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Eligibility
Claims
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Fragments
Mappings
Events
CHC replacement APIs
EDI platform
Professional Claims
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/professionalclaims/v3/submission \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--header 'Stedi-Partnership-Id: <stedi-partnership-id>' \
--header 'Stedi-Response-Type: <stedi-response-type>' \
--header 'Stedi-Transaction-Setting-Id: <stedi-transaction-setting-id>' \
--data '{
"controlNumber": "555123",
"tradingPartnerServiceId": "6400",
"submitter": {
"organizationName": "Test Data Health Services, Inc.",
"contactInformation": {
"name": "Test Data Health Services, Inc.",
"phoneNumber": "5552223333"
}
},
"receiver": {
"organizationName": "Cigna"
},
"subscriber": {
"memberId": "U7777788888",
"paymentResponsibilityLevelCode": "P",
"subscriberGroupName": "Cigna",
"firstName": "John",
"lastName": "Anon",
"gender": "M",
"dateOfBirth": "20000101",
"groupNumber": "3335555",
"address": {
"address1": "2222 Random St",
"city": "New York",
"state": "NY",
"postalCode": "100130000"
}
},
"billing": {
"providerType": "BillingProvider",
"npi": "1235600834",
"employerId": "832675429",
"taxonomyCode": "2084P0800X",
"organizationName": "Therapy Associates",
"address": {
"address1": "123 Some St",
"address2": "Floor 1",
"city": "New York",
"state": "NY",
"postalCode": "100130000"
},
"contactInformation": {
"name": "Test Data Health Services, Inc.",
"phoneNumber": "5553334444"
}
},
"claimInformation": {
"claimFilingCode": "CI",
"patientControlNumber": "22266555",
"claimChargeAmount": "109.20",
"placeOfServiceCode": "02",
"claimFrequencyCode": "1",
"signatureIndicator": "Y",
"planParticipationCode": "A",
"benefitsAssignmentCertificationIndicator": "Y",
"releaseInformationCode": "Y",
"healthCareCodeInformation": [
{
"diagnosisTypeCode": "ABK",
"diagnosisCode": "F1111"
}
],
"serviceFacilityLocation": {
"organizationName": "Smith Associates",
"address": {
"address1": "1234 Other St",
"city": "New York",
"state": "NY",
"postalCode": "100130000"
},
"npi": "4541648844"
},
"serviceLines": [
{
"serviceDate": "20240101",
"professionalService": {
"procedureIdentifier": "HC",
"procedureCode": "90837",
"procedureModifiers": [
"95"
],
"lineItemChargeAmount": "109.20",
"measurementUnit": "UN",
"serviceUnitCount": "1",
"compositeDiagnosisCodePointers": {
"diagnosisCodePointers": [
"1"
]
}
},
"renderingProvider": {
"providerType": "RenderingProvider",
"npi": "4541648844",
"taxonomyCode": "111YP2000X",
"firstName": "Jane",
"lastName": "Smith"
}
}
]
},
"tradingPartnerName": "Cigna"
}'{
"status": "SUCCESS",
"controlNumber": "555123",
"tradingPartnerServiceId": "6400",
"claimReference": {
"correlationId": "01HTCX97F6XS6F2K22D4KD59TK",
"patientControlNumber": "22266555",
"timeOfResponse": "2024-04-01T13:23:54.255Z",
"payerId": "6400",
"formatVersion": "5010",
"rhclaimNumber": "01HTCX97F6XS6F2K22D4KD59TK"
},
"httpStatusCode": "200 OK",
"meta": {
"traceId": "a7f7c912-77f7-489d-96fc-c4ab3b5c33fc"
},
"payer": {
"payerName": "Cigna",
"payerId": "6400"
}
}A direct replacement for the Change Healthcare (CHC) Claim Submission API.
- You call this endpoint with a JSON payload in the CHC Professional Claims V3 format.
- Stedi automatically maps CHC payer IDs to our IDs.
- Stedi translates the JSON to the X12 EDI 837 format and delivers it to the payer or peer clearinghouse.
- The endpoint returns a synchronous response in the CHC Professional Claims V3 JSON response format.
Differences from Change Healthcare’s APIs
The following differences are notable when using Stedi’s APIs instead of CHC APIs.
Receive claim responses and reports via webhook
In order to receive 277 Claim Responses and 835 ERAs using CHC APIs, you needed to poll the Claims Responses and Reports v2 API using the Convert Report 277 and Convert Report 835 operations.
With Stedi, you only need to make a single API call to submit the claim. Stedi then automatically delivers the 277 and 835 transactions to your API using webhooks. You receive the 277 and 835 in the same format as Change’s Convert Report APIs.
Receive 999 Acknowledgments via webhook
We return the 999 in Stedi’s JSON format through webhooks.
View files
You can view every file that Stedi sends and receives on your behalf on the Files page in the Stedi app.
Authorizations
API key authentication via the 'Authorization' header
Headers
The partnership ID.
Temporary parameter used to control the returned response shape.
change-beta The outbound transaction setting ID.
Body
Not currently used, but we may be used in the future.
This is the Payer ID. Visit the Payer Network for a complete list.
