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Health Care Services Review Information - Review (X217)
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X12 278 Health Care Services Review Information - Review (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
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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
    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 2
    Optional
    UM
    0400
    Health Care Services Review Information
    Max use 1
    Required
    REF
    0600
    Previous Review Authorization Number
    Max use 1
    Optional
    REF
    0600
    Previous Review Administrative Reference Number
    Max use 1
    Optional
    DTP
    0700
    Accident Date
    Max use 1
    Optional
    DTP
    0700
    Last Menstrual Period Date
    Max use 1
    Optional
    DTP
    0700
    Estimated Date of Birth
    Max use 1
    Optional
    DTP
    0700
    Onset of Current Symptoms or Illness Date
    Max use 1
    Optional
    DTP
    0700
    Event Date
    Max use 1
    Optional
    DTP
    0700
    Admission Date
    Max use 1
    Optional
    DTP
    0700
    Discharge Date
    Max use 1
    Optional
    HI
    0800
    Patient Diagnosis
    Max use 1
    Optional
    HSD
    0900
    Health Care Services Delivery
    Max use 1
    Optional
    CRC
    1000
    Ambulance Certification Information
    Max use 1
    Optional
    CRC
    1000
    Chiropractic Certification Information
    Max use 1
    Optional
    CRC
    1000
    Durable Medical Equipment Information
    Max use 1
    Optional
    CRC
    1000
    Oxygen Therapy Certification Information
    Max use 1
    Optional
    CRC
    1000
    Functional Limitations Information
    Max use 1
    Optional
    CRC
    1000
    Activities Permitted Information
    Max use 1
    Optional
    CRC
    1000
    Mental Status Information
    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
    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

    Code identifying the type of information in the Authorization Information

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

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

    ISA-03
    I03
    Security Information Qualifier
    Required

    Code identifying the type of information in the Security Information

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

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

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

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

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

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

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

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

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

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

    ISA-09
    I08
    Interchange Date
    Required
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    Min 1Max 1

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

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

    Code specifying the version number of the interchange control segments

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

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    Min 1Max 1

    Code indicating sender's request for an interchange acknowledgment

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

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

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

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

    >
    Component Element Separator

    Functional Group Header

    RequiredMax use 1

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

    Example
    GS-01
    479
    Functional Identifier Code
    Required

    Code identifying a group of application related transaction sets

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

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

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

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

    GS-04
    373
    Date
    Required
    CCYYMMDD format

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

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

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

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

    Assigned number originated and maintained by the sender

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

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

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

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

    005010X217
    ANSI ASC X12 Health Care Services Review Information (278) for requests for review and responses to such requests through May 2006

    Heading

    ST
    0100

    Transaction Set Header

    RequiredMax use 1

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

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

    Code uniquely identifying a Transaction Set

    • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
    278
    Health Care Services Review Information
    ST-02
    329
    Transaction Set Control Number
    Required
    Min 4Max 9

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

    Usage notes
    • The Transaction Set Control 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

    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

    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

    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

    Code identifying purpose of transaction set

    13
    Request
    BHT-03
    127
    Submitter Transaction Identifier
    Required
    Min 1Max 50

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

    • BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
    Usage notes
    • Use this element to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier must be returned in the corresponding 278 response transaction's BHT03. This identifier will only be returned by the last entity to handle the 278. This identifier will not be passed through the complete life of the transaction. All recipients of 278 request transactions are required to return the Submitter Transaction Identifier in their 278 response if one is submitted.
    BHT-04
    373
    Transaction Set Creation Date
    Required
    CCYYMMDD format

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

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

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

    • BHT05 is the time the transaction was created within the business application system.
    BHT-06
    640
    Transaction Type Code
    Optional

    Code specifying the type of transaction

    RU
    Medical Services Reservation

    Detail

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

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    2010A Utilization Management Organization (UMO) Name Loop
    RequiredMax 1
    NM1
    1700

    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 request transaction, the source of information would normally be the payer or utilization review organization making the decision on the request.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    X3
    Utilization Management Organization
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

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

    Individual first name

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

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    PI
    Payor Identification

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

    NM1-09
    67
    Utilization Management Organization (UMO) Identifier
    Required

    Code identifying a party or other code

    06111
    UHC Payer ID
    87726
    UHC Payer ID
    061118515
    Oxford Payer ID
    2000B Requester Level Loop
    RequiredMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    2010B Requester Name Loop
    RequiredMax 1
    NM1
    1700

    Requester Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This segment identifies the receiver of information. In the case of a request transaction, the receiver would normally be the entity who will ultimately be receiving the decision.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    1P
    Provider

    Use when the requester is an individual provider.

    FA
    Facility

    Use when the requester is a facility, such as a clinic or hospital.

    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    Usage notes

    The name of the provider or facility submitting the request is required.

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

    Individual first name

    NM1-05
    1037
    Requester Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    Usage notes

    NPI is required

    XX
    Centers for Medicare and Medicaid Services National Provider Identifier

    Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI;
    OR
    Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI;
    OR
    Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it;
    If not required by this implementation guide, do not send.

    NM1-09
    67
    Requester Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    REF
    1800

    Requester Supplemental Identification

    OptionalMax use 8

    To specify identifying information

    Usage notes
    • Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the UMO to identify the provider;
      OR
      Required after the mandated NPI implementation date, when the entity is a non-health care provider, and an identifier is necessary for the UMO to identify the entity.
      If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EI
    Employer's Identification Number

    Facility Tax Identification Number (TIN).
    Not used if NM108 = 24.

    ZH
    Carrier Assigned Reference Number

    Unique provider identifier assigned by payer (MPIN).

    Required when necessary to provide the requester/provider ID as assigned by the UMO identified in Loop 2000A. If not required, do not send.

