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Healthcare
EDI platform
Professional Claims
This endpoint sends 837P (professional) claims to payers. Visit Submit claims for a full how-to guide.
- Call this endpoint with a JSON payload.
- Stedi translates your request to the 837 X12 EDI format and sends it to the payer.
- The endpoint returns a response from Stedi in JSON format containing information about the claim you submitted and whether the submission was successful.
This endpoint is a direct replacement for the Change Healthcare (CHC) Claim Submission API.
Enable clearinghouse
Before you can send claims, you must enable the Stedi clearinghouse in your account. Go to EDI Settings and click Enable Stedi Clearinghouse.
Stedi automatically configures the necessary settings to send test and production claims and receive 277 and 835 payer responses.
Identify service lines
A claim can contain multiple service lines. Since the payer may accept, reject, or pay a subset of those lines, you can receive an 835 response that references a patientControlNumber, but only pertains to some of the service lines.
Therefore, even though it is technically an optional field, we strongly recommend including the provider control number as a unique identifier for each service line in your claim submission. This value appears in the 835 response as the lineItemControlNumber, allowing you to correlate the 835 response to the specific service lines from the original claim.
Test claims
To send test claims:
- Set the
Stedi-Partnership-Idheader tolocal-clearinghouse-test. Stedi processes your payload as a test claim and doesn’t send it to the payer. - Set the
Stedi-Transaction-Setting-Idheader to005010X222A1-837. - Set the
usageIndicatorfield in the test claim toT. This allows you to filter for test claims on the Transactions page in the Stedi app.
Note that you will receive a 277 Claim Acknowledgment in response to test claims, allowing you to test your workflow end to end, but you will not receive a test 835 (ERA) response.
Authorizations
API key authentication via the 'Authorization' header
Headers
The partnership ID. Set this to local-clearinghouse for production claims or local-clearinghouse-test for test claims.
The outbound transaction setting ID. Set this to 005010X222A1-837, unless support has specifically instructed you to use a different value.
Body
Not currently used.
This is the Payer ID. Visit the Payer Network for a complete list.
The entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company.
The business name of the organization submitting the claim.
The last name of the individual submitting the claim.
The first name of the individual submitting the claim.
The middle name or initial of the individual submitting the claim.
The submitter identification number. If not provided, Stedi uses the billing provider's NPI.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The entity responsible for the payment of the claim, such as an insurance company or government agency.
The business name of the payer receiving the claim, such as Aetna or Cigna.
The person or entity who is the primary policyholder for the insurance plan.
The member ID for the subscriber's insurance policy.
The subscriber's Social Security Number. This must be a string of exactly nine numbers with no separators. For example, send 111002222 instead of 111-00-2222.
Identifies the insurance company's level of responsibility for claim payment. Can be set to: 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. The U option is only used in payer to payer claims.
A, B, C, D, E, F, G, H, P, S, T, U The business name of the entity submitting the claim. When the subscriber is an organization, you should identify the patient in the dependent object.
Identifies the type of insurance policy within a specific insurance program. Visit SBR05 in the Professional Claim specification for a complete list.
12, 13, 14, 15, 16, 41, 42, 43, 47 The name of the subscriber's insurance plan. For example, Cigna or Blue Cross Blue Shield.
The subscriber's first name.
The subscriber's last name.
The subscriber's middle name or initial.
The suffix of the subscriber's name, such as Jr. or Sr.
Identifies the subscriber's gender. Can be set to F - Female, M - Male, or U - Unknown.
M, F, U The subscriber's date of birth. Expressed in format YYYYMMDD.
The subscriber's insurance plan policy number. You should provide either this field OR the groupNumber, not both.
The subscriber's insurance plan group number. You should provide this field OR the policyNumber, not both.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Dependents of the subscriber who received the medical care associated with the healthcare claim.
The patient's first name.
The patient's last name.
The patient's middle name or initial.
The patient's name suffix, such as Jr. or III.
Code indiciating the patient's gender. Can be set to F - Female, M - Male, or U - Unknown.
M, F, U The patient's date of birth, formatted as YYYYMMDD.
The patient's Social Security Number. Only used for Property and Casualty claims. The Social Security Number must be a string of exactly nine numbers with no separators. For example 123456789.
The patient's identification number. Only used in Property and Casualty claims.
Identifies the relationship of the patient to the subscriber. Can be set to 01 - Spouse, 19 - Child, 20 - Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
01, 19, 20, 21, 39, 40, 53, G8 The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Deprecated; please set all providers individually by type. For example, Referring.
