Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us.
X12 837 Health Care Claim: Institutional (X223A3)
—
Delimiters
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- * Element
- > Component
- ^ Repetition
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Admission Date/Hour
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
DTP
1350
Discharge Hour
Max use 1
Optional
DTP
1350
Statement Dates
Max use 1
Required
CL1
1400
Institutional Claim Code
Max use 1
Required
PWK
1550
Claim Supplemental Information
Max use 10
Optional
AMT
1750
Patient Estimated Amount Due
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Auto Accident State
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 5
Optional
REF
1800
Medical Record Number
Max use 1
Optional
REF
1800
Payer Claim Control Number
Max use 1
Optional
REF
1800
Peer Review Organization (PRO) Approval Number
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Repriced Claim Number
Max use 1
Optional
REF
1800
Service Authorization Exception Code
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
NTE
1900
Billing Note
Max use 1
Optional
NTE
1900
Claim Note
Max use 10
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
HI
2310
Admitting Diagnosis
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HI
2310
Diagnosis Related Group (DRG) Information
Max use 1
Optional
HI
2310
External Cause of Injury
Max use 1
Optional
HI
2310
Occurrence Information
Max use 2
Optional
HI
2310
Occurrence Span Information
Max use 2
Optional
HI
2310
Other Diagnosis Information
Max use 2
Optional
HI
2310
Other Procedure Information
Max use 2
Optional
HI
2310
Patient's Reason For Visit
Max use 1
Optional
HI
2310
Principal Diagnosis
Max use 1
Required
HI
2310
Principal Procedure Information
Max use 1
Optional
HI
2310
Treatment Code Information
Max use 2
Optional
HI
2310
Value Information
Max use 2
Optional
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Optional
AMT
3000
Coordination of Benefits (COB) Total Non-Covered Amount
Max use 1
Optional
AMT
3000
Remaining Patient Liability
Max use 1
Optional
OI
3100
Other Insurance Coverage Information
Max use 1
Required
MIA
3150
Inpatient Adjudication Information
Max use 1
Optional
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
N3
3320
Other Payer Address
Max use 1
Optional
N4
3400
Other Payer City, State, ZIP Code
Max use 1
Optional
DTP
3500
Claim Check or Remittance Date
Max use 1
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Prior Authorization Number
Max use 1
Optional
REF
3550
Other Payer Referral Number
Max use 1
Optional
REF
3550
Other Payer Secondary Identifier
Max use 2
Optional
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV2
3750
Institutional Service Line
Max use 1
Required
PWK
4200
Line Supplemental Information
Max use 10
Optional
DTP
4550
Date - Service Date
Max use 1
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
AMT
4750
Facility Tax Amount
Max use 1
Optional
AMT
4750
Service Tax Amount
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
HCP
4920
Line Pricing/Repricing Information
Max use 1
Optional
SE
5550
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA
Interchange Control Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Required
Identifier (ID)
—
- 00
- No Security Information Present (No Meaningful Information in I04)
Required
Identifier (ID)
—
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
Required
Identifier (ID)
Min 1Max 1
—
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Required
Identifier (ID)
Min 1Max 1
—
- I
- Information
- P
- Production Data
- T
- Test Data
GS
Functional Group Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
Min 1Max 2
—
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Heading
ST
0050
Heading > ST
Transaction Set Header
RequiredMax use 1
—
Example
BHT
0100
Heading > BHT
Beginning of Hierarchical Transaction
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 0019
- Information Source, Subscriber, Dependent
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
Usage notes
—
1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name LoopNM1
0200
Heading > Submitter Name Loop > NM1
Submitter Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)—
PER
0450
Heading > Submitter Name Loop > PER
Submitter EDI Contact Information
RequiredMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
Required
Identifier (ID)
—
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
1000A Submitter Name Loop end
1000B Receiver Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Name LoopNM1
0200
Heading > Receiver Name Loop > NM1
Receiver Name
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)
1000B Receiver Name Loop end
Heading end
Detail
2000A Billing Provider Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV
Billing Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
2010AA Billing Provider Name Loop
RequiredMax 1
Variants (all may be used)
Pay-to Address Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1
Billing Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3
Billing Provider Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4
Billing Provider City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider Tax Identification
RequiredMax use 1
—
Usage notes
—
Example
PER
0400
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER
Billing Provider Contact Information
OptionalMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
Required
Identifier (ID)
—
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
2010AA Billing Provider Name Loop end
2010AB Pay-to Address Name Loop
OptionalMax 1
Variants (all may be used)
Billing Provider Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1
Pay-to Address Name
RequiredMax use 1
—
Usage notes
—
Example
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3
Pay-to Address - ADDRESS
RequiredMax use 1
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4
Pay-To Address City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
2010AB Pay-to Address Name Loop end
2000B Subscriber Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR
Subscriber Information
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
Usage notes
—
- P
- Primary
- S
- Secondary
- T
- Tertiary
Required
Identifier (ID)
—
Usage notes
—
- 11
- Other Non-Federal Programs
- 12
- Preferred Provider Organization (PPO)
- 13
- Point of Service (POS)
- 14
- Exclusive Provider Organization (EPO)
- 15
- Indemnity Insurance
- 16
- Health Maintenance Organization (HMO) Medicare Risk
- 17
- Dental Maintenance Organization
- AM
- Automobile Medical
- BL
- Blue Cross/Blue Shield
- CH
- Champus
- CI
- Commercial Insurance Co.
