

24
Employer's Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Requester Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > REF

Requester Supplemental Identification

OptionalMax use 8

To specify identifying information

Usage notes
  • Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1G
Provider UPIN Number
1J
Facility ID Number
EI
Employer's Identification Number

Not used if NM108 = 24.

G5
Provider Site Number

Use to identify the physician, clinic, or group practice associated with the requester identified in this NM1 loop.

N5
Provider Plan Network Identification Number
N7
Facility Network Identification Number
SY
Social Security Number

The social security number must not be used for Medicare. Not used if NM108 = 34.

ZH
Carrier Assigned Reference Number

Use for the requester/provider ID as assigned by the UMO identified in Loop 2000A.

REF-02
127
Requester Supplemental Identifier
Required
String (AN)
Min 1Max 50

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

AAA
2300
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > AAA

Requester Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Use this segment to convey rejection information regarding the entity that initiated a request transaction.
  • Required when the request is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use for missing contact information (PER Segment) other than phone number.

35
Out of Network
41
Authorization/Access Restrictions

Use if the provider is not authorized for requests.

42
Unable to Respond at Current Time
43
Invalid/Missing Provider Identification
44
Invalid/Missing Provider Name
45
Invalid/Missing Provider Specialty
46
Invalid/Missing Provider Phone Number
47
Invalid/Missing Provider State
49
Provider is Not Primary Care Physician
51
Provider Not on File
79
Invalid Participant Identification

Use for invalid/missing requester supplemental identifier.

97
Invalid or Missing Provider Address
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
P
Please Resubmit Original Transaction
R
Resubmission Allowed
PRV
2400
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > PRV

Requester Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.
Example
If either Reference Identification Qualifier (PRV-02) or Provider Taxonomy Code (PRV-03) is present, then the other is required
PRV-01
1221
Provider Code
Required
Identifier (ID)

Code identifying the type of provider

AD
Admitting
AS
Assistant Surgeon
AT
Attending
CO
Consulting
CV
Covering
OP
Operating
OR
Ordering
OT
Other Physician
PC
Primary Care Physician
PE
Performing
RF
Referring
PRV-02
128
Reference Identification Qualifier
Optional
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Taxonomy Code
Optional
String (AN)
Min 1Max 50

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

2010B Requester Name Loop end
2000C Subscriber Level Loop
OptionalMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > HL

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
String (AN)
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
String (AN)
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
Identifier (ID)

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
Identifier (ID)

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.
2010C Subscriber Name Loop
RequiredMax 1
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment identifies the subscriber.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Subscriber Last Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Subscriber First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Subscriber Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-06
1038
Subscriber Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

NM1-07
1039
Subscriber Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

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

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

The value "II" when used in this data element, shall be defined as "HIPAA Individual Identifier" if this identifier has been adopted, under the Health Insurance Portability and Accountability Act of 1996, for use in this transaction.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

NM1-09
67
Subscriber Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

Subscriber Supplemental Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number are to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
  • Required when used by the UMO to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the request. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1L
Group or Policy Number

Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

3L
Branch Identifier
6P
Group Number
DP
Department Number
EJ
Patient Account Number

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

F6
Health Insurance Claim (HIC) Number

Use the NM1 (Subscriber Name) segment if the subscriber's HIC number is the primary identifier for his or her coverage. Use this code only in a REF segment when the payer has a different member number, and there also is a need to pass the dependent's HIC number. This might occur in a Medicare HMO situation.

HJ
Identity Card Number

Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.

IG
Insurance Policy Number
N6
Plan Network Identification Number
NQ
Medicaid Recipient Identification Number
SY
Social Security Number

Use this code only if the Social Security Number is not the primary;identifier for the subscriber. The social security number may not be;used for Medicare.

REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50

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

N3
2000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3

Subscriber Mailing Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the Subscriber address.
N3-02
166
Subscriber Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when used by the UMO to determine the appropriate location or network for service. 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
String (AN)
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
Identifier (ID)
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
Identifier (ID)
Min 3Max 15

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

N4-04
26
Country Code
Optional
Identifier (ID)
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
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
AAA
2300
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > AAA

Subscriber Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

58
Invalid/Missing Date-of-Birth
64
Invalid/Missing Patient ID
65
Invalid/Missing Patient Name
66
Invalid/Missing Patient Gender Code
67
Patient Not Found
68
Duplicate Patient ID Number
71
Patient Birth Date Does Not Match That for the Patient on the Database
72
Invalid/Missing Subscriber/Insured ID
73
Invalid/Missing Subscriber/Insured Name
74
Invalid/Missing Subscriber/Insured Gender Code
75
Subscriber/Insured Not Found
76
Duplicate Subscriber/Insured ID Number
77
Subscriber Found, Patient Not Found
78
Subscriber/Insured Not in Group/Plan Identified
79
Invalid Participant Identification

Use for invalid subscriber supplemental identifier.