    REF-02
    127
    Requester Supplemental Identifier
    Required
    Min 1Max 9

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

    Usage notes

    Must be padded with leading zeros to equal 9 digits

    N3
    2000

    Requester Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • Use to identify a specific location when the requester has multiple locations and authority varies based on location.
    • Required when necessary to identify the requester by location. If not required by this implementation guide, do not send.
    Example
    N3-01
    166
    Requester Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes
    • Use this element for the first line of the requester's address.
    N3-02
    166
    Requester Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2100

    Requester City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

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

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    PER
    2200

    Requester Contact Information

    OptionalMax use 1

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

    Usage notes
    • Required when the UMO must direct requests for additional information to a specific requester contact, electronic mail, facsimile, or telephone number. 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 Requester Contact Communication Number (PER-04) is present, then the other is required
    If either Communication Number Qualifier (PER-05) or Requester Contact Communication Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Requester Contact Communication Number (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

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

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

    Free-form name

    Usage notes

    Free form contact name. This should be the name of an individual at the submitting provider/facility that UnitedHealthcare can contact if there are questions or more information is needed about this admission notification. If an individual contact name cannot be provided, please populate this field with the facility or provider name from NM103.

    PER-03
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    Usage notes

    At least one contact phone number is required.

    TE
    Telephone
    PER-04
    364
    Requester Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    Usage notes

    Phone number - Format 10 digits no punctuation or spaces

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    Usage notes

    If applicable

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

    Complete communications number including country or area code when applicable

    Usage notes

    Extension (numeric only), if applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

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

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

    PER-08
    364
    Requester Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PRV
    2400

    Requester Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Required when needed to indicate the requester's role in the care of the patient and the requesting provider's specialty. 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

    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

    Code qualifying the Reference Identification

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

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

    2000C Subscriber Level Loop
    RequiredMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    0
    No Subordinate HL Segment in This Hierarchical Structure.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    2010C Subscriber Name Loop
    RequiredMax 1
    NM1
    1700

    Subscriber Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This segment conveys the name and identification number of the subscriber (who may also be the patient).
    • The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
      Subscriber Last Name (NM103)
      Subscriber First Name (NM104)
      Subscriber Birth Date (DMG01 and DMG02)
    • Refer to Section 2.2.2.1 Identifying the Patient for specific information on how to identify an individual to a UMO.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

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

    Code qualifying the type of entity

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

    Individual last name or organizational name

    Usage notes

    Subscriber Last name (Required)

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

    Individual first name

    Usage notes

    Subscriber First name. Required if member has a legal first name. If member has only 1 legal name, send member name in Last Name and do not populate first name.

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

    Individual middle name or initial

    NM1-06
    1038
    Subscriber Name Prefix
    Optional
    Min 1Max 10

    Prefix to individual name

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

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

    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
    Min 2Max 80

    Code identifying a party or other code

    Usage notes

    Member Identification preferably from UnitedHealth insurance card.

    REF
    1800

    Subscriber Supplemental Identification

    OptionalMax use 9

    To specify identifying information

    Usage notes
    • Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.
    • The primary identifier is the Member Identification Number in the NM1 segment.
    • 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.
    • If the requester values this segment with the Patient Account Number (REF01="EJ") on the request, the UMO is required to return the same value in this segment on the response.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    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).

    6P
    Group Number

    preferred

    HJ
    Identity Card Number

    Referral only

    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

    Referral only

    N6
    Plan Network Identification Number
    REF-02
    127
    Subscriber Supplemental Identifier
    Required
    Min 1Max 50

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

    N3
    2000

    Subscriber Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
    Example
    N3-01
    166
    Subscriber Address Line
    Required
    Min 1Max 55

    Address information

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

    Address information

    N4
    2100

    Subscriber City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of 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
    Min 2Max 30

    Free-form text for city name

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

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

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

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    DMG
    2500

    Subscriber Demographic Information

    OptionalMax use 1

    To supply demographic information

    Usage notes
    • Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
    • Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
    Example
    DMG-01
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

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

    Code indicating the sex of the individual

    Usage notes

    Gender Code is required.

    F
    Female
    M
    Male
    U
    Unknown
    INS
    2600

    Subscriber Relationship

    OptionalMax use 1

    To provide benefit information on insured entities

    Usage notes
    • Required when the subscriber's role in the military is necessary 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

    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

    Code indicating the relationship between two individuals or entities

    18
    Self
    INS-08
    584
    Employment Status Code
    Required

    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
    2000D Dependent Level Loop
    OptionalMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    2010D Dependent Name Loop
    RequiredMax 1
    NM1
    1700

    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.
    • The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
      Dependent Last Name (NM103)
      Dependent First Name (NM104)
      Dependent Birth Date (DMG01 and DMG02)
    • Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    QC
    Patient
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

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

    Individual last name or organizational name

    Usage notes

    Dependent’s Last Name

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

    Individual first name

    Usage notes

    Dependent’s First Name - Required if dependent has a legal first name. If dependent has only 1 legal name, send dependent name in Last Name and do not populate first name.

    NM1-05
    1037
    Dependent Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

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

    Suffix to individual name

    REF
    1800

    Dependent Supplemental Identification

    OptionalMax use 3

    To specify identifying information

    Usage notes
    • Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
    • If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.
    • Required when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    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
    Min 1Max 50

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

    N3
    2000

    Dependent Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
    Example
    N3-01
    166
    Dependent Address Line
    Required
    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
    Min 1Max 55

    Address information

    N4
    2100

    Dependent City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the current address of the patient is used to determine the appropriate location or network of 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
    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
    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
    Min 3Max 15

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    DMG
    2500

    Dependent Demographic Information

    OptionalMax use 1

    To supply demographic information

    Usage notes
    • Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
    • Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
    Example
    DMG-01
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

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

    Code indicating the sex of the individual

    Usage notes

    Gender Code is required

    F
    Female
    M
    Male
    U
    Unknown
    INS
    2600

    Dependent Relationship

    OptionalMax use 1

    To provide benefit information on insured entities

    Usage notes
    • Required when patient relationship to insured or birth sequence is needed by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
    • This segment may be used to further identify the patient. Examples include identifying a patient in a multiple birth or differentiating dependents with the same name.
    Example
    INS-01
    1073
    Insured Indicator
    Required

    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

    Code indicating the relationship between two individuals or entities

    01
    Spouse
    19
    Child
    G8
    Other Relationship
    INS-17
    1470
    Birth Sequence Number
    Optional
    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.).
    2000E Patient Event Level Loop
    RequiredMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