Loop: 1000A
Loop: 1000A, Segment: NM1, Element: NM103
Loop: 1000A, Segment: NM1, Element: NM103
Loop: 1000A, Segment: NM1, Element: NM104
Loop: 1000A, Segment: NM1, Element: NM105
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Loop: 1000B
Loop: 1000B, Segment: NM1, Element: NM103
Loop: 2000B
Loop: 2010BA, Segment: NM1, Element: NM109
Loop: 2010BA, Segment: REF, Element: REF02 when REF01=SY
Loop: 2000B, Segment: SBR, Element: SBR01, Allowed Values:'A' Payer Responsibility Four 'B' Payer Responsibility Five 'C' Payer Responsibility Six 'D' Payer Responsibility Seven 'E' Payer Responsibility Eight 'F' Payer Responsibility Nine 'G' Payer Responsibility Ten 'H' Payer Responsibility Eleven 'P' Primary 'S' Secondary 'T' Tertiary 'U' Unknown
A, B, C, D, E, F, G, H, P, S, T, U Loop: 2010BA, Segment: NM1, Element: NM103 when NM102=2, Notes: when subscriber is organization pass patient as dependent
Loop: 2000B, Segment: SBR, Element:SBR05 Notes: Allowed values: '12' Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan, '13' Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan, '14' Medicare Secondary, No-fault Insurance including Auto is Primary, '15' Medicare Secondary Worker's Compensation, '16' Medicare Secondary Public Health Service (PHS)or Other Federal Agency, '41' Medicare Secondary Black Lung, '42' Medicare Secondary Veteran's Administration, '43' Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP), '47' Medicare Secondary, Other Liability Insurance is Primary
12, 13, 14, 15, 16, 41, 42, 43, 47 Loop: 2000B, Segment: SBR, Element: SBR04 Notes: Freeform text
Loop: 2010BA, Segment: NM1, Element: NM104
Loop: 2010BA, Segment: NM1, Element: NM103
Loop: 2010BA, Segment: NM, Element: NM105
Loop: 2010BA, Segment: NM, Element: NM107
Loop: 2010BA, Segment: DMG, Element: DMG03 Subscriber Gender, Notes: 'M' Male, 'F' Female'U' Unknown
M, F, U Loop: 2010BA, Segment: DMG, Element: DMG02
Loop: 2000B, Segment: SBR, Element: SBR03
Loop: 2010BA, Segment: SBR, Element: SBR04
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
LOOP 2000C
Loop: 2010CA, Segment: NM1, Element: NM104
Loop: 2010CA, Segment: NM1, Element: NM103
Loop: 2010CA, Segment: NM1, Element: NM105
Loop: 2010CA, Segment: NM, Element: NM107
Loop: 2010CA, Segment: DMG, Element: DMG03, Note: Allowed Values are: 'M' Male, 'F' Female, 'U' Unknown
M, F, U Loop: 2010CA, Segment: DMG, Element: DMG02 when DMG01=D8
Loop: 2010CA, Segment: REF, Element: REF02 when REF01=SY
Loop: 2010CA, Segment: REF, Element: REF02 when REF01=1W
Loop: 2000C, Segment: PAT, Element: PAT01, Note: Allowed Values are: '01' Spouse, '19' Child, '20' Employee, '21' Unknown, '39' Organ Donor, '40' Cadaver Donor, '53' Life Partner, 'G8' Other Relationship
01, 19, 20, 21, 39, 40, 53, G8 PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
setting providers deprecated, please set all providers individually by it's type.
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Loop2300
Loop 2000B, Segment: SBR, Element: SBR09, Note: Allowed Values are: '11' Other Non-Federal Programs, '12' Preferred Provider Organization (PPO), '13' Point of Service (POS), '14' Exclusive Provider Organization (EPO), '15' Indemnity Insurance, '16' Health Maintenance Organization (HMO) Medicare Risk, '17' Dental Maintenance Organization, 'AM' Automobile Medical, 'BL' Blue Cross/Blue Shield, 'CH' Champus, 'CI' Commercial Insurance Co., 'DS' Disability, 'FI' Federal Employees Program, 'HM' Health Maintenance Organization, 'LM' Liability Medical, 'MA' Medicare Part A, 'MB' Medicare Part B, 'MC' Medicaid, 'OF' Other Federal Program, 'TV' Title V, 'VA' Veterans Affairs Plan, 'WC' Workers' Compensation Health Claim, 'ZZ' Mutually Defined
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ Loop 2010BA, Segment: REF, Element: REF02
Loop 2000B and 2000C, Segment: PAT, Element: PAT06 and PAT05=D8
Loop 2000B and 2000C, Segment: PAT, Element: PAT08 and PAT07=01
Loop 2000B and 2000C, Segment: PAT, Element: PAT09
Y Loop 2300, Segment: CLM, Element: CLM01
Loop 2300, Segment: CLM, Element: CLM02
Loop 2300, Segment: CLM, Element: CLM05-01
Loop 2300, Segment: CLM, Element: CLM05-03
Loop 2300, Segment: CLM, Element: CLM06, Note: Allowed Values are: 'N' NO, 'Y' Yes
N, Y Loop 2300, Segment: CLM, Element: CLM07, Note: Allowed Values are: 'A' Assigned, 'B' Assignment Accepted on Clinical Lab Services Only, 'C' Not Assigned
A, B, C Loop 2300, Segment: CLM, Element: CLM08, Note: Allowed Values are: 'N' No, 'W' Not Applicable - Use code 'W' when the patient refuses to assign benefits, 'Y' Yes
N, W, Y Loop 2300, Segment: CLM, Element: CLM09, Note: Allowed Values are: 'I' Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes, 'Y' Yes
I, Y Loop 2300, Segment: CLM, Element: CLM10, Note: Allowed Values are: 'P' Signature generated by provider because the patient was not physically present for services
Loop 2300, Segment: CLM, Element: CLM11-01, CLM11-02, Note: Allowed Values are: 'AA' Auto Accident, 'EM' Employment, 'OA' Other Accident
AA, EM, OA Loop 2300, Segment: CLM, Element: CLM11-04, Note: When CLM11-1 or CLM11-2 has a value of 'AA' to identify the state, province or sub-country code in which the automobile accident occurred.
AA, EM, OA Loop 2300, Segment: CLM, Element: CLM11-05, Note: When CLM11-1 or CLM11-2 = AA and the accident occurred in a country other than US or Canada.