95
Patient Not Eligible
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
DMG
2500
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
String (AN)
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
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
INS
2600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

Subscriber Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when used by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
Y
Yes
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

18
Self
INS-08
584
Employment Status Code
Required
Identifier (ID)

Code showing the general employment status of an employee/claimant

Usage notes
  • Use to qualify the patient's relationship to the military.
AO
Active Military - Overseas
AU
Active Military - USA
DI
Deceased
PV
Previous
RU
Retired Military - USA
2010C Subscriber Name Loop end
2000D Dependent Level Loop
OptionalMax 1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

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
String (AN)
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
String (AN)
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
Identifier (ID)

Code defining the characteristic of a level in a hierarchical structure

  • HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
23
Dependent
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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.
2010D Dependent Name Loop
RequiredMax 1
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

Dependent Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • This segment conveys the name of the dependent who is the patient.
  • NM108 and NM109 are situational on the response but Not Used on the request. This enables the UMO to return a unique member ID for the dependent that was not known to the requester at the time of the request. When the dependent has a unique member ID, Loop 2000D is not used.
Example
If either Identification Code Qualifier (NM1-08) or Dependent Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

QC
Patient
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Dependent Last Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Dependent First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Dependent Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Dependent Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

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

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

The value "II" when used in this data element, shall be defined as "HIPAA Individual Identifier" if this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.

MI
Member Identification Number

The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

NM1-09
67
Dependent Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

Dependent Supplemental Identification

OptionalMax use 3

To specify identifying information

Usage notes
  • Required when used by the UMO to identify the Dependent or when REF01 = "EJ" (Patient Account Number) is valued on the request. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

EJ
Patient Account Number

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

SY
Social Security Number

The social security number may not be used for Medicare.

REF-02
127
Dependent Supplemental Identifier
Required
String (AN)
Min 1Max 50

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

N3
2000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3

Dependent Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.
Example
N3-01
166
Dependent Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the Dependent address.
N3-02
166
Dependent Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4

Dependent City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.
Example
Only one of Dependent 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
Dependent City Name
Required
String (AN)
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
Dependent State Code
Optional
Identifier (ID)
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
Dependent Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

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

N4-04
26
Country Code
Optional
Identifier (ID)
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
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
AAA
2300
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > AAA

Dependent Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request is not valid at this level. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use this code to indicate missing dependent relationship information.

33
Input Errors

Use this code to indicate invalid dependent relationship information.

58
Invalid/Missing Date-of-Birth
64
Invalid/Missing Patient ID
65
Invalid/Missing Patient Name
66
Invalid/Missing Patient Gender Code
67
Patient Not Found
68
Duplicate Patient ID Number
71
Patient Birth Date Does Not Match That for the Patient on the Database
77
Subscriber Found, Patient Not Found
95
Patient Not Eligible
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
DMG
2500
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

Dependent Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Dependent Birth Date
Required
String (AN)
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
Dependent Gender Code
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
INS
2600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

Dependent Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when used by the UMO to determine the benefit/level of service for this patient. If not required by this implementation guide, do not send.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
N
No
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

01
Spouse
19
Child
G8
Other Relationship
INS-17
1470
Birth Sequence Number
Optional
Numeric (N0)
Min 1Max 9

A generic number

  • INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
2010D Dependent Name Loop end
2000E Patient Event Level Loop
OptionalMax >1
HL
0100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HL

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
String (AN)
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
String (AN)
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
Identifier (ID)

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.
EV
Event
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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.
TRN
0200
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > TRN

Patient Event Tracking Number

OptionalMax use 3

To uniquely identify a transaction to an application

Usage notes
  • Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278 response.
  • If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:

If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment.

If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.

  • If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
  • Required when this loop is returned and the request contained a tracking number at this level on the request, or when the UMO or clearinghouse assigns a trace number to this patient event in the response for tracking purposes. If not required by this implementation guide, do not send.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 response transaction (the UMO).

2
Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 request transaction.

TRN-02
127
Patient Event Trace Number
Required
String (AN)
Min 1Max 50

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

  • TRN02 provides unique identification for the transaction.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 request transaction. If TRN01 is "1", use this information to identify the UMO organization that assigned this trace number.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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

  • TRN04 identifies a further subdivision within the organization.
AAA
0300
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > AAA

Patient Event Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request is not valid at this level. If not required by this implementation guide, do not send.
  • Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

15
Required application data missing

Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.