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

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

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

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

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

    Code defining the characteristic of a level in a hierarchical structure

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

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

    • HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
    0
    No Subordinate HL Segment in This Hierarchical Structure.
    1
    Additional Subordinate HL Data Segment in This Hierarchical Structure.
    TRN
    0200

    Patient Event Tracking Number

    OptionalMax use 2

    To uniquely identify a transaction to an application

    Usage notes
    • Required when the requester needs to assign a unique trace number to the patient event request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
    • This enables the requester to
    • uniquely identify this patient event request
    • trace the request
    • match the response to the request
    • reference this request in any associated attachments containing additional patient information related to this patient event request.
    • If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
    • Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers
    TRN-02
    127
    Patient Event Trace Number
    Required
    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
    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. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.
    • 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
    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.
    UM
    0400

    Health Care Services Review Information

    RequiredMax use 1

    To specify health care services review information

    Usage notes
    • This segment identifies the type of health care services review request.
    Example
    UM-01
    1525
    Request Category Code
    Required

    Code indicating a type of request

    AR
    Admission Review

    Required if requesting an admission to a facility.

    HS
    Health Services Review

    Required if requesting a review of services related to an episode of care.

    SC
    Specialty Care Review

    Required if requesting a referral to a specialty provider.

    UM-02
    1322
    Certification Type Code
    Required

    Code indicating the type of certification

    Usage notes

    If submitting a change to a previously submitted and approved authorization, please provide the administrative Reference Number from the original authorization request in the following REF segment. This is required when submitting a revision or update.)

    I
    Initial
    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

    Code identifying the classification of service

    1
    Medical Care
    2
    Surgical
    4
    Diagnostic X-Ray
    5
    Diagnostic Lab
    12
    Durable Medical Equipment Purchase
    14
    Renal Supplies in the Home
    18
    Durable Medical Equipment Rental
    33
    Chiropractic
    37
    Dental Accident
    45
    Hospice
    54
    Long Term Care
    56
    Medically Related Transportation
    68
    Well Baby Care
    69
    Maternity
    70
    Transplants
    72
    Inhalation Therapy
    73
    Diagnostic Medical
    74
    Private Duty Nursing
    75
    Prosthetic Device
    78
    Chemotherapy
    88
    Pharmacy
    93
    Podiatry
    A9
    Rehabilitation
    AD
    Occupational Therapy
    AF
    Speech Therapy
    AG
    Skilled Nursing Care
    AL
    Vision (Optometry)
    NI
    Neonatal Intensive Care
    PT
    Physical Therapy
    UM-04
    C023
    Health Care Service Location Information
    To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
    Usage notes

    Required when UM04 is not valued at 2000F. 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

    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.
    11
    if UM04-2=A: Hospital Inpatient including Medicare Part A if UM04-2=B: Office
    13
    if UM04-2=A: Hospital Outpatient if UM04-2=B: Home
    21
    if UM04-2=A: Skilled Nursing Facility (SNF) Inpatient including Medicare Part A if UM04-2=B: Hospital Outpatient
    61
    if UM04-2=B: Rehab Facility Comprehensive Inpatient
    C023-02
    1332
    Facility Code Qualifier
    Required

    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-05
    C024
    Related Causes Information
    To identify one or more related causes and associated state or country information
    Usage notes

    Required when the patient's condition is accident or employment related. If not required by this implementation guide, do not send.

    C024-01
    1362
    Related Causes Code
    Required

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

    Usage notes
    • Always use this data element if the related cause is an auto accident.
    AA
    Auto Accident
    AP
    Another Party Responsible
    EM
    Employment
    C024-02
    1362
    Related Causes Code
    Optional

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

    AP
    Another Party Responsible
    EM
    Employment
    C024-03
    1362
    Related Causes Code
    Optional

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

    AP
    Another Party Responsible
    C024-04
    156
    State or Province Code
    Optional
    Min 2Max 2

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

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

    Code identifying the country

    UM-06
    1338
    Level of Service Code
    Optional

    Code specifying the level of service rendered

    03
    Emergency
    E
    Elective
    U
    Urgent
    UM-07
    1213
    Current Health Condition Code
    Optional

    Code indicating current health condition of the individual

    1
    Acute
    2
    Stable
    3
    Chronic
    4
    Systemic
    5
    Localized
    6
    Mild Disease
    7
    Normal, Healthy
    8
    Severe Systemic disease
    9
    Severe Systemic Disease that is a Constant Threat to Life
    E
    Excellent
    F
    Fair
    G
    Good
    P
    Poor
    UM-08
    923
    Prognosis Code
    Optional

    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
    UM-09
    1363
    Release of Information Code
    Optional

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

    Usage notes
    • The Release of Information response is limited to the information carried in this service review.
    M
    The Provider has Limited or Restricted Ability to Release Data Related to a Claim

    For professional service, this value is only used when state or federal laws supersede the HIPAA privacy rule by requiring that the provider collect a signature and the patient is either not present or physically unable to sign at the time the provider submits the request.

    Y
    Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
    UM-10
    1514
    Delay Reason Code
    Optional

    Code indicating the reason why a request was delayed

    1
    Proof of Eligibility Unknown or Unavailable
    2
    Litigation
    3
    Authorization Delays
    4
    Delay in Certifying Provider
    7
    Third Party Processing Delay
    8
    Delay in Eligibility Determination
    10
    Administration Delay in the Prior Approval Process
    11
    Other
    15
    Natural Disaster
    16
    Lack of Information
    17
    No response to initial request
    REF
    0600

    Previous Review Authorization Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This is the authorization number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
    • Required when submitting an additional health care services review request associated with a request already processed by the UMO. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFPrevious Review Administrative Reference Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    BB
    Authorization Number
    REF-02
    127
    Previous Review Authorization Number
    Required
    Min 1Max 50

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

    REF
    0600

    Previous Review Administrative Reference Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Required when submitting a follow-up to a previous health care services review request for which the UMO has returned a response that contained an administrative reference number in the REF segment where REF01 = NT and did not return a certification number in HCR02. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFPrevious Review Authorization Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    NT
    Administrator's Reference Number
    REF-02
    127
    Previous Administrative Reference Number
    Required
    Min 1Max 50

