Claims code lists

This page contains code lists that are too long to represent clearly within the API reference documentation. You can find code lists for:

• 837 claims (professional, dental, and institutional)
• 277CA claim acknowledgments
• 835 Electronic Remittance Advice (ERAs)
• 276/277 claim status checks

837 claim code lists

You may need to reference the following code lists when submitting professional, dental, and institutional claims.

Ambulance Certification Condition Codes

Used in the professional claims claimInformation.ambulanceCertification.conditionCodes property.

Ambulance Transport Reason Codes

Used in the professional claims claimInformation.ambulanceTransportInformation.ambulanceTransportReasonCode property.

Attachment Report Type Codes

Used in the following APIs and properties:

• Professional claims claimInformation.serviceLines.serviceLineSupplementalInformation.attachmentReportTypeCode property
• Institutional claims claimInformation.claimSupplementalInformation.reportInformation.attachmentReportTypeCode property
• Dental claims claimInformation.claimSupplementalInformation.reportInformation.attachmentReportTypeCode property. A subset of the codes are supported for dental claims.

Dental

For dental claims, only the following attachment report type codes are supported:

Attachment Transmission Codes

Used in the professional claims claimInformation.serviceLines.durableMedicalEquipmentCertificateOfMedicalNecessity.attachmentTransmissionCode property.

Claim Filing Indicator Codes

Used in the following APIs and properties:

• Professional Claims claimInformation.claimFilingCode and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode properties.
• Institutional Claims claimInformation.claimFilingCode and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode properties.
• Dental Claims claimInformation.claimFilingCode and claimInformation.otherSubscriberInformation.claimFilingIndicatorCode properties.

Choosing the right code

For some payers, the value for claimInformation.claimFilingCode is relatively obvious. For example, if you're submitting a claim to Medicaid California Medi-Cal, then it makes sense to default to populating claimInformation.claimFilingCode with MC (Medicaid).

For other payers, the correct code may be more difficult to determine. For example, if submitting a claim to the Centers for Medicare and Medicaid Services (CMS), you may need to submit MA (Medicare Part A) or MB (Medicare Part B).

In these cases, you can run a real-time eligibility check and evaluate whether the response contains any information that clearly suggests which claim filing code to use. For example, if the eligibility response contains "benefitsInformation.insuranceType" : "Commercial" then you should submit "claimInformation.claimFilingCode": "CI".

One thing to note is that you may not always get back a benefitsInformation.insuranceType value in an eligibility response because payers are not required to send it. In these cases, you can just submit ZZ as the claimFilingCode because the vast majority of payers will accept that value.

Once you use this workflow to determine a best guess for the Claim Filing Indicator Code for each payer, you can try sending a claim.

• Rejection: The rejection message will clearly state that the claim filing indicator code was incorrect, and should state which one to send instead.
• Acceptance: The claim filing indicator code you submitted was correct.

Claim Pricing (Institutional Claims)

For properties in the Institutional Claims claimInformation.claimPricingInformation object and the claimInformation.serviceLines.lineAdjudicationInformation object.

Exception Codes

Used in the institutional claims claimInformation.claimPricingInformation.exceptionCode property.

Policy Compliance Codes

Used in the institutional claims claimInformation.claimPricingInformation.policyComplianceCode and claimInformation.serviceLines.linePricingInformation.policyComplianceCode properties.

Pricing Methodology Codes

Used in the institutional claims claimInformation.claimPricingInformation.pricingMethodologyCode and claimInformation.serviceLines.lineRepricingInformation.pricingMethodologyCode properties.

Product or Service ID Qualifier Codes

Used in the institutional claims properties:

• claimInformation.claimPricingInformation.productOrServiceIDQualifier
• claimInformation.serviceLines.lineAdjudicationInformation.productOrServiceIDQualifier
• claimInformation.serviceLines.institutionalService.procedureIdentifier
• claimInformation.serviceLines.lineRepricingInformation.productOrServiceIDQualifier

Reject Reason Codes

Used in the institutional claims claimInformation.claimPricingInformation.rejectReasonCode and claimInformation.serviceLines.lineRepricingInformation.rejectReasonCode properties.