Loop 2300, Segment: CLM, Element: CLM12, Note: Allowed Values are: '02' Physically Handicapped Children's Program, '03' Special Federal Funding, '05' Disabolity, '09' Second Opinion or Surgery
02, 03, 05, 09 Loop 2300, Segment: CLM, Element: CLM20, Note: Allowed Values are: '1' Proof of Eligibility Unknown or Unavailable, '2' Litigation, '3' Authorization Delays, '4' Delay in Certifying Provider, '5' Delay in Supplying Billing Forms, '6' Delay in Delivery of Custom-made Appliances, '7' Third Party Processing Delay, '8' Delay in Eligibility Determination, '9' Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules, '10' Administration Delay in the Prior Approval Process, '11' Other, '15' Natural Disaster
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 Loop 2300, Segment: AMT, Element: AMT02
Loop 2300, Segment: K3, Element: K301
Loop 2300, Segment: K3, Element: K301
DTP
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop: 2300, Segment: DTP, Element: DTP03
Loop 2300, Segment: CN1
Loop: 2300,Segment: CN1, Element: CN101, Note: Allowed Values are: '01' Diagnosis Related Group (DRG), '02' Per Diem, '03' Variable Per Diem, '04' Flat, '05' Capitated, '06' Percent, '09' Other
01, 02, 03, 04, 05, 06, 09 Loop: 2300, Segment: CN1, Element: CN102
Loop: 2300, Segment: CN1, Element: CN103
Loop: 2300, Segment: CN1, Element: CN104
Loop: 2300, Segment: CN1, Element: CN105
Loop: 2300, Segment: CN1, Element: CN106
PWK and REF
Loop: 2400, Segment: PWK, Element: PWK01, Notes: Allowed Values are: '03' Report Justifying Treatment Beyond Utilization Guidelines, '04' Drugs Administered, '05' Treatment Diagnosis, '06' Initial Assessment, '07' Functional Goals, '08' Plan of Treatment, '09' Progress Report, '10' Continued Treatment, '11' Chemical Analysis, '13' Certified Test Report, '15' Justification for Admission, '21' Recovery Plan, 'A3' Allergies/Sensitivities Document, 'A4' Autopsy Report, 'AM' Ambulance Certification, 'AS' Admission Summary, 'B2' Prescription, 'B3' Physician Order, 'B4' Referral Form, 'BR' Benchmark Testing Results, 'BS' Baseline, 'BT' Blanket Test Results, 'CB' Chiropractic Justification, 'CK' Consent Form(s), 'CT' Certification, 'D2' Drug Profile Document, 'DA' Dental Models, 'DB' Durable Medical Equipment Prescription, 'DG' Diagnostic Report, 'DJ' Discharge Monitoring Report, 'DS' Discharge Summary, 'EB' Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor), 'HC' Health Certificate, 'HR' Health Clinic Records, 'I5' Immunization Record,'IR' State School Immunization Records, 'LA' Laboratory Results, 'M1' Medical Record Attachment, 'MT' Models, 'NM Nursing Notes', 'OB' Operative Note, 'OC' Oxygen Content Averaging Report, 'OD' Orders and Treatments Document, 'OE' Objective Physical Examination (including vital signs) Document, 'OX' Oxygen Therapy Certification, 'OZ' Support Data for Claim, 'P4' Pathology Report, 'P5' Patient Medical History Document, 'PE' Parenteral or Enteral Certification, 'PN' Physical Therapy Notes, 'PO' Prosthetics or Orthotic Certification, 'PQ' Paramedical Results, 'PY' Physician's Report, 'PZ' Physical Therapy Certification, 'RB' Radiology Films, 'RR' Radiology Reports, 'RT' Report of Tests and Analysis Report, 'RX' Renewable Oxygen Content Averaging Report, 'SG' Symptoms Document, 'V5' Death Notification, 'XP' Photographs
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NM, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP Loop: 2400, Segment: PWK, Element: PWK02 Allowed Values are: 'AA' Available on Request at Provider Site, 'BM' By Mail,'EL' Electronically Only, 'EM' E-Mail, 'FT' File Transfer, 'FX' By Fax
AA, BM, EL, EM, FT, FX Loop 2400, Segment: PWK, Element: PWK05
Loop: 2300, Segment: REF, Element: REF02 and REF01=G1
Loop: 2300, Segment: REF, Element: REF02 and REF01=9F
Loop: 2300, Segment: REF, Element: REF02 and REF01=F8
Loop: 2300, Segment: REF, Element: REF02 and REF01=X4
Loop: 2300, Segment: REF, Element: REF02 and REF01=9A
Loop: 2300, Segment: REF, Element: REF02 and REF01=9C
Loop: 2300, Segment: REF, Element: REF02 and REF01=LX
Loop: 2300, Segment: REF, Element: REF02 and REF01=D9
Loop: 2300, Segment: REF, Element: REF02 and REF01=EW
Loop: 2300, Segment: REF, Element: REF02 and REF01=EA
Loop: 2300, Segment: REF, Element: REF02 and REF01=P4
Loop: 2300, Segment: REF, Element: REF02 and REF01=1J
Loop: 2300, Segment: REF, Element: REF02 and REF01=F5
Loop: 2300, Segment: REF, Element: REF02 and REF01=4N, Note: '1' Immediate/Urgent Care, '2' Services Rendered in a Retroactive Period, '3' Emergency Care, '4' Client has Temporary Medicaid, '5' Request from County for Second Opinion to Determine if Recipient Can Work, '6' Request for Override Pending, '7' Special Handling, Null
1, 2, 3, 4, 5, 6, 7 NTE
Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=ADD
Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=CER
Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=DCP
Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=DGN
Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=TPO
CR1
Segment: CR1, Element: CR102
CR104, Note: Allowed Values are: '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
A, B, C, D, E Segment: CR1, Element: CR106
Segment: CR1, Element: CR109
Segment: CR1, Element: CR110
Loop 2300, Segment: CR2
Loop: 2300, Segment: CR, Element: CR208
Loop: 2300, Segment: CR, Element: CR210 Note: Allowed Values are: 'A' Acute Condition, 'C' Chronic Condition, 'D' Chronic Condition, 'E' Non-Life Threatening, 'F' Routine, 'G' Symptomatic, 'M' Acute Manifestation of a Chronic Condition
A, C, D, E, F, G, M Loop: 2300, Segment: CR, Element: CR211
Loop 2300, Segment: CRC
Loop: 2300, Segment: CRC, Element: CRC02 when CRC01 = 07, Note: Allowed Values are: 'N' No, 'Y' Yes
N, Y Loop: 2300, Segment: CRC, Element: CRC03, CRC04, CRC05, CRC06, CRC07, Note: Allowed Values are: '01' Patient was admitted to a hospital, '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, '12' Patient is confined to a bed or chair
01, 04, 05, 06, 07, 08, 09, 12 Loop 2300, Segment: CRC
Loop: 2300, Segment: CRC, Element: CRC01, Notes: Allowed Values are: 'E1' Spectacle Lenses, 'E2' Contact Lenses, 'E3' Spectacle Frames
E1, E2, E3 Loop: 2300, Segment: CRC, Element: CRC02, Notes: Allowed Values are: 'N' No, 'Y' Yes