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

    DTP
    0700

    Accident Date

    OptionalMax use 1

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

    Usage notes
    • Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    DTP
    0700

    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 the certification is pregnancy related. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    DTP
    0700

    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 the certification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    ABC
    Estimated Date of Birth
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    0700

    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 the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    DTP
    0700

    Event Date

    OptionalMax use 1

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

    Usage notes
    • Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.
    • If UM01 = AR use Admit Date.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    AAH
    Event
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

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

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

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

    DTP
    0700

    Admission Date

    OptionalMax use 1

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

    Usage notes
    • Required when requesting an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

    DTP-03
    1251
    Proposed or Actual Admission Date
    Required
    Min 1Max 35

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

    DTP
    0700

    Discharge Date

    OptionalMax use 1

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

    Usage notes
    • Required when requesting an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

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

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

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

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

    HI
    0800

    Patient Diagnosis

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • Required when known by the requester to convey diagnosis information. If not required by this implementation guide, do not send.
    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    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

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    Usage notes

    ICD-10 is to be used with DATE OF SERVICE AS OF OCT 1, 2015 - In order to assign appropriate resources to the case; UnitedHealthcare needs to
    understand why the patient is being treated. A Principal or Admitting diagnosis code is required. Please send it in this HI segment.

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    Usage notes

    ICD-10 to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.

    ABF
    International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
    ABJ
    International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

    ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    Usage notes

    ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.

    ABF
    International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

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

    • C022-03 is the date format that will appear in C022-04.
    Usage notes

    CD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

    D8
    Date Expressed in Format CCYYMMDD
    C022-04
    1251
    Diagnosis Date
    Optional
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

    Code identifying a specific industry code list

    • C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
    Usage notes

    ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.

    ABF
    International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

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

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

    • C022-03 is the date format that will appear in C022-04.
    Usage notes

    ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX

    D8
    Date Expressed in Format CCYYMMDD
    C022-04
    1251
    Diagnosis Date
    Optional
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    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
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when there are additional diagnoses to communicate. 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

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

    Code indicating a code from a specific industry code list

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

    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
    Min 1Max 35

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

    HSD
    0900

    Health Care Services Delivery

    OptionalMax use 1

    To specify the delivery pattern of health care services

    Usage notes
    • 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".

    • Required when requesting services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
    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

    Code specifying the type of quantity

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

    Numeric value of quantity

    Usage notes
    • If this is a request for an extension to an existing certification (UM02 = 4), then HSD02 represents the number of visits by which the certification is extended. If this is a request to revise an existing certification (UM02 = S), then HSD02 represents the new total.
    HSD-03
    355
    Unit or Basis for Measurement Code
    Optional

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

    DA
    Days
    MO
    Months
    WK
    Week
    HSD-04
    1167
    Sample Selection Modulus
    Optional
    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

    Code defining periods

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

    Total number of periods

    HSD-07
    678
    Delivery Frequency Code
    Optional

    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
    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

    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)
    CRC
    1000

    Ambulance Certification Information

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required when health care services review is requesting ambulance certification. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Category
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    07
    Ambulance Certification
    CRC-02
    1073
    Certification Condition Indicator
    Required

    Code indicating a Yes or No condition or response

    • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
    N
    No
    Y
    Yes
    CRC-03
    1321
    Condition Code
    Required

    Code indicating a condition

    01
    Patient was admitted to a hospital
    02
    Patient was bed confined before the ambulance service
    03
    Patient was bed confined after the ambulance service
    04
    Patient was moved by stretcher
    05
    Patient was unconscious or in shock
    5A
    Treatment is rendered related to the terminal illness
    06
    Patient was transported in an emergency situation
    07
    Patient had to be physically restrained
    08
    Patient had visible hemorrhaging
    09
    Ambulance service was medically necessary
    9D
    Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
    41
    Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
    43
    Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
    60
    Transportation Was To the Nearest Facility
    CRC-04
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-05
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-06
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-07
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC
    1000

    Chiropractic Certification Information

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required when health care services review is requesting chiropractic certification. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Category
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    08
    Chiropractic Certification
    CRC-02
    1073
    Certification Condition Indicator
    Required

    Code indicating a Yes or No condition or response

    • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
    N
    No
    Y
    Yes
    CRC-03
    1321
    Condition Code
    Required

    Code indicating a condition

    11
    Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
    12
    Patient is confined to a bed or chair
    14
    Ambulation is Impaired and Walking Aid is Used for Mobility
    24
    Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
    25
    Item has been prescribed as part of a planned regimen of treatment in patient home
    27
    Patient or a care-giver has been instructed in use of equipment
    30
    Without the equipment, the patient would require surgery
    CRC-04
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-05
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-06
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-07
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC
    1000

    Durable Medical Equipment Information

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required when health care services is requesting durable medical equipment. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Category
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    09
    Durable Medical Equipment Certification
    CRC-02
    1073
    Certification Condition Indicator
    Required

    Code indicating a Yes or No condition or response

    • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
    N
    No
    Y
    Yes
    CRC-03
    1321
    Condition Code
    Required