The National Provider Identifier (NPI) of the supervising provider. The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards.
The social security number. Must be a string of nine numbers with no separators.
Employer ID number is typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer.
The commercial number of the supervising provider.
The location number of the supervising provider.
The state license number of the supervising provider.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The first name of the supervising provider.
The last name of the supervising provider.
The middle name or initial of the supervising provider.
The suffix of the supervising provider's name, such as Jr. or III.
The supervising provider's business name, when the provider is not an individual.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
Information about the healthcare claim.
A code identifying the type of claim. For example DS - Disability. Use OF when submitting Medicare Part D claims. Use ZZ when you don't know the type of insurance. Visit SBR09 in the Professional Claim specification for a complete list.
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ The agency claim number for this transaction. Used when services included in this claim are part of a property and casualty claim.
The patient's date of death, formatted as YYYYMMDD.
The patient's weight in pounds. Enter as a decimal, such as 150.5.
Code indicating whether the patient is pregnant. Can be set to Y - Yes.
Y An identifier you assign to the claim. It can be up to 20 characters. We strongly recommend submitting a unique value for this field so that you can use it to correlate this claim with responses from the payer, such as the 835 Electronic Remittance Advice (ERA).
The total dollar amount charged for the services on this claim, expressed as a decimal. For example, 100.50. This is the total amount before any adjustments or payments. The amount must balance to the sum of the service line charges.
Code identifying the type of facility where the services were or may be performed.
01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 65, 66, 71, 72, 81, 99 Code specifying the frequency of the claim. This is the third position of the Uniform Billing Claim Form Bill Type.
Indicates whether the provider's signature is on file. Can be set to N - No or Y - Yes.
N, Y Code indicating whether the provider accepts assignment. This refers to whether the provider accepts assignment and/or has a participation agreement with the destination payer. It does not indicate whether the patient has assigned benefits to the provider. Can be set to A - Assigned, B - Assignment Accepted on Clinical Lab Services Only, or C - Not Assigned. Choose A when the provider accepts assignment and/or has a participation agreement with the destination payer, OR the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under the participating provider benefits allowed under certain plans.
A, B, C A code indicating whether the patient or an authorized person has assigned benefits to the provider. Use W when the patient refuses to assign benefits. Can be set to N - No, Y - Yes, or W - Not Applicable (use when patient refuses to assign benefits).
N, W, Y Indicates whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to Y - Yes, or I - Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues. Use I when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
I, Y Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. Can be set tp P - Signature generated by provider because the patient was not physically present for services. This means the signature was generated by an entity other than the patient according to State or Federal law.
Code identifying an accompanying cause of an illness, injury or an accident. Can be set to AA - Auto Accident, EM - Employment, or OA - Other Accident.
AA, EM, OA A code identifying the state or province in which the automobile accident occurred. Use this code when relatedCausesCode is set to AA.
AA, EM, OA The country code where the accident occurred. Use when relatedCausesCode = AA and the accident occurred in a country other than US or Canada.
Code indicating the Special Program under which the services rendered to the patient were performed. Used for Medicaid claims only. Can be set to 02 - Physically Handicapped Children's Program, 03 - Special Federal Funding, 05 - Disability, or 09 - Second Opinion or Surgery.
02, 03, 05, 09 Code indicating the reason for the delay in claim submission. Visit CLM20 in the Professional Claim specification for a complete list.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 The total amount in dollars the patient or their representatives have paid on this claim. For example, 20.50.
Used to send additional data specifically requested by the payer. Not commonly used.
You must provide at least one date related to the claim. For example, the date on which the patient was admitted to the hospital. All dates are formatted as YYYYMMDD.
The date the patient began experiencing acute symptoms for the current illness or condition. Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service.
The date the patient first received treatment for the current illness or condition. Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy.
The date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Required when claims involve services for routine foot care and this date is known to impact the payer's adjudication process.
The date the patient first experienced acute symptoms for a chronic condition. Required when the patientConditionCode = A (Acute Condition) or M (Acute Manifestation of a Chronic Condition), the claim involves spinal manipulation, and the payer is Medicare.
The date of the accident related to this claim. Required when relatedCausesCode is set to AA - Auto Accident or OA - Other Accident. Also required when relatedCausesCode is set to EM - Employment and this claim is the result of an accident.
The date of the patient's last menstrual period. Required when the provider believes the services on this claim are related to the patient's pregnancy.
The date of the patient's last x-ray. Required when claim involves spinal manipulation and an x-ray was taken.
The date of the patient's hearing and vision prescription. Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim.