Composite Medical Procedure - Product or Service ID Qualifier Codes

Used in the professional claims claimInformation.serviceLines.lineAdjudicationInformation.serviceIdQualifier and claimInformation.serviceLines.professionalService.procedureIdentifier properties.

Delay Reason Codes

Used in the following APIs and properties:

• Professional claims claimInformation.delayReasonCode property.
• Institutional claims claimInformation.delayReasonCode property.
• Dental claims claimInformation.delayReasonCode property.

Drug Identification Product or Service ID Qualifier Codes

Used in the professional claims claimInformation.serviceLines.drugIdentification.serviceIdQualifier property.

Individual Relationship Codes

Used in the following APIs and properties:

• Professional claims claimInformation.otherSubscriberInformation.individualRelationshipCode property.
• Institutional claims claimInformation.otherSubscriberInformation.individualRelationshipCode property.
• Dental claims claimInformation.otherSubscriberInformation.individualRelationshipCode property.

Insurance Type Codes

Used in the following APIs and properties:

• Professional claims subscriber.insuranceTypeCode and claimInformation.otherSubscriberInformation.insuranceTypeCode properties.
• Dental claims subscriber.insuranceTypeCode and claimInformation.otherSubscriberInformation.insuranceTypeCode properties.

Payment Responsibility Sequence Number Codes

Used in the following APIs and properties:

• Professional claims subscriber.paymentResponsibilityLevelCode and claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode properties.
• Institutional claims claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode property.
• Dental claims subscriber.paymentResponsibilityLevelCode and claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode properties.

Pricing/Repricing (Professional and Dental Claims)

Used in the professional claims and dental claims APIs.

Exception Codes

Used in the following APIs and properties:

• Professional claims claimInformation.claimPricingRepricingInformation.exceptionCode and claimInformation.serviceLines.linePricingRepricingInformation.exceptionCode properties.
• Dental claims claimInformation.claimPricingRepricingInformation.exceptionCode and claimInformation.serviceLines.linePricingRepricingInformation.exceptionCode properties.

Policy Compliance Codes

Used in the following APIs and properties:

• Professional claims claimInformation.claimPricingRepricingInformation.policyComplianceCode and claimInformation.serviceLines.linePricingRepricingInformation.policyComplianceCode properties.
• Dental claims claimInformation.claimPricingRepricingInformation.policyComplianceCode and claimInformation.serviceLines.linePricingRepricingInformation.policyComplianceCode properties.

Pricing Methodology Codes

Used in the following APIs and properties:

• Professional claims claimInformation.claimPricingRepricingInformation.pricingMethodologyCode and claimInformation.serviceLines.linePricingRepricingInformation.pricingMethodologyCode properties.
• Dental claims claimInformation.claimPricingRepricingInformation.pricingMethodologyCode and claimInformation.serviceLines.linePricingRepricingInformation.pricingMethodologyCode properties.

Reject Reason Codes

Used in the following APIs and properties:

• Professional claims claimInformation.claimPricingRepricingInformation.rejectReasonCode and claimInformation.serviceLines.linePricingRepricingInformation.rejectReasonCode properties.
• Dental claims claimInformation.claimPricingRepricingInformation.rejectReasonCode and claimInformation.serviceLines.linePricingRepricingInformation.rejectReasonCode properties.

Service Authorization Exception Codes

Used in the following APIs and properties:

• Professional claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode property
• Institutional claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode property.
• Dental claims claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode property

Vision Condition Codes

Used in the professional claims claimInformation.patientConditionInformationVision.conditionCodes property.

277CA code lists

You may need to refer to the following code lists while evaluating the 277CA claim acknowledgment.

Claim Status Category Code

A claim's status is reported using a category code, which is returned in multiple locations within the 277CA. For each instance, Stedi returns two properties:

• healthCareClaimStatusCategoryCode: The code, such as A1, P2, or F1.
• healthCareClaimStatusCategoryCodeValue: The description associated with that code.