N, Y Loop: 2300, Segment: CRC, Element: CRC03 to CRC07, Notes: CRC03 is required, others are situational. Allowed Values are: 'L1' General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met, 'L2' Replacement Due to Loss or Theft, 'L3' Replacement Due to Breakage or Damage, L4' Replacement Due to Patient Preference, 'L5' Replacement Due to Medical Reason
L1, L2, L3, L4, L5 Loop 2300, Segment: CRC
CRC
Loop: 2300, Segment: CRC, Element: CRC02 When CRC01=ZZ, Note: 'N' No, 'Y' Yes
N, Y Loop: 2300, Segment: CRC, Elements: CRC03, CRC04, CRC05 Note: Allowed Values are: 'AV' Available- Not Used, 'NU' Not Used, 'S2' Under Treatment, 'ST' New Services Requested
AV, NU, S2, ST Loop 2300, Segment: HI
Loop: 2440, Segment: HI, Element: HI01-01 or HI02-01 or HI03-01 or HI04-01 or HI05-01 or HI06-01 or HI07-01 or HI08-01 or HI09-01 or HI10-01 or HI11-01 or HI12-01, Note: Allowed Values are: 'BK' International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, 'ABK' International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, 'BF' International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, 'ABF' International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BK, ABK, BF, ABF Loop: 2440, Segment: HI, Element: HI01-02 or HI02-02 or HI03-02 or HI04-02 or HI05-02 or HI06-02 or HI07-02 or HI08-02 or HI09-02 or HI10-02 or HI11-02 or HI12-02
Loop 2300, Segment: HI
Loop 2300, Segment: HI
HCP
Loop: 2300, Segment: HCP, Element: HCP01, Note: Allowed Values are: '00' Zero Pricing (Not Covered Under Contract), '01' Priced as Billed at 100%, '02' Priced at the Standard Fee Schedule, '03' Priced at a Contractual Percentage, '04' Bundled Pricing, '05' Peer Review Pricing, '06' Bundled Pricing, '07' Flat Rate Pricing, '08' Combination Pricing, '09' Maternity Pricing, '10' Other Pricing, '11' Lower of Cost, '12' Ratio of Cost, '13' Cost Reimbursed, '14' Adjustment Pricing
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 Loop: 2300, Segment: HCP, Element: HCP02
Loop: 2300, Segment: HCP, Element: HCP03
Loop: 2300, Segment: HCP, Element: HCP04
Loop: 2300, Segment: HCP, Element: HCP05
Loop: 2300, Segment: HCP, Element: HCP06
Loop: 2300, Segment: HCP, Element: HCP07
Loop: 2300, Segment: HCP, Element: HCP13, Note: Allowed Values are: 'T1' Cannot Identify Provider as TPO (Third Party Organization) Participant, 'T2' Cannot Identify Payer as TPO (Third Party Organization) Participant, 'T3' Cannot Identify Insured as TPO (Third Party Organization) Participant, 'T4' Payer Name or Identifier Missing, 'T5' Certification Information Missing, '16' Claim does not contain enough information for repricing
T1, T2, T3, T4, T5, T6 Loop: 2300, Segment: HCP, Element: HCP14, Note: Allowed Values are: '1' Procedure Followed (Compliance), '2' Not Followed - Call Not Made (Non-Compliance Call Not Made), '3' Not Medically Necessary (Non-Compliance Non-Medically Necessary), '4' Not Followed Other (Non-Compliance Other), '5' Emergency Admit to Non-Network Hospital
1, 2, 3, 4, 5 Loop: 2300, Segment: HCP, Element: HCP15, Note: Allowed Values are: '1' Non-Network Professional Provider in Network Hospital, '2' Emergency Care, '3' Services or Specialist not in Network, '4' Out-of-Service Area, '5' State Mandates, '6' Other
1, 2, 3, 4, 5, 6 Loop: 2420C, Segment: NM1, Element: NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
Loop: 2420C, Segment: NM1, Element: NM109, Note: National Provider Identifier
Loop: 2420C: Segment: REF, Notes: A list containing qualifier (REF01), identifier (REF02), and otherIdentifier(REF04)
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop: 2310C, Segment: PER, Element: PER02
Loop: 2310C, Segment: PER, Element: PER04
Loop: 2310C, Segment: PER, Element: PER06
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
Loop 2320
Loop: 2320, Segment: SBR, Element: SBR01, Notes: Allowable values are 'A' Payer Responsibility Four, 'B' Payer Responsibility Five, 'C' Payer Responsibility Six, 'D' Payer Responsibility Seven, 'E' Payer Responsibility Eight, 'F' Payer Responsibility Nine, 'G' Payer Responsibility Ten, 'H' Payer Responsibility Eleven, 'P' Primary, 'S' Secondary, 'T' Tertiary, and 'U' Unknown
A, B, C, D, E, F, G, H, P, S, T, U Loop: 2320, Segment: SBR, Element: SBR02, Notes: Required when patient is the subscriber, Notes: Allowed Values are: '01' Spouse, '18' Self, '19' Child, '20' Employee, '21' Unknown, '39' Organ Donor, '40' Cadaver Donor, '53' Life Partner, 'G8' Other Relationship
01, 18, 19, 20, 21, 39, 40, 53, G8 Loop: 2320, Segment: SBR, Element: SBR03
Loop: 2000B, Segment: SBR, Element: SBR04
Loop: 2320, Segment: SBR, Element: SBR05, Notes: Allowable Values are: '12' Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan, '13' Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period, '14' Medicare Secondary, No-fault Insurance including Auto is Primary, '15' Medicare Secondary Worker's Compensation, '16' Medicare Secondary Public Health Service (PHS)or Other Federal Agency, '41' Medicare Secondary Black Lung, '42' Medicare Secondary Veteran's Administration, '43' Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP), '47' Medicare Secondary, Other Liability Insurance is Primary
12, 13, 14, 15, 16, 41, 42, 43, 47 Loop: 2320, Segment: SBR, Element: SBR09, Notes: Allowed Values are: '11' Other Non-Federal Programs, '12' Preferred Provider Organization (PPO), '13' Point of Service (POS), '14' Exclusive Provider Organization (EPO), '15' Indemnity Insurance, '16' Health Maintenance Organization (HMO) Medicare Risk, '17' Dental Maintenance Organization, 'AM' Automobile Medical, 'BL' Blue Cross/Blue Shield, 'CH' Champus, 'CI' Commercial Insurance Co., 'DS' Disability, 'FI' Federal Employees Program, 'HM' Health Maintenance Organization, 'LM' Liability Medical, 'MA' Medicare Part A, 'MB' Medicare Part B,'MC' Medicare Part C, 'OF' Other Federal Program, 'TV' Title V, 'VA' Veterans Affairs Plan, 'WC' Worker's Compensation Health Claim, 'ZZ' Mutually Defined
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ Loop: 2320, Segment: CAS
Loop: 2430, Segment: CAS, Element: CAS01, Notes: Code identifying the general category of payment adjustment
CO, CR, OA, PI, PR Loop: 2430, Segment: CAS
Loop: 2430, Segment: CAS, Element: CAS02, CAS05, CAS08, CAS11, CAS14, CAS17
Loop: 2430, Segment: CAS, Element: CAS03, CAS06, CAS09, CAS12, CAS15, CAS18