The start date of the patient's disability period. You can include this date without providing a disabilityEndDate if the patient is currently disabled and the end date is unknown. Used for claims involving disability where the provider judges that the patient was or will be unable to perform the duties normally associated with their work.
The end date of the patient's disability period. You can include this date without including a disabilityStartDate if the patient is no longer disabled and the start date is unknown. Used for claims involving disability where the provider judges that the patient was or will be unable to perform the duties normally associated with their work.
The date the patient last worked, related to disability claims. Required on claims where this information is necessary for adjudication, such as workers compensation claims.
The date the provider has authorized the patient to return to work. Required on claims where this information is necessary for adjudication, such as workers compensation claims.
The date the patient was admitted to the hospital. Required on ambulance claims when the patient was known to be admitted to the hospital. Also required on inpatient claims.
The date the patient was discharged from the hospital. Required for inpatient claims when the patient was discharged from the facility and the discharge date is known
The the date the provider filing this claim assumed care from another provider during post-operative care. Required when providers share post-operative care (global surgery claims).
The date the provider filing this claim relinquished post-operative care to another provider. Required when providers share post-operative care (global surgery claims).
The date the repricing entity received the initial claim. Required when a repricer is passing the claim onto the payer.
Date the patient first consulted the provider for their condition by any means. This is not necessarily the same as the initial treatment date. Required for Property and Casualty claims when state mandated.
Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.
A code identifying the type of contract. Can be set to 01 - Diagnosis Related Group (DRG), 02 - Per Diem, 03 - Variable Per Diem, 04 - Flat, 05 - Capitated, 06 - Percent, or 09 - Other.
01, 02, 03, 04, 05, 06, 09 The total dollar amount of the contract, expressed as a decimal. For example, 100.50.
The allowance or charge percent, expressed as a decimal. For example, 0.80.
The contract code. This is a unique identifier for the contract.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date.
An additional identifer for the contract. Identifies the revision level of a particular format, program, technique or algorithm.
Additional information or documentation required for the claim.
Required when there is a paper attachment following this claim, when attachments are sent electronically with the claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit PWK01 in the Professional Claim specification for a complete list.
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 Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
AA, BM, EL, EM, FT, FX The control number assigned to the attachment.
Required when an authorization number is assigned by the payer or UMO and the services on this claim were preauthorized. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information.
Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) and a referral is involved.
Required when the claimFrequencyCode indicates this claim is a replacement or void to a previously adjudicated claim.
Required for all CLIA certified facilities performing CLIA covered laboratory services. When this claim contains both in-house and outsourced laboratory services, use the the CLIA Number for laboratory services performed by the billing or rendering provider. You can report outsourced laboratory services in the serviceLines object.
Required when the repricer believes this information is necessary. Providers should not complete this field.
Required when the repricer believes this information is necessary. Providers should not complete this field.
Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, you must split into separate claims.
The claim number assigned by clearinghouse, van, etc. Providers should not complete this field.
Required when mammography services are rendered by a certified mammography provider.
Required when the provider needs to identify the actual medical record of the patient for this episode of care.
Required when it is necessary to identify claims that are atypical in ways such as content, purpose, and/or payment. For example, claims made as the result of a demonstration or a clinical trial.
Required when the physician is billing Medicare for Care Plan Oversight (CPO). This is the number of the home health agency or hospice providing Medicare covered services to the patient.
Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim.
Code indicating the reason for the service authorization exception. Visit REF02 in the Professional Claim specification for a complete list.
1, 2, 3, 4, 5, 6, 7 Comments or special instructions related to the claim. Contains information required to substantiate the medical treatment that isn't provided elsewhere in the claim.
Additional information.
Certification narrative.
Information about goals, rehabilitation potential, or discharge plans.
Additional information about the diagnosis.
Notes from a third-party organization.
Information about the ambulance service provided to the patient.
The weight of the patient, in pounds, at the time of transport. Provide this value as a decimal, such as 150.5
Code indicating the reason for ambulance transport. For example, A - Patient was transported to nearest facility for care of symptoms, complaints, or both. Visit CR104 in the Professional Claim specification for a complete list.
A, B, C, D, E The number of miles the ambulance traveled to transport the patient. Provide this value as a decimal, such as 20.5. Note that 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
The reason for the round trip ambulance service.
The reason for usage of a stretcher during ambulance service.
Information about a chiropractic service rendered to the patient. Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process.
A code indicating the nature of a patient's condition. Visit CR208 in the Professional Claim specification for a complete list.