33
Input Errors

Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid diagnosis codes and diagnosis dates.

52
Service Dates Not Within Provider Plan Enrollment

Use for Event Date(s).

56
Inappropriate Date

Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.

57
Invalid/Missing Date(s) of Service

Use for invalid/missing event date.

60
Date of Birth Follows Date(s) of Service

Use for Date(s) of Event.

61
Date of Death Precedes Date(s) of Service

Use for Date(s) of Event.

62
Date of Service Not Within Allowable Inquiry Period

Use for Date of Event.

AA
Authorization Number Not Found
AF
Invalid/Missing Diagnosis Code(s)
AH
Invalid/Missing Onset of Current Condition or Illness Date
AI
Invalid/Missing Accident Date
AJ
Invalid/Missing Last Menstrual Period Date
AK
Invalid/Missing Expected Date of Birth
AM
Invalid/Missing Admission Date
AN
Invalid/Missing Discharge Date
T5
Certification Information Missing

Use to indicate missing previous certification number information.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

C
Please Correct and Resubmit
N
Resubmission Not Allowed
UM
0400
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > UM

Health Care Services Review Information

RequiredMax use 1

To specify health care services review information

Usage notes
  • Identifies the type of health care services review.
Example
UM-01
1525
Request Category Code
Required
Identifier (ID)

Code indicating a type of request

AR
Admission Review

Required when this is a response to a request regarding admission to a facility.

HS
Health Services Review

Required when this is a response to a request for review of services related to an episode of care.

IN
Individual

Required when BHT06 is equal to "RU".

SC
Specialty Care Review

Required when this is a response to a request for a referral to a specialty provider.

UM-02
1322
Certification Type Code
Required
Identifier (ID)

Code indicating the type of certification

1
Appeal - Immediate

Use this value only for appeals of review decisions where the level of;service required is emergency or urgent. If UM02 = 1 then UM06 must be;valued.

2
Appeal - Standard

Use this value for appeals of review decisions where the level of service required is not emergency or urgent.

3
Cancel
4
Extension

Use this value to indicate that this is an extension request to a prior approved service.

I
Initial
N
Reconsideration
R
Renewal

Various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

S
Revised

Use if the requester is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.

UM-03
1365
Service Type Code
Optional
Identifier (ID)

Code identifying the classification of service

1
Medical Care
2
Surgical
3
Consultation
4
Diagnostic X-Ray
5
Diagnostic Lab
6
Radiation Therapy
7
Anesthesia
8
Surgical Assistance
11
Used Durable Medical Equipment
12
Durable Medical Equipment Purchase
14
Renal Supplies in the Home
15
Alternate Method Dialysis
16
Chronic Renal Disease (CRD) Equipment
17
Pre-Admission Testing
18
Durable Medical Equipment Rental
20
Second Surgical Opinion
21
Third Surgical Opinion
23
Diagnostic Dental
24
Periodontics
25
Restorative

Use for restorative dental.

26
Endodontics
27
Maxillofacial Prosthetics
28
Adjunctive Dental Services
33
Chiropractic
35
Dental Care
36
Dental Crowns
37
Dental Accident
38
Orthodontics
39
Prosthodontics
40
Oral Surgery
42
Home Health Care
44
Home Health Visits
45
Hospice
46
Respite Care
54
Long Term Care
56
Medically Related Transportation
61
In-vitro Fertilization
62
MRI/CAT Scan
63
Donor Procedures
64
Acupuncture
65
Newborn Care
66
Pathology
67
Smoking Cessation
68
Well Baby Care
69
Maternity
70
Transplants
71
Audiology Exam
72
Inhalation Therapy
73
Diagnostic Medical
74
Private Duty Nursing
75
Prosthetic Device
76
Dialysis
77
Otological Exam
78
Chemotherapy
79
Allergy Testing
80
Immunizations
82
Family Planning
83
Infertility
84
Abortion
85
AIDS
86
Emergency Services
87
Cancer
88
Pharmacy
93
Podiatry
A4
Psychiatric
A6
Psychotherapy
A9
Rehabilitation
AD
Occupational Therapy
AE
Physical Medicine
AF
Speech Therapy
AG
Skilled Nursing Care
AH
Skilled Nursing Care - Room and Board
AI
Substance Abuse
AJ
Alcoholism
AK
Drug Addiction
AL
Vision (Optometry)
AR
Experimental Drug Therapy
B1
Burn Care
BB
Partial Hospitalization (Psychiatric)
BC
Day Care (Psychiatric)
BD
Cognitive Therapy
BE
Massage Therapy
BF
Pulmonary Rehabilitation
BG
Cardiac Rehabilitation
BL
Cardiac
BN
Gastrointestinal
BP
Endocrine
BQ
Neurology
BS
Invasive Procedures
BY
Physician Visit - Office: Sick
BZ
Physician Visit - Office: Well
C1
Coronary Care
CQ
Case Management
GY
Allergy
IC
Intensive Care
MH
Mental Health
NI
Neonatal Intensive Care
ON
Oncology
PT
Physical Therapy
PU
Pulmonary
RN
Renal
RT
Residential Psychiatric Treatment
TC
Transitional Care
TN
Transitional Nursery Care
UM-04
C023
Health Care Service Location Information
OptionalMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
Usage notes

Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

C023-01
1331
Facility Type Code
Required
String (AN)
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.

Usage notes
  • Use to indicate a facility code value from the code source referenced in UM04-2.
C023-02
1332
Facility Code Qualifier
Required
Identifier (ID)

Code identifying the type of facility referenced

  • C023-02 qualifies C023-01 and C023-03.
A
Uniform Billing Claim Form Bill Type
B
Place of Service Codes for Professional or Dental Services
UM-06
1338
Level of Service Code
Optional
Identifier (ID)

Code specifying the level of service rendered

03
Emergency
E
Elective
U
Urgent
HCR
0500
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HCR

Health Care Services Review

OptionalMax use 1

To specify the outcome of a health care services review

Usage notes
  • If the UMO for this service was unable to review the request due to missing or invalid application data at this level, the UMO must return a 278 response containing a AAA segment at this level.
  • If Loop 2000E is present in the response, either the AAA segment or the HCR segment must be returned in loop 2000E.
  • If the review outcome is pending additional medical information and the 278 response includes a request for additional information using either a PWK segment or an HI segment that specifies LOINC values, then the associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the appropriate health care services review decision reason code to indicate that additional information is required.

Refer to Section 2.5 for more information.

  • Required when the UMO has reviewed the request at this level to provide patient event review outcome information or to indicate that the final decision is pending. If not required by this implementation guide, do not send.
  • If the response contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.
Example
HCR-01
306
Action Code
Required
Identifier (ID)

Code indicating type of action

A1
Certified in total
A2
Certified - partial

Use to identify that the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

A3
Not Certified
A4
Pended
A6
Modified
C
Cancelled
CT
Contact Payer
NA
No Action Required

Use only if certification is not required.

HCR-02
127
Review Identification Number
Optional
String (AN)

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

  • HCR02 is the number assigned by the information source to this review outcome.
A1
Certified in total
A6
Modified
HCR-03
1271
Review Decision Reason Code
Optional
String (AN)
Max use 5
Min 1Max 30

Code indicating a code from a specific industry code list

  • HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
Usage notes
  • This data element is a repeating data element and can be repeated the maximum number allowed by the standard in this implementation guide.
HCR-04
1073
Second Surgical Opinion Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
N
No
Y
Yes
REF
0600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Administrative Reference Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the HCR segment is valued in this loop, HCR01 = A3, A4 or CT and the UMO has assigned an administrative reference number associated with this service review. If not required by this implementation guide, do not send.
  • This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for reconsideration (UM02=6), to reference this UMO response.
Example
Variants (all may be used)
REFPrevious Review Authorization Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

NT
Administrator's Reference Number
REF-02
127
Administrative Reference Number
Required
String (AN)

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

A3
Not Certified
A4
Pended
CT
Contact payer
REF
0600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the certification number assigned by the UMO to the original service review outcome was used by the UMO to determine the outcome of this service review at the event level. If not required by this implementation guide, do not send.
  • This is the authorization number assigned by the UMO to the original review outcome associated with this event. This is not the trace number assigned by the requester.
Example
Variants (all may be used)
REFAdministrative Reference Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

BB
Authorization Number
REF-02
127
Previous Review Authorization Number
Required
String (AN)
Min 1Max 50

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Accident Date

OptionalMax use 1

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

Usage notes
  • Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

439
Accident
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Admission Date

OptionalMax use 1

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

Usage notes
  • Required when the UMO authorizes admission for a specific date or date range. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

435
Admission
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use this for the range of dates when admission can occur. Use the HSD segment for length of stay.