    Code indicating a condition

    01
    Patient was admitted to a hospital
    02
    Patient was bed confined before the ambulance service
    03
    Patient was bed confined after the ambulance service
    04
    Patient was moved by stretcher
    05
    Patient was unconscious or in shock
    06
    Patient was transported in an emergency situation
    07
    Patient had to be physically restrained
    08
    Patient had visible hemorrhaging
    09
    Ambulance service was medically necessary
    9D
    Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
    9H
    Patient Requires Intensive IV Therapy
    9J
    Patient Requires Protective Isolation
    9K
    Patient Requires Frequent Monitoring
    10
    Patient is ambulatory
    11
    Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
    12
    Patient is confined to a bed or chair
    13
    Patient is Confined to a Room or an Area Without Bathroom Facilities
    14
    Ambulation is Impaired and Walking Aid is Used for Mobility
    15
    Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
    16
    Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
    17
    Patient's Ability to Breathe is Severely Impaired
    18
    Patient condition requires frequent and/or immediate changes in body positions
    19
    Patient can operate controls
    20
    Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
    21
    Patient owns equipment
    22
    Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
    23
    Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
    24
    Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
    25
    Item has been prescribed as part of a planned regimen of treatment in patient home
    26
    Patient is highly susceptible to decubitus ulcers
    27
    Patient or a care-giver has been instructed in use of equipment
    29
    A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds
    30
    Without the equipment, the patient would require surgery
    31
    Patient has had a total knee replacement
    32
    Patient has intractable lymphedema of the extremities
    33
    Patient is in a nursing home
    35
    This Feeding is the Only Form of Nutritional Intake for This Patient
    37
    Oxygen delivery equipment is stationary
    38
    Certification signed by the physician is on file at the supplier's office
    40
    Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
    41
    Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
    42
    Patient Requires Leg Elevation for Edema or Body Alignment
    43
    Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
    44
    Patient Requires Reclining Function of a Wheelchair
    45
    Patient is Unable to Operate a Wheelchair Manually
    46
    Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
    58
    Durable Medical Equipment (DME) Purchased New
    59
    Durable Medical Equipment (DME) Is Under Warranty
    60
    Transportation Was To the Nearest Facility
    IH
    Independent at Home
    LB
    Legally Blind
    SL
    Speech Limitations
    CRC-04
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-05
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-06
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-07
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC
    1000

    Oxygen Therapy Certification Information

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required when health care services review is requesting oxygen therapy certification. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Category
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    11
    Oxygen Therapy Certification
    CRC-02
    1073
    Certification Condition Indicator
    Required

    Code indicating a Yes or No condition or response

    • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
    N
    No
    Y
    Yes
    CRC-03
    1321
    Condition Code
    Required

    Code indicating a condition

    5A
    Treatment is rendered related to the terminal illness
    06
    Patient was transported in an emergency situation
    9J
    Patient Requires Protective Isolation
    9K
    Patient Requires Frequent Monitoring
    16
    Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
    17
    Patient's Ability to Breathe is Severely Impaired
    25
    Item has been prescribed as part of a planned regimen of treatment in patient home
    33
    Patient is in a nursing home
    37
    Oxygen delivery equipment is stationary
    39
    Patient Has Mobilizing Respiratory Tract Secretions
    DY
    Dyspnea with Minimal Exertion
    CRC-04
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-05
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-06
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-07
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC
    1000

    Functional Limitations Information

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required when the assessing provider has defined function limitation for the patient. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Category
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    75
    Functional Limitations
    CRC-02
    1073
    Certification Condition Indicator
    Required

    Code indicating a Yes or No condition or response

    • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
    N
    No
    Y
    Yes
    CRC-03
    1321
    Condition Code
    Required

    Code indicating a condition

    02
    Patient was bed confined before the ambulance service
    03
    Patient was bed confined after the ambulance service
    04
    Patient was moved by stretcher
    05
    Patient was unconscious or in shock
    5A
    Treatment is rendered related to the terminal illness
    06
    Patient was transported in an emergency situation
    9E
    Sudden Onset of Disorientation
    9F
    Sudden Onset of Severe, Incapacitating Pain
    9H
    Patient Requires Intensive IV Therapy
    11
    Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
    12
    Patient is confined to a bed or chair
    14
    Ambulation is Impaired and Walking Aid is Used for Mobility
    15
    Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
    16
    Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
    17
    Patient's Ability to Breathe is Severely Impaired
    18
    Patient condition requires frequent and/or immediate changes in body positions
    19
    Patient can operate controls
    20
    Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
    21
    Patient owns equipment
    22
    Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
    23
    Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
    24
    Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
    25
    Item has been prescribed as part of a planned regimen of treatment in patient home
    26
    Patient is highly susceptible to decubitus ulcers
    27
    Patient or a care-giver has been instructed in use of equipment
    28
    Patient has poor diabetic control
    30
    Without the equipment, the patient would require surgery
    31
    Patient has had a total knee replacement
    32
    Patient has intractable lymphedema of the extremities
    35
    This Feeding is the Only Form of Nutritional Intake for This Patient
    37
    Oxygen delivery equipment is stationary
    39
    Patient Has Mobilizing Respiratory Tract Secretions
    40
    Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
    41
    Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
    42
    Patient Requires Leg Elevation for Edema or Body Alignment
    43
    Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
    44
    Patient Requires Reclining Function of a Wheelchair
    45
    Patient is Unable to Operate a Wheelchair Manually
    46
    Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
    68
    Severe
    69
    Moderate
    AA
    Amputation
    AL
    Ambulation Limitations
    BL
    Bowel Limitations, Bladder Limitations, or both (Incontinence)
    BPD
    Beneficiary is Partially Dependent
    BTD
    Beneficiary is Totally Dependent
    CA
    Cane Required
    CB
    Complete Bedrest
    CNJ
    Cumulative Injury
    CO
    Contracture
    DY
    Dyspnea with Minimal Exertion
    EL
    Endurance Limitations
    EP
    Exercises Prescribed
    HL
    Hearing Limitations
    LB
    Legally Blind
    LE
    Lethargic
    OL
    Other Limitation
    PA
    Paralysis
    PW
    Partial Weight Bearing
    SL
    Speech Limitations
    TNJ
    Traumatic Injury
    WA
    Walker Required
    WR
    Wheelchair Required
    CRC-04
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-05
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-06
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-07
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC
    1000

    Activities Permitted Information

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required when the assessing provider has defined activities permitted for the patient. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Category
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    76
    Activities Permitted
    CRC-02
    1073
    Certification Condition Indicator
    Required

    Code indicating a Yes or No condition or response

    • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
    N
    No
    Y
    Yes
    CRC-03
    1321
    Condition Code
    Required

    Code indicating a condition

    10
    Patient is ambulatory
    13
    Patient is Confined to a Room or an Area Without Bathroom Facilities
    19
    Patient can operate controls
    21
    Patient owns equipment
    22
    Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
    27
    Patient or a care-giver has been instructed in use of equipment
    31
    Patient has had a total knee replacement
    40
    Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
    BR
    Bedrest BRP (Bathroom Privileges)
    CA
    Cane Required
    CB
    Complete Bedrest
    CR
    Crutches Required
    EL
    Endurance Limitations
    EP
    Exercises Prescribed
    IH
    Independent at Home
    NR
    No Restrictions
    PA
    Paralysis
    PW
    Partial Weight Bearing
    TR
    Transfer to Bed, or Chair, or Both
    UT
    Up as Tolerated
    WA
    Walker Required
    WR
    Wheelchair Required
    CRC-04
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-05
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-06
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-07
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC
    1000