A description of the patient's condition.
A, C, D, E, F, G, M Additional description of the patient's condition
Required when the claim involves ambulance transport services.
Code indicating whether there is an ambulance certification.
N, Y Code indicating the condition of the patient at the time of tramsport. Visit CRC03 in the Professional Claim specification for a complete list.
01, 04, 05, 06, 07, 08, 09, 12 Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement.
Identifies the category to which the conditionCode applies. Can be set to E1 - Spectacle Lenses, E2 - Contact Lenses, or E3 - Spectacle Frames.
E1, E2, E3 Code indicating whether there is a certification. Can be set to N - No or Y - Yes.
N, Y Code indicating the reason for the vision services. Visit CRC03 in the Professional Claim specification for a complete list.
L1, L2, L3, L4, L5 Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient.
Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim.
Code indicating whether an EPSDT referral was given to the patient. Can be set to N - No or Y - Yes.
N, Y Code indicating the patient's status. Set to AV when the patient refused the referral. Set to NU when you set certificationConditionCodeAppliesIndicator to N. Set to S2 when the patient is currently under treatment for the referred diagnostic or corrective health problem. Set to ST when either the patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals) or the patient is scheduled for another appointment with the screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
AV, NU, S2, ST Details about the patient's healthcare diagnosis. Use ABK as the type for the principal diagnosis code and ABF for any other diagnosis codes you include. One ABK code is required as the first object, and then you can submit up to 11 ABF codes as needed. If you need to submit more codes than this, you must create additional, separate claims.
Code indicating the specific industry code list. Can be set to ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or ABF - International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis.
BK, ABK, BF, ABF The diagnosis code.
The surgical code. Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code.
The condition code. Required when condition information applies to the claim.
Repricing information about the claim or a line item. This information is completed by repricers, not providers. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code indicating the pricing or repricing methodology. Visit the HCP01 in the Professional Claim specification for a complete list.
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 The dollar amount, expressed as a decimal. For example, 100.50.
The dollar amount, expressed as a decimal.
The identifier of the organization that repriced the claim.
The the pricing rate associated with per diem or flat rate repricing, expressed as a decimal.
The code indicating the type of repricing.
The dollar amount, expressed as a decimal.
Code indicating the rejection message returned from the third party organization. Visit HCP13 in the Professional Claim specification for a complete list.
T1, T2, T3, T4, T5, T6 Code indicating the policy compliance. Visit HCP14 in the Professional Claim specification for a complete list.
1, 2, 3, 4, 5 Code specifying the exception reason for consideration of out-of-network health care services. This is the reason generated by the third-party health organization. Visit HCP15 in the Professional Claim specification for a complete list.
1, 2, 3, 4, 5, 6 Required when the location for the service is different from the billing provider's address. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use ambulancePickupLocation and ambulanceDropoffLocation instead.
The last name (if the provider was an individual) or the organization's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The National Provider Identifier (NPI) assigned to the provider.
Secondary identifier for the service facility location. Used when another identifier is needed for the claims processor to identify the facility or when the entity is not a healthcare provider and does not have an NPI.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the country or area code. For example, you would format the phone number `123-456-789. Do not submit long distance access numbers, such as 1, in the telephone number.
The telephone extension, if applicable.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Required when other payers are known to potentially be involved in paying on this claim.
Code identifying the insurance carrier's level of responsibility for a payment of a claim. Visit SBR01 in the Professional Claim specification for a complete list.
A, B, C, D, E, F, G, H, P, S, T, U Code identifying the the relationship to the person insured. Visit SBR02 in the Professional Claim specification for a complete list.
01, 18, 19, 20, 21, 39, 40, 53, G8 The group or policy number.
The name of the insurance plan.
Code identifying the type of insurance policy within a specific insurance program. Visit SBR05 in the Professional Claim specification for a complete list.
12, 13, 14, 15, 16, 41, 42, 43, 47 A code identifying the type of claim. For example DS - Disability. Use OF when submitting Medicare Part D claims. Use ZZ when you don't know the type of insurance. Visit SBR09 in the Professional Claim specification for a complete list.
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ Use this object to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, you must convert them to standard Claim Adjustment Reason Codes.
Code identifying the general category of payment adjustment. Visit CAS01 in the Professional Claim specification for a complete list.
CO, CR, OA, PI, PR Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.
The dollar amount of the adjustment, expressed as a decimal. For example, 100.50.
The units of service being adjusted.
The total amount in dollars the payer has paid on this claim. It is acceptable to set this to 0 (Zero). This is required when you include the payToPlan object, and you should set it to the amount the Medicaid agency actually paid.
Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in otherSubscriberInformation.otherPayerName. The amount must equal the total claim charge amount you reported in claimInformation.claimChargeAmount.
This is the remaining amount (as determined by the provider) to be paid after the other payer identified in the otherPayerName object has adjudicated the claim.
Code indicating whether whether or not the insured has authorized the plan to remit payment directly to the provider. Can be set to N - No, W - Not Applicable, or Y - Yes.
N, W, Y Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. Can be set to P - Signature generated by provider because the patient was not physically present for services. This means the signature was generated by an entity other than the patient according to State or Federal law.
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to I - Informed Consent to Release Medical Information or Y - Yes. Set to I when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
I, Y Claim-level data related to the adjudication of Medicare claims not related to an inpatient setting. Required when outpatient adjudication information is reported in the remittance advice or when you need to report remark codes.
The reimbursement percentage, expressed as a decimal.
The the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount, expressed as a decimal.
The remark code. Visit the X12 Remittance Advice Remark Codes for a complete list.
The End-Stage Renal Disease (ESRD) payment amount, expressed as a decimal.
The the professional component amount billed but not payable, expressed as a decimal.
The person or entity who is the primary policyholder for the insurance plan.
Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.
1, 2 The primary policyholder's last name or organizational name.
The primary policyholder's first name, if they are an individual.
The primary policyholder's middle name or initial, if they are an individual.
The primary policyholder's name suffix, such as Jr. or III.
Code identifying the type of identifier. Can be set to II - Standard Unique Health Identifier for each individual in the United States or MI - Member Identification Number. The code MI should be the subscriber's identification number as assigned by the payer, such as their subscriber ID. You should also use MI in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). For IHS/CHS claims, you should also put the SSN in the otherInsuredAdditionalIdentifier field.)
II, MI The identifier you specified in otherInsuredIdentifierTypeCode.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The primary policyholder's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. For example 123456789.
Details about the other payer.
The payer's organization name.
Code designating the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
PI, XV The identifier specified in otherPayerIdentifierCode. When sending Line Adjudication Information for this payer, the identifier sent in lineAdjudicationInformation.otherPayerPrimaryIdentifier must match this value.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The date the other payer adjudicated the claim. Required when this payer has previously adjudicated the claim and you aren’t including a value for LineAdjudicationInformation.adjudicationOrPaymentDate.
An additional identication number to identify the other payer.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
The authorization number assigned by this payer.
The referral number assigned by this payer.
The only valid value is true. Required when Required when the claim is being sent in the payer-to-payer COB model AND the destination payer is secondary to this payer AND this payer has re-adjudicated the claim.
The claim control number assigned by this payer.
Information about the referring provider.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
Information about the rendering provider.
Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.
1, 2 The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
Information about the service facility location.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
Information about the supervising provider.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
Information about the billing provider.
Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.
1, 2 The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
Information about one or more services rendered to the patient. Each service line must be a unique procedure. Service lines can share the same dates of service if the patient received multiple services on the same day.
This serves as a line counter. It must begin with 1 and be incremented by one for each additional service line of the claim.
The date the service was rendered (for services performed on a single day), expressed as YYYYMMDD. When you send this field with serviceEndDate, it will be used as the start date for the date range in which the service was rendered.
The end date of the service period, expressed as YYYYMMDD. If you send this field, you must also send serviceDate.
A unique identifier for this service line within the claim. We strongly recommend setting this field for each service line. It appears in the 835 (ERA) response as lineItemControlNumber, allowing you to correlate ERAs to the specific service lines from the original claim.
Information about the service rendered.
Code identifying the specific industry code list used for the procedureCode. Visit C00301 in the Professional Claim specification for a complete list.
ER, HC, IV, WK The procedure code.
A modifier code that clarifies or improves the reporting accuracy of the associated procedure code. If not required, do not send.
A free form description to clarify the procedure code and any procedure modifiers, as needed.
The total charge amount for the service, including the provider's base charge and any applicable tax or postage. It is acceptable to set this to 0 (zero).
Code identifying the unit of measurement. Can be set to MJ - Minutes or UN - Unit. Minutes is required for anesthesia services. Note that anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel.
MJ, UN The number of units of the service provided, formatted as a decimal.
A code identifying the location where services were rendered. Visit Place of Service Codes for a complete list.
Diagnosis codes in order of importance to this service line. The first diagnosis code is the primary diagnosis code.
A diagnosis code for this service line.