DTP-03
1251
Proposed or Actual Admission Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Effective Date

OptionalMax use 1

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

Usage notes
  • Required when the authorization is limited by effective dates to indicate the date or date range when the authorization is effective. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

007
Effective
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Certification Effective Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Expiration Date

OptionalMax use 1

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

Usage notes
  • Required when the authorization has an expiration date to indicate the date on which the authorization will expire. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

036
Expiration
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Certification Expiration Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Certification Issue Date

OptionalMax use 1

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

Usage notes
  • Required when the UMO assigns a certification issue date to this authorization. If not required by this implementation guide, do not send.
  • This is not the effective date of the authorization. The issue date is that date when the UMO issued the authorization.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

102
Issue
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Certification Issue Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Discharge Date

OptionalMax use 1

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

Usage notes
  • Required when the UMO authorizes services or admission based on the proposed or actual discharge date. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

096
Discharge
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Proposed or Actual Discharge Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Estimated Date of Birth

OptionalMax use 1

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

Usage notes
  • Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

ABC
Estimated Date of Birth
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Estimated Birth Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Event Date

OptionalMax use 1

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

Usage notes
  • Required when the UMO authorizes service for a specific date or date range. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

AAH
Event
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Proposed or Actual Event Date
Required
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Last Menstrual Period Date

OptionalMax use 1

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

Usage notes
  • Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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
Identifier (ID)

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
String (AN)
Min 1Max 35

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

DTP
0700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Onset of Current Symptoms or Illness Date

OptionalMax use 1

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

Usage notes
  • Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
  • The total number of DTP segments in the 2000E loop cannot exceed 9.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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
Identifier (ID)

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 Date
Required
String (AN)
Min 1Max 35

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

HI
0800
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HI

Patient Diagnosis

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • If the response has not been rendered and this segment is used to request additional information associated with a specific diagnosis, place the specific diagnosis code in the HI C022 composite that precedes the HI C022 composite(s) containing the LOINC. If the original request contained more than six diagnosis codes and you are using LOINC to request additional information for each of these diagnosis codes or if you need to specify multiple questions/LOINC codes per diagnosis you cannot exceed the limit of 12 occurrences of the C022 composite.
  • Required when used by the UMO to render a medical decision or if the UMO is requesting additional information. If not required by this implementation guide, do not send.
  • The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes that identify the specific information that the UMO requires from the provider to complete the medical review. In the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical Observation Identifier Names and Codes (LOINC®) List. These codes identify high-level health care information groupings, specific data elements, and associated modifiers.

Refer to Section 1.12.5.2 of this guide for more information on requesting additional information in the 278 response.

Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-05
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-06
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-07
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-08
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-09
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-10
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes

See Section 2.5 for information on using LOINC to request additional information.

PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-11
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HI-12
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

Code identifying a specific industry code list

  • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR
Diagnosis Related Group (DRG)
LOI
Logical Observation Identifier Names and Codes (LOINC<190>) Codes
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

  • C022-03 is the date format that will appear in C022-04.
D8
Date Expressed in Format CCYYMMDD
C022-04
1251
Diagnosis Date
Optional
String (AN)
Min 1Max 35

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

HSD
0900
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

To specify the delivery pattern of health care services

Usage notes
  • Required when the UMO authorizes services that have a specific pattern of delivery for the patient event. If not required by this implementation guide, do not send.
  • Report authorized delivery patterns for specific services in the Service Level (Loop 2000F).
  • An explanation of the uses of this segment follows.

HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".

Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".

An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".

Example
If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required
If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required
HSD-01
673
Quantity Qualifier
Optional
Identifier (ID)

Code specifying the type of quantity

DY
Days
FL
Units
HS
Hours
MN
Month
VS
Visits
HSD-02
380
Service Unit Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

HSD-03
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

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

DA
Days
MO
Months
WK
Week
HSD-04
1167
Sample Selection Modulus
Optional
Decimal number (R)
Min 1Max 6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

HSD-05
615
Time Period Qualifier
Optional
Identifier (ID)

Code defining periods

6
Hour
7
Day
21
Years
26
Episode
27
Visit
34
Month
35
Week
HSD-06
616
Period Count
Optional
Numeric (N0)
Min 1Max 3

Total number of periods

HSD-07
678
Delivery Frequency Code
Optional
Identifier (ID)