Loop: 2430, Segment: CAS, Element: CAS04, CAS07, CAS10, CAS13, CAS16, CAS19
Loop: 2320, Segment: AMT, Element: AMT02 when AMT01=D, Notes: It is acceptable to show '0' (Zero)
Loop: 2320, Segment: AMT, Element: AMT02 when AMT01=A8
Loop: 2320, Segment: AMT, Element: AMT02 when AMT01=EAF
Loop: 2320, Segment: OI, Element: OI03, Notes: Allowable values are: 'N' No, 'W' Not Applicable, 'Y' Yes
N, W, Y Loop: 2320, Segment: OI, Element: OI04, Notes: Allowable value is 'P' Signature generated by provider because the patient was not physically present for services
Loop: 2320, Segment: OI, Element: OI04, Notes: Allowable values are 'I' Informed Consent to Release Medical Information, 'Y' Yes
I, Y Loop: 2320, Segment: MOA
Loop 2320, Segment: MOA; Element: MOA01
Loop 2320, Segment: MOA; Element: MOA02
Loop: 2320: Segment: MOA, Element: MOA03 to MOA07
Loop 2320, Segment: MOA; Element: MOA08
Loop 2320, Segment: MOA; Element: MOA09
Loop: 2330A
Loop: 2330A, Segment: NM1, Element: NM102, Notes: Allowed Values are: '1' Person, '2' Non-Person Entity
1, 2 Loop: 2330A, Segment: NM1, Element: NM103
Loop: 2330A, Segment: NM1, Element: NM102, Notes: Required when NM102 = 1 (Person)
Loop: 2330A, Segment: NM1, Element: NM105, Notes: Required when NM102 = 1 (Person)
Loop: 2330A, Segment: NM1, Element: NM107, Notes: Required when NM102 = 1 (Person)
Loop: 2330A, Segment: NM1, Element: NM108, Notes: Allowable values are: 'II' Standard Unique HealthIdentifier for each individual in the United States and 'MI' member identification number
II, MI Loop: 2330A, Segment: NM1, Element: NM109
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
Loop: 2330A, Segment: REF, Element: REF02 when REF01=SY
Loop: 2330B
Loop: 2330B; Segment: NM1, Element: NM111
Loop: 2330B; Segment: NM1, Element: NM103
Loop: 2330B; Segment: NM1, Element: NM108, Notes: Allowable values: 'PI' Payor Identification and 'XV' Centers for Medicare/Medicaid Services PlanID
PI, XV Loop: 2330B; Segment: NM1, Element: NM109
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
Loop: 2330B, Segment: DTP, Element: DTP03
Loop: 2330B, Segment: REF
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop: 2330B, Segment: REF, Element: REF02 when REF01=G1
Loop: 2330B; Segment: REF, Element: REF02 when REF01=9F
Loop: 2330B, Segment: REF, Element: REF02 when REF01=T4
Loop: 2330B, Segment: REF, Element: REF02 when REF01=F8
Loop 2330E, Segment: NM1 and REF
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop: 2330D, Segment NM1, Element: NM102, Notes: Allowable values are '1' Person and '2' Non-Person Entity
1, 2 Loop 2330D, Segment: NM1 and REF
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop 2330E, Segments: NM1 and REF
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop 2330F, Segments: NM1 and REF
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop 2330G, Segment: NM1; Element: NM101, Notes: Code identifying an organizational entity, a physical location, property or an individual. Allowablevalues: '1' Person, '2' Non-Person Entity
1, 2 Loop 2330G, Segment: NM1 and REF
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop 2400
Loop: 2400, Segment: LX, Element: LX01
Loop: 2400, Segment: DTP, Element: DTP03, Notes: When sent with serviceDateEnd it will be used as the start date for Date Time period, if sent without serviceDateEnd will use DTP02 = D8. Expressed in Format CCYYMMDD
Loop: 2400, Segment: DTP, Element: DTP03, Notes: Range of Dates Expressed in Format CCYYMMDD
Loop: 2400, Segment: REF, Element: REF04-02 when REF01=6R
Loop: 2400, Segment: SV1, Element: SV101-01, Notes: Allowed Values are: 'ER' Jurisdiction Specific Procedure and Supply Codes, 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, 'IV' Home Infusion EDI Coalition (HIEC) Product/Service Code,'WK' Advanced Billing Concepts (ABC) Codes
ER, HC, IV, WK Loop 2400, Segment: SV1, Element: SV101-02
Loop 2400, Segment: SV1, Elements: SV101-03 to SV101-06, Notes: Required when modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required then do not send
Loop 2400, Segment: SV1, Element: SV101-07, Notes: A free form description to clarify teh related data elements and their content
Loop 2400, Segment: SV1, Element: SV102, Notes: Required value for total charge amount, '0' (Zero) is acceptable for this value
Loop 2400, Segment: SV1, Element: SV103, Notes: Allowed values are 'MJ' Minutes, 'UN' Unit
MJ, UN Loop 2400, Segment: SV1, Element: SV104, Notes: When a decimal is needed to report units, include it in this element
Loop 2400, Segment: SV1, Element: SV105
SVC107
Loop: 2400, Segment: SV1, Element: SV107-01, SV107-02, SV107-03, SV107-04
Loop 2400, Segment: SV1, Element: SV109
Y Loop 2400, Segment: SV1, Element: SV111
Y Loop 2400, Segment: SV1, Element: SV112
Y Loop 2400, Segment: SV1, Element: SV115
0 SV5
Loop: 2410, Segment: SV5, Element: SV503
Loop: 2410, Segment: SV5, Element: SV504
Loop: 2410, Segment: SV5, Element: SV505
Loop: 2410, Segment: SV5, Element: SV506, Note: Allowed Values are: '1' weekly, '4' monthly, '6' daily
1, 4, 6 Loop: 2400, Segment: PWK, Element: PWK01, Notes: Allowed Values are: '03' Report Justifying Treatment Beyond Utilization Guidelines, '04' Drugs Administered, '05' Treatment Diagnosis, '06' Initial Assessment, '07' Functional Goals, '08' Plan of Treatment, '09' Progress Report, '10' Continued Treatment, '11' Chemical Analysis, '13' Certified Test Report, '15' Justification for Admission, '21' Recovery Plan, 'A3' Allergies/Sensitivities Document, 'A4' Autopsy Report, 'AM' Ambulance Certification, 'AS' Admission Summary, 'B2' Prescription, 'B3' Physician Order, 'B4' Referral Form, 'BR' Benchmark Testing Results, 'BS' Baseline, 'BT' Blanket Test Results, 'CB' Chiropractic Justification, 'CK' Consent Form(s), 'CT' Certification, 'D2' Drug Profile Document, 'DA' Dental Models, 'DB' Durable Medical Equipment Prescription, 'DG' Diagnostic Report, 'DJ' Discharge Monitoring Report, 'DS' Discharge Summary, 'EB' Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor), 'HC' Health Certificate, 'HR' Health Clinic Records, 'I5' Immunization Record,'IR' State School Immunization Records, 'LA' Laboratory Results, 'M1' Medical Record Attachment, 'MT' Models, 'NM Nursing Notes', 'OB' Operative Note, 'OC' Oxygen Content Averaging Report, 'OD' Orders and Treatments Document, 'OE' Objective Physical Examination (including vital signs) Document, 'OX' Oxygen Therapy Certification, 'OZ' Support Data for Claim, 'P4' Pathology Report, 'P5' Patient Medical History Document, 'PE' Parenteral or Enteral Certification, 'PN' Physical Therapy Notes, 'PO' Prosthetics or Orthotic Certification, 'PQ' Paramedical Results, 'PY' Physician's Report, 'PZ' Physical Therapy Certification, 'RB' Radiology Films, 'RR' Radiology Reports, 'RT' Report of Tests and Analysis Report, 'RX' Renewable Oxygen Content Averaging Report, 'SG' Symptoms Document, 'V5' Death Notification, 'XP' Photographs