Code indicating whether the service was related to an emergency. Can be set to Y - Yes. An emergency is when the patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions.
Y Code indicating whether there was EPSDT involvement in the service. Can be set to Y - Yes. EPSDT is a program that provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.
Y Code indicating whether the service was related to family planning. Can be set to Y - Yes.
Y Code indicating whether co-payment requirements were met. Can be set to O - Copay exempt.
0 Information about durable medical equipment. For example, the rental and purchase price information.
The length of medical treatment required.
The rental price for the equipment, expressed as a decimal. For example, 100.50.
The purchase price for the equipment, expressed as a decimal. For example, 100.50.
Code indicating the frequency at which the rental equipment is billed. Can be set to 1 - weekly, 4 - monthly, or 6 - daily.
1, 4, 6 Supporting documentation for the service line. Required when there is a paper attachment following this claim, when attachments are sent electronically, or when the provider needs to identify additional information that is being held at their office and is available upon request.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit PWK01 in the Professional Claim specification for a complete list.
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 Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
AA, BM, EL, EM, FT, FX The control number assigned to the attachment.
Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN).
Code indicating the timing, transmission method, or format by which attachments will be sent. Required when the actual attachment is maintained by an attachment warehouse or similar vendor. Visit PWK02 in the Professional Claim specification for a complete list. Use code NS when the paperwork is available on request at the provider's site, but is not being sent with the claim at this time.
AB, AD, AF, AG, NS Information about the ambulance service provided to the patient.
The weight of the patient, in pounds, at the time of transport. Provide this value as a decimal, such as 150.5
Code indicating the reason for ambulance transport. For example, A - Patient was transported to nearest facility for care of symptoms, complaints, or both. Visit CR104 in the Professional Claim specification for a complete list.
A, B, C, D, E The number of miles the ambulance traveled to transport the patient. Provide this value as a decimal, such as 20.5. Note that 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
The reason for the round trip ambulance service.
The reason for usage of a stretcher during ambulance service.
Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line.
Code indicating the type of certification. Can be set to I - Initial, R - Renewal, or S - Revised.
I, R, S The length of time the DME equipment is needed.
Code indicating whether there is an ambulance certification.
N, Y Code indicating the condition of the patient at the time of tramsport. Visit CRC03 in the Professional Claim specification for a complete list.
01, 04, 05, 06, 07, 08, 09, 12 Whether the rendering provider is a hospice employee. Required on all Medicare claims involving physician services to hospice patients. Set to true if the rendering provider is a hospice employee, and false if they are not.
Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication.
Code indicating whether there is a certification. Can be set to N - No or Y - Yes.
Y, N Code indicating the condition of the certificate. Can be set to 38 - Certification signed by the physician is on file at the supplier's office or ZV - Replacement Item.
38, ZV A second code indicating the condition of the certificate. Can be set to 38 - Certification signed by the physician is on file at the supplier's office or ZV - Replacement Item.
38, ZV Identify specific dates related to the service rendered, formatted as YYYYMMDD.
Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written).
Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line.
This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF).
This is the date of the latest visit or consultation.
Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported.
Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported.
Required when billing or reporting products that were shipped.
Required for claims involving spinal manipulation.
Required when this date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology.
The number of patients transported by the ambulance. Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services.
The number of units reported by an anesthesia provider to reflect additional complexity of services.
Required on Dialysis related service lines for ESRD, or required on on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier.
Code identifying the type of measurement. Can be set to OG - Original or TR - Test Results.
OG, TR Code identifying the specific measurement. Can be set to HT - Height, R1 - Hemoglobin, R2 - Hematocrit, R3 - Epoetin Starting Dosage, or R4 - Creatinine.
HT, R1, R2, R3, R4 The value of the measurement.
Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.
Code indicating the type of contract. Visit CN101 in the Professional Claims specification for a complete list.
01, 02, 03, 04, 05, 06, 09 The total dollar amount of the contract, expressed as a decimal. For example, 100.50.
The allowance or charge percent, expressed as a decimal. For example, 0.80.
The contract code. This is an identifier for the contract.
Terms discount percentage, expressed as a decimal, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date.
An additional identifier for the contract. Identifies the revision level of a particular format, program, technique or algorithm.
Additional identifiers for the service line.
Required when a repricing (pricing) organization needs to have an identifying number on the service line.
Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line.
This must match the value in claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifier.
Sales tax, formatted as a decimal. When you include this field, the total lineItemChargeAmount for this service line must include this sales tax value.
The amount of the postage, formatted as a decimal. When you include this field, the total lineItemChargeAmount for this service line must include this postage value.