Code which specifies the routine shipments, deliveries, or calendar pattern

1
1st Week of the Month
2
2nd Week of the Month
3
3rd Week of the Month
4
4th Week of the Month
5
5th Week of the Month
6
1st & 3rd Weeks of the Month
7
2nd & 4th Weeks of the Month
8
1st Working Day of Period
9
Last Working Day of Period
A
Monday through Friday
B
Monday through Saturday
C
Monday through Sunday
D
Monday
E
Tuesday
F
Wednesday
G
Thursday
H
Friday
J
Saturday
K
Sunday
L
Monday through Thursday
M
Immediately
N
As Directed
O
Daily Mon. through Fri.
P
1/2 Mon. & 1/2 Thurs.
Q
1/2 Tues. & 1/2 Thurs.
R
1/2 Wed. & 1/2 Fri.
S
Once Anytime Mon. through Fri.
SA
Sunday, Monday, Thursday, Friday, Saturday
SB
Tuesday through Saturday
SC
Sunday, Wednesday, Thursday, Friday, Saturday
SD
Monday, Wednesday, Thursday, Friday, Saturday
SG
Tuesday through Friday
SL
Monday, Tuesday and Thursday
SP
Monday, Tuesday and Friday
SX
Wednesday and Thursday
SY
Monday, Wednesday and Thursday
SZ
Tuesday, Thursday and Friday
T
1/2 Tue. & 1/2 Fri.
U
1/2 Mon. & 1/2 Wed.
V
1/3 Mon., 1/3 Wed., 1/3 Fri.
W
Whenever Necessary
WE
Weekend
X
1/2 By Wed., Bal. By Fri.
Y
None (Also Used to Cancel or Override a Previous Pattern)
HSD-08
679
Delivery Pattern Time Code
Optional
Identifier (ID)

Code which specifies the time for routine shipments or deliveries

A
1st Shift (Normal Working Hours)
B
2nd Shift
C
3rd Shift
D
A.M.
E
P.M.
F
As Directed
G
Any Shift
Y
None (Also Used to Cancel or Override a Previous Pattern)
CL1
1100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CL1

Institutional Claim Code

OptionalMax use 1

To supply information specific to hospital claims

Usage notes
  • Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Example
CL1-01
1315
Admission Type Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating the priority of this admission

CL1-02
1314
Admission Source Code
Optional
Identifier (ID)
Min 1Max 1

Code indicating the source of this admission

CL1-03
1352
Patient Status Code
Optional
Identifier (ID)
Min 1Max 2

Code indicating patient status as of the "statement covers through date"

CR1
1200
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR1

Ambulance Transport Information

OptionalMax use 1

To supply information related to the ambulance service rendered to a patient

Usage notes
  • Use this segment for certifications involving non-emergency transport of the patient.
  • Required when used by the UMO to authorize specific non-emergency transport services. If not required by this implementation guide, do not send.
Example
If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required
CR1-03
1316
Ambulance Transport Code
Required
Identifier (ID)

Code indicating the type of ambulance transport

I
Initial Trip
R
Return Trip
T
Transfer Trip
X
Round Trip
CR1-05
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

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

DH
Miles
DK
Kilometers
CR1-06
380
Transport Distance
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR106 is the distance traveled during transport.
CR2
1300
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR2

Spinal Manipulation Service Information

OptionalMax use 1

To supply information related to the chiropractic service rendered to a patient

Usage notes
  • Required when used by the UMO to authorize spinal manipulation services that have a specific pattern of delivery usage. If not required by this implementation guide, do not send.
Example
If either Treatment Series Number (CR2-01) or Treatment Count (CR2-02) is present, then the other is required
If Subluxation Level Code (CR2-04) is present, then Subluxation Level Code (CR2-03) is required
CR2-01
609
Treatment Series Number
Optional
Numeric (N0)
Min 1Max 9

Occurrence counter

  • CR201 is the number this treatment is in the series.
CR2-02
380
Treatment Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR202 is the total number of treatments in the series.
CR2-03
1367
Subluxation Level Code
Optional
Identifier (ID)

Code identifying the specific level of subluxation

  • When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.
C1
Cervical 1
C2
Cervical 2
C3
Cervical 3
C4
Cervical 4
C5
Cervical 5
C6
Cervical 6
C7
Cervical 7
CO
Coccyx
IL
Ilium
L1
Lumbar 1
L2
Lumbar 2
L3
Lumbar 3
L4
Lumbar 4
L5
Lumbar 5
OC
Occiput
SA
Sacrum
T1
Thoracic 1
T10
Thoracic 10
T11
Thoracic 11
T12
Thoracic 12
T2
Thoracic 2
T3
Thoracic 3
T4
Thoracic 4
T5
Thoracic 5
T6
Thoracic 6
T7
Thoracic 7
T8
Thoracic 8
T9
Thoracic 9
CR2-04
1367
Subluxation Level Code
Optional
Identifier (ID)