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NM, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP Loop: 2400, Segment: PWK, Element: PWK02 Allowed Values are: 'AA' Available on Request at Provider Site, 'BM' By Mail,'EL' Electronically Only, 'EM' E-Mail, 'FT' File Transfer, 'FX' By Fax
AA, BM, EL, EM, FT, FX Loop 2400, Segment: PWK, Element: PWK05
PWK
Loop: 2400, Segment: PWK, Element: PWK02 when PWK01=CT, Note: Allowed Values are: 'AB' Previously Submitted to Payer, 'AD' Certification Included in this Claim, 'AF' Narrative Segment Included in this Claim, 'AG' No Documentation is Required, 'NS' Not Specified
AB, AD, AF, AG, NS CR1
Segment: CR1, Element: CR102
CR104, Note: Allowed Values are: '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
A, B, C, D, E Segment: CR1, Element: CR106
Segment: CR1, Element: CR109
Segment: CR1, Element: CR110
CR3
Loop: 2400, Segment: CR3, Element: CR301, Note: Allowed Values are: 'I' Initial, 'R' Renewal, 'S' Revised
I, R, S Loop: 2400, Segment: CR3, Element: CR303 when CR302=MO
Loop: 2300, Segment: CRC, Element: CRC02 when CRC01 = 07, Note: Allowed Values are: 'N' No, 'Y' Yes
N, Y Loop: 2300, Segment: CRC, Element: CRC03, CRC04, CRC05, CRC06, CRC07, Note: Allowed Values are: '01' Patient was admitted to a hospital, '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, '12' Patient is confined to a bed or chair
01, 04, 05, 06, 07, 08, 09, 12 Loop: 2400, Segment: CRC, Element: CRC02 Notes: True or False
CRC
Loop 2400, Segment: CRC, Element: CRC02 and CRC01=09, Note: Allowed Values are: 'N' No, 'Y' Yes
Y, N Loop 2400, Segment: CRC, Element: CRC03, Note: Allowed Values are: '38' Certification signed by the physician is on file at the supplier's office, 'ZV' Replacement Item
38, ZV Loop 2400, Segment: CRC, Element: CRC04, Note: Allowed Values are: '38' Certification signed by the physician is on file at the supplier's office, 'ZV' Replacement Item
38, ZV Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=471, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=607, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=463, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=461, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=304, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=738, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=739, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=011, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=455, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: DPT, Element: DTP03 when DPT01=454, Notes: Date Expressed in Format CCYYMMDD
Loop: 2400, Segment: QTY, Element: QTY02 when QTY01=PT
Loop: 2400, Segment: QTY, Element: QTY02 when QTY01=FL
Loop 2400, Segment: MEA; Element: MEA01, Notes: Allowable values are 'OG' Original and 'TR' Test Results
OG, TR Loop 2400, Segment: MEA; Element: MEA02, Notes: Allowable values are 'HT' Height, 'R1' Hemoglobin, 'R2' Hematocrit, 'R3' Epoetin Starting Dosage, 'R4' Creatinine
HT, R1, R2, R3, R4 Loop 2400, Segment: MEA; Element: MEA03
CN1
Segment: CN1, Element: CN101, Allowed Values are: '01' Diagnosis Related Group (DRG), '02' Per Diem, '03' Variable Per Diem, '04' Flat, '05' Capitated, '06' Percent, '09' Other
01, 02, 03, 04, 05, 06, 09 Segment: CN1, Element: CN102
Segment: CN1, Element: CN103
Segment: CN1, Element: CN104
Segment: CN1, Element: CN105
Segment: CN1, Element: CN106
Loop: 2400, Segment: REF, Element: REF02 Notes: When REF01=9B
Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=9D
Loop 2400 REF
Loop: 2400, Segment: REF, Element: REF02 when REF01=G1
Loop: 2400, Segment: REF, Element: REF04-2 when REF04-1=2U
Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=EW
Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=X4
Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=F4
Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=BT
Loop: 2400, Segment: REF, Element: REF Note: When REF01=9F
Loop: 2400, Segment: AMT, Element: AMT02 when AMT01=T
Loop: 2400, Segment: AMT, Element: AMT02 when AMT01=F4
Loop: 2400, Segment: K3, Element: K301
Loop: 2400, Segment: NTE, Element: NTE02 when NTE01=ADD
Loop: 2400, Segment: NTE, Element: NTE02 when NTE01=DCP
Loop: 2400, Segment: NTE, Element: NTE02 when NTE01=TPO
Loop: 2400, Segment: PS1, Element: PS101
Loop: 2400, Segment: PS1, Element: PS102
HCP
Loop: 2300, Segment: HCP, Element: HCP01, Note: Allowed Values are: '00' Zero Pricing (Not Covered Under Contract), '01' Priced as Billed at 100%, '02' Priced at the Standard Fee Schedule, '03' Priced at a Contractual Percentage, '04' Bundled Pricing, '05' Peer Review Pricing, '06' Bundled Pricing, '07' Flat Rate Pricing, '08' Combination Pricing, '09' Maternity Pricing, '10' Other Pricing, '11' Lower of Cost, '12' Ratio of Cost, '13' Cost Reimbursed, '14' Adjustment Pricing
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 Loop: 2300, Segment: HCP, Element: HCP02
Loop: 2300, Segment: HCP, Element: HCP03
Loop: 2300, Segment: HCP, Element: HCP04
Loop: 2300, Segment: HCP, Element: HCP05
Loop: 2300, Segment: HCP, Element: HCP06
Loop: 2300, Segment: HCP, Element: HCP07
Loop: 2300, Segment: HCP, Element: HCP13, Note: Allowed Values are: 'T1' Cannot Identify Provider as TPO (Third Party Organization) Participant, 'T2' Cannot Identify Payer as TPO (Third Party Organization) Participant, 'T3' Cannot Identify Insured as TPO (Third Party Organization) Participant, 'T4' Payer Name or Identifier Missing, 'T5' Certification Information Missing, '16' Claim does not contain enough information for repricing