    Mental Status Information

    OptionalMax use 1

    To supply information on conditions

    Usage notes
    • Required when the patient mental status is relevant to the health care services review. If not required by this implementation guide, do not send.
    Example
    CRC-01
    1136
    Code Category
    Required

    Specifies the situation or category to which the code applies

    • CRC01 qualifies CRC03 through CRC07.
    77
    Mental Status
    CRC-02
    1073
    Certification Condition Indicator
    Required

    Code indicating a Yes or No condition or response

    • CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
    N
    No
    Y
    Yes
    CRC-03
    1321
    Condition Code
    Required

    Code indicating a condition

    01
    Patient was admitted to a hospital
    05
    Patient was unconscious or in shock
    5A
    Treatment is rendered related to the terminal illness
    07
    Patient had to be physically restrained
    9E
    Sudden Onset of Disorientation
    9F
    Sudden Onset of Severe, Incapacitating Pain
    9J
    Patient Requires Protective Isolation
    9K
    Patient Requires Frequent Monitoring
    13
    Patient is Confined to a Room or an Area Without Bathroom Facilities
    20
    Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
    22
    Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
    23
    Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
    26
    Patient is highly susceptible to decubitus ulcers
    33
    Patient is in a nursing home
    34
    Patient is conscious
    68
    Severe
    69
    Moderate
    AG
    Agitated
    BPD
    Beneficiary is Partially Dependent
    BTD
    Beneficiary is Totally Dependent
    CB
    Complete Bedrest
    CM
    Comatose
    DI
    Disoriented
    DP
    Depressed
    FO
    Forgetful
    HO
    Hostile
    LE
    Lethargic
    MC
    Other Mental Condition
    OT
    Oriented
    UN
    Uncooperative
    CRC-04
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-05
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-06
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CRC-07
    1321
    Condition Code
    Optional
    Min 2Max 3

    Code indicating a condition

    Usage notes
    • Use codes listed in CRC03.
    CL1
    1100

    Institutional Claim Code

    OptionalMax use 1

    To supply information specific to hospital claims

    Usage notes
    • Required when requesting certification for admission (UM01 = AR) to a facility. If not required by this implementation guide, do not send.
    Example
    CL1-01
    1315
    Admission Type Code
    Optional
    Min 1Max 1

    Code indicating the priority of this admission

    CL1-02
    1314
    Admission Source Code
    Optional
    Min 1Max 1

    Code indicating the source of this admission

    CL1-03
    1352
    Patient Status Code
    Optional
    Min 1Max 2

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

    CL1-04
    1345
    Nursing Home Residential Status Code
    Optional

    Code specifying the status of a nursing home resident at the time of service

    1
    Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
    2
    Newly Admitted
    3
    Newly Eligible
    4
    No Longer Eligible
    5
    Still a Resident
    6
    Temporary Absence - Hospital
    7
    Temporary Absence - Other
    8
    Transferred to Intermediate Care Facility - Level II (ICF II)
    9
    Other
    CR1
    1200

    Ambulance Transport Information

    OptionalMax use 1

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

    Usage notes
    • Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.
    • When the CR1 segment is used, then Loop 2010EB is required.
    Example
    If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required
    If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required
    CR1-01
    355
    Unit or Basis for Measurement Code
    Optional

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

    KG
    Kilogram
    LB
    Pound
    CR1-02
    81
    Patient Weight
    Optional
    Min 1Max 10

    Numeric value of weight

    • CR102 is the weight of the patient at time of transport.
    CR1-03
    1316
    Ambulance Transport Code
    Required

    Code indicating the type of ambulance transport

    I
    Initial Trip
    R
    Return Trip
    T
    Transfer Trip
    X
    Round Trip
    CR1-04
    1317
    Ambulance Transport Reason Code
    Optional

    Code indicating the reason for ambulance transport

    A
    Patient was transported to nearest facility for care of symptoms, complaints, or both
    B
    Patient was transported for the benefit of a preferred physician
    C
    Patient was transported for the nearness of family members
    D
    Patient was transported for the care of a specialist or for availability of specialized equipment
    E
    Patient Transferred to Rehabilitation Facility
    F
    Patient Transferred to Residential Facility
    CR1-05
    355
    Unit or Basis for Measurement Code
    Optional

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

    DH
    Miles
    DK
    Kilometers
    CR1-06
    380
    Transport Distance
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR106 is the distance traveled during transport.
    CR1-09
    352
    Round Trip Purpose Description
    Optional
    Min 1Max 80

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

    • CR109 is the purpose for the round trip ambulance service.
    CR1-10
    352
    Stretcher Purpose Description
    Optional
    Min 1Max 80

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

    • CR110 is the purpose for the usage of a stretcher during ambulance service.
    CR2
    1300

    Spinal Manipulation Service Information

    OptionalMax use 1

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

    Usage notes
    • Required when requesting certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. 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
    Min 1Max 9

    Occurrence counter

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

    Numeric value of quantity

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

    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

    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
    CR2-08
    1342
    Patient Condition Code
    Required

    Code indicating the nature of a patient's condition

    A
    Acute Condition
    C
    Chronic Condition
    D
    Non-acute
    E
    Non-Life Threatening
    F
    Routine
    G
    Symptomatic
    M
    Acute Manifestation of a Chronic Condition
    CR2-09
    1073
    Complication Indicator
    Required

    Code indicating a Yes or No condition or response

    • CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an uncomplicated condition.
    N
    No
    Y
    Yes
    CR2-10
    352
    Patient Condition Description
    Optional
    Min 1Max 80

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

    • CR210 is a description of the patient's condition.
    CR2-11
    352
    Patient Condition Description
    Optional
    Min 1Max 80

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

    • CR211 is an additional description of the patient's condition.
    CR2-12
    1073
    X-ray Availability Indicator
    Optional