Used to send additional data specifically requested by the payer. Not commonly used.
Additional information the provider feels is necessary to substantiate the medical treatment that cannot be provided in other claim fields. Don't use this field to describe non-specific procedure codes.
The provider's goals, rehabilitation potential, or discharge plans for the patient.
Required when the TPO/repricer needs to forward additional information to the payer. Providers shouldn't complete this field.
Specify information about services that were purchased.
The identifier for the purchased service provider.
The cost of the purchased service.
Repricing information about the claim or a line item. This information is completed by repricers, not providers. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code indicating the pricing or repricing methodology. Visit the HCP01 in the Professional Claim specification for a complete list.
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 The dollar amount, expressed as a decimal. For example, 100.50.
The dollar amount, expressed as a decimal.
The identifier of the organization that repriced the claim.
The the pricing rate associated with per diem or flat rate repricing, expressed as a decimal.
The code indicating the type of repricing.
The dollar amount, expressed as a decimal.
Code indicating the rejection message returned from the third party organization. Visit HCP13 in the Professional Claim specification for a complete list.
T1, T2, T3, T4, T5, T6 Code indicating the policy compliance. Visit HCP14 in the Professional Claim specification for a complete list.
1, 2, 3, 4, 5 Code specifying the exception reason for consideration of out-of-network health care services. This is the reason generated by the third-party health organization. Visit HCP15 in the Professional Claim specification for a complete list.
1, 2, 3, 4, 5, 6 To report prescribed drugs and biologics.
Code indicating the source of the drug code or product number. Visit LIN02 in the Professional Claim specification for a complete list.
EN, EO, HI, N4, ON, UK, UP The numeric value of the drug quantity.
Code identifying the unit of measurement. Can be set to F2 - International Unit, GR - Gram, ME - Milligram, ML - Milliliter, or UN - Unit.
F2, GR, ME, ML, UN Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. The link sequence number is a provider assigned number that is unique to this claim. It allows the receiver to piece together the components of the compound.
In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
The National Provider Identifier (NPI) assigned to the provider.
The National Association of Insurance Commissioners (NAIC) code.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
The National Provider Identifier (NPI) assigned to the provider.
The National Association of Insurance Commissioners (NAIC) code.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
Required when the location for the service is different from the billing provider's address. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use ambulancePickupLocation and ambulanceDropoffLocation instead.
The last name (if the provider was an individual) or the organization's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The National Provider Identifier (NPI) assigned to the provider.
Secondary identifier for the service facility location. Used when another identifier is needed for the claims processor to identify the facility or when the entity is not a healthcare provider and does not have an NPI.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the country or area code. For example, you would format the phone number `123-456-789. Do not submit long distance access numbers, such as 1, in the telephone number.
The telephone extension, if applicable.
The National Provider Identifier (NPI) assigned to the provider.
The National Association of Insurance Commissioners (NAIC) code.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
Set to OrderingProvider.
The National Provider Identifier (NPI) assigned to the provider.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number, formatted as AAABBBCCCC.
The email address.
The phone extension, if applicable.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
The National Provider Identifier (NPI) assigned to the provider.
The National Association of Insurance Commissioners (NAIC) code.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The code identifying the type of reference number. Can be set to G2 - Provider Commercial Number or LU - Location Number.
The reference number.
An additional identifier.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Includes service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers.
The payer ID for the payer responsible for reimbursement.
The amount paid for this service line, expressed as a decimal. Zero (0) is an acceptable value.
Code identifying the type of procedureCode. Visit C00301 in the Professional Claim specification for a complete list.
ER, HC, HP, IV, WK The procedure code.
A modifier that conveys special circumstances related to the performance of the service.
The meaning of the procedure code.
The number of paid units from the remittance advice. expressed as a decimal. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
The LX assigned number of the service line into which this service line is bundled. It's only used to bundle service lines.
Required when the payer made line level adjustments which caused the amount paid to differ from the amount originally charged.
Code identifying the general category of payment adjustment. Visit CAS01 in the Professional Claim specification for a complete list.
CO, CR, OA, PI, PR Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.
The dollar amount of the adjustment, expressed as a decimal. For example, 100.50.
The units of service being adjusted.
The date the other payer adjudicated or paid the claim, formatted as YYYYMMDD.
The amount of the service line that the other payer is responsible for, expressed as a decimal.
Use this object to attach standardized supplemental information to the claim when required by the payer. One example is payer documentation requirements for home health services.
