ADI Health care claim adjudication information

To provide adjudication information for all services in a health care claim.

Position
Element
Name
Type
Requirement
Min
Max
Repeat
010
Object identification
Composite (composite)
Mandatory
3
010
Object identifier
String (AN)
Mandatory
1
35
-
Code specifying the unique identity of an object.
020
Object identification code qualifier
String (AN)
Conditional
1
3
-
Code qualifying the identification of an object.
030
Status description code
String (AN)
Conditional
1
3
-
Code specifying a status.
1 For transport status, use UN/ECE Recommendation 24.
020
Service
Composite (composite)
Conditional
3
010
Product identifier
String (AN)
Mandatory
1
35
-
To identify a product.
020
Code list identification code
String (AN)
Conditional
1
17
-
Code identifying a user or association maintained code list.
1 The codes for this data element are provided by the code list responsible agency defined in data element 3055.
030
Procedure modification code
String (AN)
Conditional
1
3
-
Code specifying the procedure modification.
040
Procedure modification code
String (AN)
Conditional
1
3
-
Code specifying the procedure modification.
050
Procedure modification code
String (AN)
Conditional
1
3
-
Code specifying the procedure modification.
060
Procedure modification code
String (AN)
Conditional
1
3
-
Code specifying the procedure modification.
030
Action request/notification description code
String (AN)
Conditional
1
3
1
Code specifying the action to be taken or already taken.
040
Monetary amount
Composite (composite)
Conditional
15
010
Monetary amount type code qualifier
String (AN)
Conditional
1
3
-
Code qualifying the type of monetary amount.
020
Monetary amount
Numeric (N)
Conditional
1
35
-
To specify a monetary amount.
030
Currency identification code
String (AN)
Conditional
1
3
-
Code specifying a monetary unit.
1 Use ISO 4217 three alpha code.
040
Currency type code qualifier
String (AN)
Conditional
1
3
-
Code qualifying the type of currency.
050
Status description code
String (AN)
Conditional
1
3
-
Code specifying a status.
1 For transport status, use UN/ECE Recommendation 24.
050
Quantity
String (AN)
Conditional
1
35
3
Alphanumeric representation of a quantity.
060
Adjustment information
Composite (composite)
Conditional
15
010
Adjustment category code
String (AN)
Mandatory
1
3
-
Code specifying the general category of adjustment.
020
Adjustment reason description code
String (AN)
Mandatory
1
3
-
Code specifying the adjustment reason.
030
Monetary amount
Numeric (N)
Conditional
1
35
-
To specify a monetary amount.
070
Policy limitation identifier
String (AN)
Conditional
1
10
4
Code specifying a policy limitation.
080
Product group name code
String (AN)
Conditional
1
25
1
Code specifying the name of a product group.
090
Date/time/period
Composite (composite)
Conditional
1
010
Date or time or period function code qualifier
String (AN)
Mandatory
1
3
-
Code qualifying the function of a date, time or period.
020
Date or time or period text
String (AN)
Conditional
1
35
-
The value of a date, a date and time, a time or of a period in a specified representation.
030
Date or time or period format code
String (AN)
Conditional
1
3
-
Code specifying the representation of a date, time or period.
100
Diagnosis category code
String (AN)
Conditional
1
3
1
Code specifying a diagnosis category.
110
Percentage
Numeric (N)
Conditional
1
10
1
To specify a percentage.

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