These values indicate the status of a claim or encounter.

ERA code lists

You may need to refer to the following code lists while evaluating the 835 Electronic Remittance Advice (ERA).

Claim Adjustment Group Code

This code is returned in the transactions.detailInfo.paymentInfo.claimAdjustments.claimAdjustmentGroupCode property. It categorizes the adjustment reason codes returned in the claimAdjustments object.

Claim Adjustment Reason Code (CARC)

This code is returned in the following properties:

• transactions[].detailInfo[].paymentInfo[].claimAdjustments[].adjustmentReasonCode (1-6)
• transactions[].detailInfo[].paymentInfo[].serviceLines[].serviceAdjustments[].adjustmentReasonCode (1-6)

CARCs identify the reason for an adjustment. Visit Claim Adjustment Reason Codes in the X12 documentation for a complete list.

Claim Filing Indicator Code

This code is returned in the transactions.detailInfo.paymentInfo.claimPaymentInfo.claimFilingIndicatorCode property. It identifies the type of claim submitted.

Claim Status Code

This code is returned in the transactions.detailInfo.paymentInfo.claimPaymentInfo.claimStatusCode property. It identifies the status of an entire claim as assigned by the payer, claim review organization, or repricing organization.

Codes 19, 20, and 21 indicate that the claim is a crossover claim that has been forwarded to an additional payer for processing. This practice is common in coordination of benefits (COB) scenarios. You may need to enroll the provider with the additional payer before they can process the claim.

Credit or Debit Flag Code

This code is returned in the transactions.financialInformation.creditOrDebitFlagCode property. It indicates whether the payment is a credit or a debit.

Payment Method Code

This code is returned in the transactions.financialInformation.paymentMethodCode property. It identifies the payment format. Note that the remaining properties in the financialInformation object contain additional requirements and information about the payment.

Provider Adjustment Reason Code

This code is returned in the transactions[].providerAdjustments[].adjustments[].adjustmentReasonCode property.

This code identifies the reason for an adjustment made to the provider's account outside of the claim-level and service-line-level adjustments. The valid codes for X12 release 5010, which Stedi uses for ERAs, differ from the Provider Adjustment Reason Codes list on the X12 website. Use the following code list for ERAs you receive through Stedi.

Remittance Advice Remark Code (RARC)

This code is returned in the following properties:

• transactions[].detailInfo[].paymentInfo[].inpatientAdjudication.claimPaymentRemarkCode (1-6)
• transactions[].detailInfo[].paymentInfo[].outpatientAdjudication.claimPaymentRemarkCode (1-6)
• transactions[].detailInfo[].paymentInfo[].serviceLines[].healthCareCheckRemarkCodes[].remarkCode - this property can either be a RARC or a National Council for Prescription Drug Programs Reject/Payment Code

RARCs provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing.

Visit Remittance Advice Remark Codes in the X12 documentation for a complete list.

Transaction Handling Code

This code is returned in the transactions.financialInformation.transactionHandlingCode property. It indicates the actions taken by both the sender and the receiver.

Claim status code lists

You may need to reference the following code lists when working with the 276/277 claim status request or response.

Claim status

Used in the claims.claimStatus.statusCode property. This is the status code used to identify the status of an entire claim or a service line. For example, code 20 means Accepted for Processing.

This is either a Health Care Claim Status Code or a National Council for Prescription Drug Programs (NCPDP) Reject/Payment Code, when the status is related to pharmacy claims.

• Visit Claim Status Codes in the official X12 documentation for a complete list of Health Care Claim Status Codes.
• Visit the National Council for Prescription Drug Programs website for access to the Reject/Payment Code list.

Claim status category

Used in the claims.claimStatus.statusCategoryCode property. For example, code F1 means Finalized/Revised - Adjudication information has been changed.

Visit Claim Status Category Codes in the official X12 documentation for a complete list.

Product or service ID qualifier

Used in the serviceLineInformation.productOrServiceIDQualifier request property and the claims.serviceDetails.service.serviceIdQualifierCode property in the response.