    Code indicating a Yes or No condition or response

    • CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier review; an "N" value indicates X-rays are not maintained and available for carrier review.
    N
    No
    Y
    Yes
    CR5
    1400

    Home Oxygen Therapy Information

    OptionalMax use 1

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

    Usage notes
    • Required when requesting initial, extended, or revised certification of;home oxygen therapy. If not required by this implementation guide, do not send.
    • Use the UM segment data element UM02 instead of CR501 to specify the;Certification Type Code.
    • Use the HSD segment instead of CR502 to specify the treatment period.
    Example
    CR5-03
    1348
    Oxygen Equipment Type Code
    Required

    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

    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
    CR5-05
    352
    Equipment Reason Description
    Optional
    Min 1Max 80

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

    • CR505 is the reason for equipment.
    CR5-06
    380
    Oxygen Flow Rate
    Required
    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
    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
    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
    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.
    CR5-10
    380
    Arterial Blood Gas Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR510 is the arterial blood gas.
    Usage notes
    • Either CR510 or CR511 is required.
    CR5-11
    380
    Oxygen Saturation Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR511 is the oxygen saturation.
    Usage notes
    • Either CR510 or CR511 is required.
    CR5-12
    1349
    Oxygen Test Condition Code
    Optional

    Code indicating the conditions under which a patient was tested

    E
    Exercising
    N
    No special conditions for test
    O
    On oxygen
    R
    At rest on room air
    S
    Sleeping
    W
    Walking
    X
    Other
    CR5-13
    1350
    Oxygen Test Findings Code
    Optional

    Code indicating the findings of oxygen tests performed on a patient

    1
    Dependent edema suggesting congestive heart failure
    2
    "P" Pulmonale on Electrocardiogram (EKG)
    3
    Erythrocythemia with a hematocrit greater than 56 percent
    CR5-14
    1350
    Oxygen Test Findings Code
    Optional

    Code indicating the findings of oxygen tests performed on a patient

    1
    Dependent edema suggesting congestive heart failure
    2
    "P" Pulmonale on Electrocardiogram (EKG)
    3
    Erythrocythemia with a hematocrit greater than 56 percent
    CR5-15
    1350
    Oxygen Test Findings Code
    Optional

    Code indicating the findings of oxygen tests performed on a patient

    1
    Dependent edema suggesting congestive heart failure
    2
    "P" Pulmonale on Electrocardiogram (EKG)
    3
    Erythrocythemia with a hematocrit greater than 56 percent
    CR5-16
    380
    Portable Oxygen System Flow Rate
    Optional
    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

    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

    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

    Home Health Care Information

    OptionalMax use 1

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

    Usage notes
    • Required when requesting for certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.
    • Requests for home health care must include a principal diagnosis (HI01=BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.
    Example
    If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required
    If either Surgery Date (CR6-09), Product or Service ID Qualifier (CR6-10) or Surgical Procedure Code (CR6-11) are present, then the others are required
    If either Date Time Period Format Qualifier (CR6-15), Last Admission Period (CR6-16) or Patient Location Code (CR6-17) are present, then the others are required
    CR6-01
    923
    Prognosis Code
    Required

    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
    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

    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
    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

    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

    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

    Indicates that this is an extension request to a prior approved service.

    6
    Verification

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

    I
    Initial
    R
    Renewal

    Indicates that this is a request to renew a prior approved service.

    S
    Revised

    Use if the requester is revising the specifics of a certification for which services have not been rendered.

    CR6-09
    373
    Surgery Date
    Optional
    CCYYMMDD format

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

    • CR609 is the date that the surgery identified in CR611 was performed.
    CR6-10
    235
    Product or Service ID Qualifier
    Optional

    Code identifying the type/source of the descriptive number used in Product/Service ID (234)

    • CR610 qualifies CR611.
    HC
    Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

    Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.

    ID
    International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
    CR6-11
    1137
    Surgical Procedure Code
    Optional
    Min 1Max 15

    Code value for describing a medical condition or procedure

    • CR611 is the surgical procedure most relevant to the care being rendered.
    CR6-12
    373
    Physician Order Date
    Optional
    CCYYMMDD format

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

    • CR612 is the date the agency received the verbal orders from the physician for start of care.
    CR6-13
    373
    Last Visit Date
    Optional
    CCYYMMDD format

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

    • CR613 is the date that the patient was last seen by the physician.
    CR6-14
    373
    Physician Contact Date
    Optional
    CCYYMMDD format

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

    • CR614 is the date of the home health agency's most recent contact with the physician.
    CR6-15
    1250
    Date Time Period Format Qualifier
    Optional

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

    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
    CR6-16
    1251
    Last Admission Period
    Optional
    Min 1Max 35

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

    • CR616 is the date range of the most recent inpatient stay.
    CR6-17
    1384
    Patient Location Code
    Optional

    Code identifying the location where patient is receiving medical treatment

    • CR617 indicates the type of facility from which the patient was most recently discharged.
    A
    Acute Care Facility
    B
    Boarding Home
    C
    Hospice
    D
    Intermediate Care Facility
    E
    Long-term or Extended Care Facility
    F
    Not Specified
    G
    Nursing Home
    H
    Sub-acute Care Facility
    L
    Other Location
    M
    Rehabilitation Facility
    O
    Outpatient Facility
    P
    Private Home
    R
    Residential Treatment Facility
    S
    Skilled Nursing Home
    T
    Rest Home
    PWK
    1550

    Additional Patient Information

    OptionalMax use 10

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

    Usage notes
    • Required when needed to report missing teeth on requests for dental services, or if the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
    • This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
    • The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

    Refer to Section 2.5 for more information on using this PWK 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

    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

    Required when using the PWK segment to provide missing teeth information.

    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

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

    AA
    Available on Request at Provider Site

    Required when using the PWK segment to provide missing teeth information.

    This means that the paperwork is not being sent with the request at this time. Instead, it is available to the UMO (or appropriate entity) on request.