Code indicating the type of form. Can be set to AS - Form Type Code or UT - Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms. Set this to AS when you plan to include a home health form in the formIdentifier field.
AS, UT A code from the industry code list you identified in formTypeCode.
Use to provide information in response to a coded questionnaire document.
Code indicating a yes or no condition response to the question. Can be set to N - No, W - Not Applicable, or Y - Yes.
N, W, Y A text response to the question.
Date expressed as YYYYMMDD.
Percent formatted as a decimal.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Use for subrogation payment requests. If you include this information, you must also set the claimInformation.otherSubscriberInformation.payerPaidAmount to the amount the payer (for example, Medicaid) actually paid.
The last name of the individual, or the business name of the pay-to-plan organization.
Code identifying the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
PI, XV The identifier you specified in primaryIdentifierTypeCode.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
Code identifying the type of secondary identifier. Can be set to 2U - Payer Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners. You should only set this to 2U when you set the primaryIdentifierTypeCode to XV.
2U, FY, NF The secondary identifier you specified in secondaryIdentifierTypeCode.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
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.
Information about the billing provider.
Set to BillingProvider.
The billing provider's National Provider Identifier (NPI).
The billing provider's Social Security Number. Must be a string of exactly nine numbers with no separators.
The billing provider's Employer Identification Number. Typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer.
The billing provider's state license number.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the billing provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The billing provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
Information about the referring provider.
Set to ReferringProvider.
The National Provider Identifier (NPI) assigned to the provider.
The provider's commercial number.
The provider's state license number.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
Information about the person or company (laboratory or other facility) who rendered the care. Use this object for all types of rendering providers including laboratories. When a substitute provider (locum tenens) was used, enter that provider's information here.
Set to RenderingProvider.
The National Provider Identifier (NPI) assigned to the provider.
The provider's commercial number.
The provider's location number.
The provider's state license number.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The provider's first name, if the provider is an individual.
The provider's last name, if the provider is an individual.
The provider's middle name or initial, if the provider is an individual.
The provider's name suffix, such as Jr. or III.
The provider's business name.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
Deprecated; please use ClaimInformation.serviceLines.orderingProvider instead.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
The entity responsible for supervising the healthcare services provided. Applies when the rendering provider is supervised by a physician.
The National Provider Identifier (NPI) of the supervising provider. The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards.
The social security number. Must be a string of nine numbers with no separators.
Employer ID number is typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer.
The commercial number of the supervising provider.
The location number of the supervising provider.
The state license number of the supervising provider.
Deprecated; do not use.
Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 207QG0300X is for geriatric medicine.
The first name of the supervising provider.
The last name of the supervising provider.
The middle name or initial of the supervising provider.
The suffix of the supervising provider's name, such as Jr. or III.
The supervising provider's business name, when the provider is not an individual.
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
The state or province code. Only required when the city is in the Unites States and Canada.
The postal zone or zip code. Exclude punctuation and spaces.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code. For example, you would format the phone number 123-456-7890 as 1234567890. You should always include the area code, if applicable. Don't include long distance access numbers (such as 1) or extensions in this field.
The fax number.
The email address.
The phone extension, if applicable.
This is the Payer ID. Visit the Payer Network for a complete list.
Response
The status of the claim submission.
An identifier for the transaction.
An ID for the payer you identified in the original claim. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.
Information about the claim.
An identifier Stedi assigns to the claim.
Stedi's ID for the entity that submitted the claim.
A tracking number that Stedi assigns to the claim.
The patientControlNumber from the original request, if supplied. This is a unique identifier that you assign to the claim so you can track the claim and correlate it with responses from the payer.
A timestamp for Stedi's response to the claim submission.
The type of claim, currently not used.
The ID of the payer. This is the same as the tradingPartnerServiceId.
The X12 EDI version Stedi used to generate the claim for the payer. This is always 5010.
A tracking number Stedi assigns to the claim. This is the same as the correlationId.
A list of errors. Currently not used.
The field related to the error.
The value for the data causing the error.
The error code.
The description of the error code.
Recommended followup actions to correct the error.
Where the error is located in the original request.
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 Metadata from Stedi about the request.
The submitter ID assigned to this request.
The sender ID assigned to this request.
The biller ID assigned to this request.
The file execution ID, a unique identifier assigned to the processed file within the Stedi platform.
Indicates where this request can be found for support.
Currently not used.
Currently not used.
Information about the payer for the submitted claim.
The payer's business name, such as Aetna or Cigna.
The payer's ID. This is the same as the tradingPartnerServiceId.
Currently not used.
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