T1, T2, T3, T4, T5, T6 Loop: 2300, Segment: HCP, Element: HCP14, Note: Allowed Values are: '1' Procedure Followed (Compliance), '2' Not Followed - Call Not Made (Non-Compliance Call Not Made), '3' Not Medically Necessary (Non-Compliance Non-Medically Necessary), '4' Not Followed Other (Non-Compliance Other), '5' Emergency Admit to Non-Network Hospital
1, 2, 3, 4, 5 Loop: 2300, Segment: HCP, Element: HCP15, Note: Allowed Values are: '1' Non-Network Professional Provider in Network Hospital, '2' Emergency Care, '3' Services or Specialist not in Network, '4' Out-of-Service Area, '5' State Mandates, '6' Other
1, 2, 3, 4, 5, 6 LOOP 2410
Loop: 2410, Segment: LIN, Element: LIN02, Note: Allowed Values are: 'EN' EAN/UCC - 13, 'EO' EAN/UCC - 8, 'HI' HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message, 'N4' National Drug Code in 5-4-2 Format, 'ON' Customer Order Number, 'UK' GTIN 14-digit Data Structure, 'UP' UCC - 12
EN, EO, HI, N4, ON, UK, UP Loop: 2410, Segment: LIN, Element: LIN03
Loop: 2410, Segment: CTP, Element: CTP04
Loop: 2410, Segment: CTP05, Element: CTP05-01, Allowed Values are: 'F2' International Unit, 'GR' Gram, 'ME' Milligram, 'ML' Milliliter, 'UN' Unit
F2, GR, ME, ML, UN Loop: 2410, Segment: REF, Element: REF02 when REF01=VY
Loop: 2410, Segment: REF, Element: REF02 when REF01=XZ
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop: 2420C, Segment: NM1, Element: NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
Loop: 2420C, Segment: NM1, Element: NM109, Note: National Provider Identifier
Loop: 2420C: Segment: REF, Notes: A list containing qualifier (REF01), identifier (REF02), and otherIdentifier(REF04)
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
Loop: 2310C, Segment: PER, Element: PER02
Loop: 2310C, Segment: PER, Element: PER04
Loop: 2310C, Segment: PER, Element: PER06
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 or PER08, Note: PER05=EX or PER07=EX
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Segment: REF, Element: REF01
Segment: REF, Element: REF02
Segment: REF, Element: REF03
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
Loop: 2430, Segment: SVD, Element: SVD01
Loop: 2430, Segment: SVD, Element: SVD02
Loop: 2430, Segment: SVD, Element: SVD03-01, Note: Allowed Values are: 'ER' Jurisdiction Specific Procedure and Supply Codes, 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, 'HP' Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, 'IV' Home Infusion EDI Coalition (HIEC) Product/Service Code, 'WK' Advanced Billing Concepts (ABC) Codes
ER, HC, HP, IV, WK Loop: 2430, Segment: SVD, Element: SVD03-02
Loop: 2430, Segment: SVD, Element: SVD03-07
Loop: 2430, Segment: SVD, Element: SVD05
Loop: 2430, Segment: SVD, Element: SVD06
Loop: 2430, Segment: CAS
Loop: 2430, Segment: CAS, Element: CAS01, Notes: Code identifying the general category of payment adjustment
CO, CR, OA, PI, PR Loop: 2430, Segment: CAS
Loop: 2430, Segment: CAS, Element: CAS02, CAS05, CAS08, CAS11, CAS14, CAS17
Loop: 2430, Segment: CAS, Element: CAS03, CAS06, CAS09, CAS12, CAS15, CAS18
Loop: 2430, Segment: CAS, Element: CAS04, CAS07, CAS10, CAS13, CAS16, CAS19
Loop: 2430, Segment: DTP, Element=DTP03 when DTP02=D8 and DTP01=573
Loop: 2430, Segment: AMT, Element=AMT02 when AMT01=EAF
Loop: 2440, Segment: LQ, Element: LQ01, Note: Allowed Values are:'AS' Form Type Code, 'UT' Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms
AS, UT Loop: 2440, Segment: LQ, Element: LQ02
Loop: 2440, Segment: FRM
Loop: 2440, Segment: FRM, Element: FRM01
Loop: 2440, Segment: FRM, Element: FRM02, Notes: Allowed Values are: 'N' No, 'W' Not Applicable, 'Y' Yes
N, W, Y Loop: 2440, Segment: FRM, Element: FRM03
Loop: 2440, Segment: FRM, Element: FRM04
Loop: 2440, Segment: FRM, Element: FRM05
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
2010AC
Loop: 2010AC, Segment: NM1, Element: NM103
Loop: 2010AC, Segment: NM1, Element: NM108, Notes: 'PI' Payor Identification and 'XV' Centers for Medicare/Medicaid Services PlanID
PI, XV Loop: 2010AC, Segment: NM1, Element: NM109
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
Loop: 2010AC, Segment: REF, Element: REF01, Notes: '2U Payer Identification Number, 'FY' Claim Office Number, 'NF National Association of Insurance Commissioners'
2U, FY, NF Loop: 2010AC, Segment: REF, Element: REF02
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=EI
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
The Interchange Usage Indicator (ISA-15) in the X12 EDI file. You only need to set this field if you want to be able to filter claims in the Stedi app by production or test data. By default, this field is set to P for production data. Use T to designate a file as test data.
Loop: 2000A
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Loop: 2420F
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Loop: 2420A
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Loop: 2420E, Setting ProviderType equal to OrderingProvider is deprecated, please use ClaimInformation.serviceLines.orderingProvider
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Loop: 2420D
NM109, Notes: National Provider Identifier
REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators
REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators
REF02 when REF01=G2
REF02 when REF01=LU
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U
LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY
Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code
REF02 when REF01=0B
REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999
PRV03
NM104
NM103
NM105
NM107
NM103
N3 and N4
Segment: N3, Element: N301
Segment: N3, Element: N302
Segment: N4, Element: N401
Segment: N4, Element: N402
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N407
PER
Segment: PER, Element: PER02 and PER01=IC
Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)
Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX
Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM
Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)
Loop 2010BB NM103
Response
Status of claim
Transaction Set Control Number
Payer ID
Collection of info specific to a given claim
Claim correlation ID
Submitter ID for transaction
Claim number
Control number for claim
Time of response for claim
Claim Type
Payer ID
Format version
List of errors
The field related to the error
Value for bad data error
Error code
Description of error message.