Code identifying the specific level of subluxation

C1
Cervical 1
C2
Cervical 2
C3
Cervical 3
C4
Cervical 4
C5
Cervical 5
C6
Cervical 6
C7
Cervical 7
CO
Coccyx
IL
Ilium
L1
Lumbar 1
L2
Lumbar 2
L3
Lumbar 3
L4
Lumbar 4
L5
Lumbar 5
OC
Occiput
SA
Sacrum
T1
Thoracic 1
T10
Thoracic 10
T11
Thoracic 11
T12
Thoracic 12
T2
Thoracic 2
T3
Thoracic 3
T4
Thoracic 4
T5
Thoracic 5
T6
Thoracic 6
T7
Thoracic 7
T8
Thoracic 8
T9
Thoracic 9
CR5
1400
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR5

Home Oxygen Therapy Information

OptionalMax use 1

To supply information regarding certification of medical necessity for home oxygen therapy

Usage notes
  • Required when used by the UMO to authorize specific usage of home oxygen therapy. If not required by this implementation guide, do not send.
Example
CR5-03
1348
Oxygen Equipment Type Code
Optional
Identifier (ID)

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

A
Concentrator
B
Liquid Stationary
C
Gaseous Stationary
D
Liquid Portable
E
Gaseous Portable
O
Other
CR5-04
1348
Oxygen Equipment Type Code
Optional
Identifier (ID)

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

A
Concentrator
B
Liquid Stationary
C
Gaseous Stationary
D
Liquid Portable
E
Gaseous Portable
O
Other
CR5-06
380
Oxygen Flow Rate
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR506 is the oxygen flow rate in liters per minute.
CR5-07
380
Daily Oxygen Use Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR507 is the number of times per day the patient must use oxygen.
CR5-08
380
Oxygen Use Period Hour Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR508 is the number of hours per period of oxygen use.
CR5-09
352
Respiratory Therapist Order Text
Optional
String (AN)
Min 1Max 80

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

  • CR509 is the special orders for the respiratory therapist.
CR5-16
380
Portable Oxygen System Flow Rate
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
CR5-17
1382
Oxygen Delivery System Code
Required
Identifier (ID)

Code to indicate if a particular form of delivery was prescribed

A
Nasal Cannula
B
Oxygen Conserving Device
C
Oxygen Conserving Device with Oxygen Pulse System
D
Oxygen Conserving Device with Reservoir System
E
Transtracheal Catheter
CR5-18
1348
Oxygen Equipment Type Code
Optional
Identifier (ID)

Code indicating the specific type of equipment being prescribed for the delivery of oxygen

A
Concentrator
B
Liquid Stationary
C
Gaseous Stationary
D
Liquid Portable
E
Gaseous Portable
O
Other
CR6
1500
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR6

Home Health Care Information

OptionalMax use 1

To supply information related to the certification of a home health care patient

Usage notes
  • Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Example
If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required
CR6-01
923
Prognosis Code
Required
Identifier (ID)

Code indicating physician's prognosis for the patient

1
Poor
2
Guarded
3
Fair
4
Good
5
Very Good
6
Excellent
7
Less than 6 Months to Live
8
Terminal
CR6-02
373
Home Health Start Date
Required
Date (DT)
CCYYMMDD format

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

  • CR602 is the date covered home health services began.
CR6-03
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

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

RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
CR6-04
1251
Home Health Certification Period
Optional
String (AN)
Min 1Max 35

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

  • CR604 is the certification period covered by this plan of treatment.
CR6-07
1073
Medicare Coverage Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.
W
Not Applicable
CR6-08
1322
Certification Type Code
Required
Identifier (ID)

Code indicating the type of certification

Usage notes
  • This element must have the same value as UM02.
1
Appeal - Immediate

Use this value only for appeals of review decisions where the level of service required is emergency or urgent.

2
Appeal - Standard

Use this value for appeals of review decisions where the level of service required is not emergency or urgent.

3
Cancel
4
Extension
5
Notification
6
Verification

This code is used to request the UMO to reconsider a previously denied referral or certification request.

I
Initial
R
Renewal
S
Revised
PWK
1550
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > PWK

Additional Patient Information

OptionalMax use 10

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

Usage notes
  • If the UMO has pended the decision on this health care services review request (HCR01 = A4) because additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the type of documentation needed such as forms that the provider must complete. The UMO can also indicate what medium it has used to send these forms.
  • Required when the UMO requests additional patient information. If not required by this implementation guide, do not send.
  • Paperwork requested at the patient level should apply to the patient event and/or all the services requested. Use the PWK segment in the appropriate Service loop if requesting medical necessity information for a specific service.
  • This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be referenced in the corresponding electronic attachment.
  • This PWK segment should not be used if
    a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid.

b. the 278 request (ST-SE) does not support this information and the needed information pertains to a specific service identified in Loop 2000F and not to all the services requested.