    BM
    By Mail
    EL
    Electronically Only

    Use to indicate that the 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

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

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

    Code identifying a party or other code

    Usage notes
    • The requester can use it when PWK02 equals "AA" if the requester wants to send a document control number for an attachment remaining at the Provider's office.
    PWK-07
    352
    Attachment Description
    Optional
    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.
    Usage notes
    • To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2) bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the second byte with a space.
    MSG
    1600

    Message Text

    OptionalMax use 1

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

    Usage notes
    • Required when needed to transmit a text message to the UMO about the patient event. If not required by this implementation guide, do not send.
    • Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
    Example
    MSG-01
    933
    Free Form Message Text
    Required
    Min 1Max 264

    Free-form message text

    2010EA Patient Event Provider Name Loop
    OptionalMax 14
    NM1
    1700

    Patient Event Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
    • If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.
    • Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.
    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

    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

    Do not use if the entity identified in 2010B is the 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

    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
    Min 1Max 60

    Individual last name or organizational name

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

    Individual first name

    NM1-05
    1037
    Patient Event Provider Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-06
    1038
    Patient Event Provider Name Prefix
    Optional
    Min 1Max 10

    Prefix to individual name

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

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

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

    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 submitter.
    OR
    Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.
    If not required by this implementation guide, do not send.

    NM1-09
    67
    Patient Event Provider Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    REF
    1800

    Patient Event Provider Supplemental Information

    OptionalMax use 7

    To specify identifying information

    Usage notes
    • Use the NM1 Segment for the primary identifier.
    • Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
      OR
      Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider.
      OR
      Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider.
      If not required by this implementation guide, do not send.
    Example
    At least one of Patient Event Provider Supplemental Identifier (REF-02) or License Number State Code (REF-03) is required
    REF-01
    128
    Reference Identification Qualifier
    Required

    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 may not be used for Medicare. Not used if NM108 = 34.

    ZH
    Carrier Assigned Reference Number

    Use when the requestor has not been assigned an NPI, or NPI is not mandated for use and the UMO identified in loop 2010A has assigned its own identifier for this provider.

    REF-02
    127
    Patient Event Provider Supplemental Identifier
    Required
    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
    Min 1Max 80

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

    N3
    2000

    Patient Event Provider Address

    OptionalMax use 1

    To specify the location of the named party

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

    Address information

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

    Address information

    N4
    2100

    Patient Event Provider City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the provider has multiple locations to identify the specific location for this patient event. 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
    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
    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
    Min 3Max 15

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

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

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

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    PER
    2200

    Patient Event 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.
    • 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

    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
    Min 1Max 60

    Free-form name

    Usage notes
    • Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required, do not send.
    PER-03
    365
    Communication Number Qualifier
    Optional

    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
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension

    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)
    PER-06
    364
    Patient Event Provider Contact Communications Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension

    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)
    PER-08
    364
    Patient Event Provider Contact Communications Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PRV
    2400

    Patient Event Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
    Example
    PRV-01
    1221
    Provider Code
    Required

    Code identifying the type of provider

    AD
    Admitting

    Use only when NM101 = AAJ.

    AS
    Assistant Surgeon

    Use only when NM101 = DD.

    AT
    Attending

    Use only when NM101 = 71.

    OP
    Operating

    Use only when NM101 = 72.

    OR
    Ordering

    Use only when NM101 = DK.

    OT
    Other Physician

    Use only when NM101 = 73.

    PC
    Primary Care Physician

    Use only when NM101 = P3.

    PE
    Performing

    Use only when NM101 = SJ.

    RF
    Referring

    Use only when NM101 = DN.

    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

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

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

    2010EB Patient Event Transport Information Loop
    OptionalMax 5
    NM1
    1700

    Patient Event Transport Information

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.
    • At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
    • When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:

    a. ND is used to indicate the first stop
    b. R3 is used to indicate the second stop
    c. 45 is used to indicate the third stop

    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    45
    Drop-off Location
    FS
    Final Scheduled Destination
    ND
    Next Destination
    PW
    Pickup Address
    R3
    Next Scheduled Destination
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Patient Event Transport Location Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    N3
    2000

    Patient Event Transport Location Address

    RequiredMax use 1

    To specify the location of the named party

    Example
    N3-01
    166
    Patient Event Transport Location Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes
    • Use this element for the first line of the Transport Location address.
    N3-02
    166
    Patient Event Transport Location Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2100

    Patient Event Transport Location City/State/ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

    Example
    N4-01
    19
    Patient Event Transport Location City Name
    Optional
    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 Transport Location State or Province Code
    Optional
    Min 2Max 2

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

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

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

    2010EC Patient Event Other UMO Name Loop
    OptionalMax 3
    NM1
    1700

    Patient Event Other UMO Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

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

    00
    Alternate Insurer

    Use this code to indicate that the other UMO is commercial insurance.

    CA
    Carrier

    Use this code to indicate that the other UMO is Medicare Part B.

    GG
    Intermediary

    Use this code to indicate that the other UMO is Medicare Part A.

    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Other UMO Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    REF
    1800

    Other UMO Denial Reason

    RequiredMax use 1

    To specify identifying information

    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    ZZ
    Mutually Defined

    Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

    REF-02
    127
    Other UMO Denial Reason
    Required
    Min 1Max 50

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

    REF-04
    C040
    Reference Identifier
    To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.
    Usage notes

    Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.

    If either Reference Identification Qualifier (C040-03) or Other UMO Denial Reason (C040-04) is present, then the other is required
    If either Reference Identification Qualifier (C040-05) or Reference Identification (C040-06) is present, then the other is required
    C040-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    ZZ
    Mutually Defined

    Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

    C040-02
    127
    Other UMO Denial Reason
    Required
    Min 1Max 50

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

    C040-03
    128
    Reference Identification Qualifier
    Optional

    Code qualifying the Reference Identification

    ZZ
    Mutually Defined

    Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

    C040-04
    127
    Other UMO Denial Reason
    Optional
    Min 1Max 50

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

    C040-05
    128
    Reference Identification Qualifier
    Optional

    Code qualifying the Reference Identification

    ZZ
    Mutually Defined

    Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.

    C040-06
    127
    Reference Identification
    Optional
    Min 1Max 50

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

    DTP
    2700

    Other UMO Denial Date

    RequiredMax use 1

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

    Example
    DTP-01
    374
    Date Time Qualifier
    Required

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

    598
    Rejected