Follow up action to correct
Location of error
100 CONTINUE, 101 SWITCHING_PROTOCOLS, 102 PROCESSING, 103 CHECKPOINT, 200 OK, 201 CREATED, 202 ACCEPTED, 203 NON_AUTHORITATIVE_INFORMATION, 204 NO_CONTENT, 205 RESET_CONTENT, 206 PARTIAL_CONTENT, 207 MULTI_STATUS, 208 ALREADY_REPORTED, 226 IM_USED, 300 MULTIPLE_CHOICES, 301 MOVED_PERMANENTLY, 302 FOUND, 302 MOVED_TEMPORARILY, 303 SEE_OTHER, 304 NOT_MODIFIED, 305 USE_PROXY, 307 TEMPORARY_REDIRECT, 308 PERMANENT_REDIRECT, 400 BAD_REQUEST, 401 UNAUTHORIZED, 402 PAYMENT_REQUIRED, 403 FORBIDDEN, 404 NOT_FOUND, 405 METHOD_NOT_ALLOWED, 406 NOT_ACCEPTABLE, 407 PROXY_AUTHENTICATION_REQUIRED, 408 REQUEST_TIMEOUT, 409 CONFLICT, 410 GONE, 411 LENGTH_REQUIRED, 412 PRECONDITION_FAILED, 413 PAYLOAD_TOO_LARGE, 413 REQUEST_ENTITY_TOO_LARGE, 414 URI_TOO_LONG, 414 REQUEST_URI_TOO_LONG, 415 UNSUPPORTED_MEDIA_TYPE, 416 REQUESTED_RANGE_NOT_SATISFIABLE, 417 EXPECTATION_FAILED, 418 I_AM_A_TEAPOT, 419 INSUFFICIENT_SPACE_ON_RESOURCE, 420 METHOD_FAILURE, 421 DESTINATION_LOCKED, 422 UNPROCESSABLE_ENTITY, 423 LOCKED, 424 FAILED_DEPENDENCY, 425 TOO_EARLY, 426 UPGRADE_REQUIRED, 428 PRECONDITION_REQUIRED, 429 TOO_MANY_REQUESTS, 431 REQUEST_HEADER_FIELDS_TOO_LARGE, 451 UNAVAILABLE_FOR_LEGAL_REASONS, 500 INTERNAL_SERVER_ERROR, 501 NOT_IMPLEMENTED, 502 BAD_GATEWAY, 503 SERVICE_UNAVAILABLE, 504 GATEWAY_TIMEOUT, 505 HTTP_VERSION_NOT_SUPPORTED, 506 VARIANT_ALSO_NEGOTIATES, 507 INSUFFICIENT_STORAGE, 508 LOOP_DETECTED, 509 BANDWIDTH_LIMIT_EXCEEDED, 510 NOT_EXTENDED, 511 NETWORK_AUTHENTICATION_REQUIRED Meta data about the request
submitterId assigned to this request
senderId assigned to this request
billerId assigned to this request
This is the file execution ID, a unique identifier assigned to the processed file within the Stedi platform.
Used by to identify where this request can be found for support
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curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/professionalclaims/v3/submission \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--header 'Stedi-Partnership-Id: <stedi-partnership-id>' \
--header 'Stedi-Response-Type: <stedi-response-type>' \
--header 'Stedi-Transaction-Setting-Id: <stedi-transaction-setting-id>' \
--data '{
"controlNumber": "555123",
"tradingPartnerServiceId": "6400",
"submitter": {
"organizationName": "Test Data Health Services, Inc.",
"contactInformation": {
"name": "Test Data Health Services, Inc.",
"phoneNumber": "5552223333"
}
},
"receiver": {
"organizationName": "Cigna"
},
"subscriber": {
"memberId": "U7777788888",
"paymentResponsibilityLevelCode": "P",
"subscriberGroupName": "Cigna",
"firstName": "John",
"lastName": "Anon",
"gender": "M",
"dateOfBirth": "20000101",
"groupNumber": "3335555",
"address": {
"address1": "2222 Random St",
"city": "New York",
"state": "NY",
"postalCode": "100130000"
}
},
"billing": {
"providerType": "BillingProvider",
"npi": "1235600834",
"employerId": "832675429",
"taxonomyCode": "2084P0800X",
"organizationName": "Therapy Associates",
"address": {
"address1": "123 Some St",
"address2": "Floor 1",
"city": "New York",
"state": "NY",
"postalCode": "100130000"
},
"contactInformation": {
"name": "Test Data Health Services, Inc.",
"phoneNumber": "5553334444"
}
},
"claimInformation": {
"claimFilingCode": "CI",
"patientControlNumber": "22266555",
"claimChargeAmount": "109.20",
"placeOfServiceCode": "02",
"claimFrequencyCode": "1",
"signatureIndicator": "Y",
"planParticipationCode": "A",
"benefitsAssignmentCertificationIndicator": "Y",
"releaseInformationCode": "Y",
"healthCareCodeInformation": [
{
"diagnosisTypeCode": "ABK",
"diagnosisCode": "F1111"
}
],
"serviceFacilityLocation": {
"organizationName": "Smith Associates",
"address": {
"address1": "1234 Other St",
"city": "New York",
"state": "NY",
"postalCode": "100130000"
},
"npi": "4541648844"
},
"serviceLines": [
{
"serviceDate": "20240101",
"professionalService": {
"procedureIdentifier": "HC",
"procedureCode": "90837",
"procedureModifiers": [
"95"
],
"lineItemChargeAmount": "109.20",
"measurementUnit": "UN",
"serviceUnitCount": "1",
"compositeDiagnosisCodePointers": {
"diagnosisCodePointers": [
"1"
]
}
},
"renderingProvider": {
"providerType": "RenderingProvider",
"npi": "4541648844",
"taxonomyCode": "111YP2000X",
"firstName": "Jane",
"lastName": "Smith"
}
}
]
},
"tradingPartnerName": "Cigna"
}'{
"status": "SUCCESS",
"controlNumber": "555123",
"tradingPartnerServiceId": "6400",
"claimReference": {
"correlationId": "01HTCX97F6XS6F2K22D4KD59TK",
"patientControlNumber": "22266555",
"timeOfResponse": "2024-04-01T13:23:54.255Z",
"payerId": "6400",
"formatVersion": "5010",
"rhclaimNumber": "01HTCX97F6XS6F2K22D4KD59TK"
},
"httpStatusCode": "200 OK",
"meta": {
"traceId": "a7f7c912-77f7-489d-96fc-c4ab3b5c33fc"
},
"payer": {
"payerName": "Cigna",
"payerId": "6400"
}
}