Refer to Section 2.5 for more information on using this segment.

Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
PWK-01
755
Attachment Report Type Code
Required
Identifier (ID)

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

Expected outcomes of rehabilitative services.

08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
48
Social Security Benefit Letter
55
Rental Agreement

Use for medical or dental equipment rental.

59
Benefit Letter
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification

Information to support necessity of ambulance trip.

AS
Admission Summary

A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.

AT
Purchase Order Attachment

Use for purchase of medical or dental equipment.

B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification

Lists the reasons chiropractic is just and appropriate treatment.

CK
Consent Form(s)
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
FM
Family Medical History Document
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
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
P4
Pathology Report
P5
Patient Medical History Document
P6
Periodontal Charts
P7
Periodontal Reports
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
QC
Cause and Corrective Action Report
QR
Quality Report
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
Report Transmission Code
Required
Identifier (ID)

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

BM
By Mail
EL
Electronically Only

Use to indicate that attachment is being transmitted in a separate X12 functional group.

EM
E-Mail
FX
By Fax
VO
Voice

Use this for voicemail or phone communication.

PWK-05
66
Identification Code Qualifier
Optional
Identifier (ID)

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
String (AN)
Min 2Max 80

Code identifying a party or other code

PWK-07
352
Attachment Description
Optional
String (AN)
Min 1Max 80

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

  • PWK07 may be used to indicate special information to be shown on the specified report.
MSG
1600
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > MSG

Message Text

OptionalMax use 1

To provide a free-form format that allows the transmission of text information

Usage notes
  • Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.
Example
MSG-01
933
Free Form Message Text
Required
String (AN)
Min 1Max 264

Free-form message text

2010EA Patient Event Provider Name Loop
OptionalMax 14
NM1
1700
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

Patient Event Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this patient event. If not required by this implementation guide, do not send.
  • Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
Example
If either Identification Code Qualifier (NM1-08) or Patient Event Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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

71
Attending Physician
72
Operating Physician
73
Other Physician
77
Service Location
AAJ
Admitting Services
DD
Assistant Surgeon
DK
Ordering Physician
DN
Referring Provider
FA
Facility
G3
Clinic
P3
Primary Care Provider
QB
Purchase Service Provider
QV
Group Practice
SJ
Service Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Patient Event Provider Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Patient Event Provider First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Patient Event Provider Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-06
1038
Patient Event Provider Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

NM1-07
1039
Patient Event Provider Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

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

24
Employer's Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
XX
Centers for Medicare and Medicaid Services National Provider Identifier

Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the UMO has the capability to send it.
If not required by this implementation guide, do not send.

NM1-09
67
Patient Event Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
1800
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

Patient Event Provider Supplemental Identification

OptionalMax use 7

To specify identifying information

Usage notes
  • Required when used by the UMO to identify the Patient Event Provider. If not required by this implementation guide, do not send.
  • Use the NM1 segment for the primary identifier.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0B
State License Number
1G
Provider UPIN Number
1J
Facility ID Number
EI
Employer's Identification Number

Not used if NM108 = 24.

N5
Provider Plan Network Identification Number
N7
Facility Network Identification Number
SY
Social Security Number

The social security number must not be used for Medicare. Not used if NM108 = 34.

ZH
Carrier Assigned Reference Number

Use for the provider ID as assigned by the UMO identified in Loop 2000A.

REF-02
127
Patient Event Provider Supplemental Identifier
Required
String (AN)
Min 1Max 50

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

REF-03
352
License Number State Code
Optional
String (AN)
Min 1Max 80

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

N3
2000
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N3

Patient Event Provider Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.
Example
N3-01
166
Patient Event Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this element for the first line of the service provider's address.
N3-02
166
Patient Event Provider Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
2100
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N4

Patient Event Provider City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.
Example
Only one of Patient Event Provider 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
Patient Event Provider City Name
Required
String (AN)
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
Patient Event Provider State Code
Optional
Identifier (ID)
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
Patient Event Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

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

N4-04
26
Country Code
Optional
Identifier (ID)
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
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
PER
2200
Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PER

Provider Contact Information

OptionalMax use 1

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 should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
  • By definition of the standard, if PER03 is used, PER04 is required.
  • Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Example
If either Communication Number Qualifier (PER-03) or Patient Event Provider Contact Communications Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Patient Event Provider Contact Communications Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Patient Event Provider Contact Communications Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

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

IC
Information Contact
PER-02
93
Patient Event Provider Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-04
364
Patient Event Provider Contact Communications Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communicati