EDI
API DocsTerminal

CLM Health Claim

To specify basic data about the claim

Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
1028
Claim Submitter's Identifier
String (AN)
Mandatory
1
38
1
Identifier used to track a claim from creation by the health care provider through payment
02
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
CLM02 is the total amount of all submitted charges of service segments for this claim.
03
Claim Filing Indicator Code
Identifier (ID)
Optional
1
2
1
Code identifying type of claim
Codes (48)
04
Non-Institutional Claim Type Code
Identifier (ID)
Optional
1
2
1
Code identifying the type of provider or claim
Codes (47)
05
Health Care Service Location Information
Composite (composite)
Optional
1
01
Facility Code Value
String (AN)
Mandatory
1
2
-
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
02
Facility Code Qualifier
Identifier (ID)
Optional
1
2
-
Code identifying the type of facility referenced
C023-02 qualifies C023-01 and C023-03.
Codes (2)
03
Claim Frequency Type Code
Identifier (ID)
Optional
1
1
-
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
06
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
Codes (4)
07
Provider Accept Assignment Code
Identifier (ID)
Optional
1
1
1
Code indicating whether the provider accepts assignment
Codes (4)
08
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
Codes (4)
09
Release of Information Code
Identifier (ID)
Optional
1
1
1
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
Codes (6)
10
Patient Signature Source Code
Identifier (ID)
Optional
1
1
1
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
Codes (5)
11
Related Causes Information
Composite (composite)
Optional
1
01
Related-Causes Code
Identifier (ID)
Mandatory
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
Codes (6)
02
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
Codes (6)
03
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
Codes (6)
04
State or Province Code
Identifier (ID)
Optional
2
2
-
Code (Standard State/Province) as defined by appropriate government agency
C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
05
Country Code
Identifier (ID)
Optional
2
3
-
Code identifying the country
12
Special Program Code
Identifier (ID)
Optional
2
3
1
Code indicating the Special Program under which the services rendered to the patient were performed
Codes (10)
13
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file; an "N" value indicates statement of nonavailability is not on file or not necessary.
Codes (4)
14
Level of Service Code
Identifier (ID)
Optional
1
3
1
Code specifying the level of service rendered
Codes (18)
15
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM15 is charges itemized by service indicator. A "Y" value indicates charges are itemized by service; an "N" value indicates charges are summarized by service.
Codes (4)
16
Provider Agreement Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of agreement under which the provider is submitting this claim
Codes (7)
17
Claim Status Code
Identifier (ID)
Optional
1
2
1
Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization
Codes (41)
18
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM18 is explanation of benefit (EOB) indicator. A "Y" value indicates that a paper EOB is requested; an "N" value indicates that no paper EOB is requested.
Codes (4)
19
Claim Submission Reason Code
Identifier (ID)
Optional
2
2
1
Code identifying reason for claim submission
Codes (18)
20
Delay Reason Code
Identifier (ID)
Optional
1
2
1
Code indicating the reason why a request was delayed
Codes (14)

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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.