- DS
- Disability
- FI
- Federal Employees Program
- HM
- Health Maintenance Organization
- LM
- Liability Medical
- MA
- Medicare Part A
- MB
- Medicare Part B
- MC
- Medicaid
- OF
- Other Federal Program—
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined—
2010BA Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Payer Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1
Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3
Subscriber Address
OptionalMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4
Subscriber City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG
Subscriber Demographic Information
OptionalMax use 1
—
Usage notes
—
Example
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF
Property and Casualty Claim Number
OptionalMax use 1
—
Usage notes
—
Example
2010BA Subscriber Name Loop end
2010BB Payer Name Loop
RequiredMax 1
Variants (all may be used)
Subscriber Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1
Payer Name
RequiredMax use 1
—
Usage notes
—
Example
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3
Payer Address
OptionalMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4
Payer City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF
Billing Provider Secondary Identification
OptionalMax use 1
—
Usage notes
—
Example
2010BB Payer Name Loop end
2300 Claim Information Loop
OptionalMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM
Claim Information
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
Required
Identifier (ID)
—
Usage notes
—
- A
- Assigned—
- B
- Assignment Accepted on Clinical Lab Services Only—
- C
- Not Assigned—
Required
Identifier (ID)
—
Usage notes
—
- N
- No
- W
- Not Applicable—
- Y
- Yes
Required
Identifier (ID)
—
Usage notes
—
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes—
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim—
Optional
Identifier (ID)
—
Usage notes
—
- 1
- Proof of Eligibility Unknown or Unavailable
- 2
- Litigation
- 3
- Authorization Delays
- 4
- Delay in Certifying Provider
- 5
- Delay in Supplying Billing Forms
- 6
- Delay in Delivery of Custom-made Appliances
- 7
- Third Party Processing Delay
- 8
- Delay in Eligibility Determination
- 9
- Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
- 10
- Administration Delay in the Prior Approval Process
- 11
- Other
- 15
- Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Admission Date/Hour
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- D8
- Date Expressed in Format CCYYMMDD
- DT
- Date and Time Expressed in Format CCYYMMDDHHMM
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Repricer Received Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Discharge Hour
OptionalMax use 1
—
Usage notes
—
Example
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Statement Dates
RequiredMax use 1
—
Example
CL1
1400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CL1
Institutional Claim Code
RequiredMax use 1
—
Example
PWK
1550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK
Claim Supplemental Information
OptionalMax use 10
—
Usage notes
—
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
Required
Identifier (ID)
—
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Required
Identifier (ID)
—
- BM
- By Mail
- EL
- Electronically Only—
- FT
- File Transfer—
- FX
- By Fax
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT
Patient Estimated Amount Due
OptionalMax use 1
—
Usage notes
—
Example
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Adjusted Repriced Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Auto Accident State
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Claim Identifier For Transmission Intermediaries
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Demonstration Project Identifier
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Investigational Device Exemption Number
OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Medical Record Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Payer Claim Control Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Peer Review Organization (PRO) Approval Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Prior Authorization
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Referral Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Repriced Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Service Authorization Exception Code
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFAuto Accident StateREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record NumberREFPayer Claim Control NumberREFPeer Review Organization (PRO) Approval NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberK3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3
File Information
OptionalMax use 10
—
Usage notes
—
Example
NTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE
Billing Note
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
NTEClaim NoteNTE
1900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE
Claim Note
OptionalMax use 10
—
Usage notes
—
Example
Variants (all may be used)
NTEBilling NoteRequired
Identifier (ID)
—
- ALG
- Allergies
- DCP
- Goals, Rehabilitation Potential, or Discharge Plans
- DGN
- Diagnosis Description
- DME
- Durable Medical Equipment (DME) and Supplies
- MED
- Medications
- NTR
- Nutritional Requirements
- ODT
- Orders for Disciplines and Treatments
- RHB
- Functional Limitations, Reason Homebound, or Both
- RLH
- Reasons Patient Leaves Home
- RNH
- Times and Reasons Patient Not at Home
- SET
- Unusual Home, Social Environment, or Both
- SFM
- Safety Measures
- SPT
- Supplementary Plan of Treatment
- UPI
- Updated Information
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC
EPSDT Referral
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- N
- No—
- Y
- Yes
Required
Identifier (ID)
—
Usage notes
—
- AV
- Available - Not Used—
- NU
- Not Used—
- S2
- Under Treatment—
- ST
- New Services Requested—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Admitting Diagnosis
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
HICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis—
- BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Condition Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Diagnosis Related Group (DRG) Information
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationHI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
External Cause of Injury
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABN
- International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code—
- BN
- International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes)
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Occurrence Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Occurrence Span Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Other Diagnosis Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis—
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Other Procedure Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- BBQ
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes—
- BQ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Patient's Reason For Visit
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit—
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit—
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit—
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Principal Diagnosis
RequiredMax use 1
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal Procedure InformationHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis—
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Principal Procedure Information
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHITreatment Code InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- BBR
- International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes—
- BR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes
- CAH
- Advanced Billing Concepts (ABC) Codes
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Treatment Code Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHIValue InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Value Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
HIAdmitting DiagnosisHICondition InformationHIDiagnosis Related Group (DRG) InformationHIExternal Cause of InjuryHIOccurrence InformationHIOccurrence Span InformationHIOther Diagnosis InformationHIOther Procedure InformationHIPatient's Reason For VisitHIPrincipal DiagnosisHIPrincipal Procedure InformationHITreatment Code InformationRequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
HCP
2410
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP
Claim Pricing/Repricing Information
OptionalMax use 1
—
Usage notes
—
Example
If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required
Required
Identifier (ID)
—
Usage notes
—
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Optional
Identifier (ID)
—
Usage notes
—
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Optional
Identifier (ID)
—
Usage notes
—
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Optional
Identifier (ID)
—
Usage notes
—
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
2310A Attending Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > NM1
Attending Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV
Attending Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF
Attending Provider Secondary Identification
OptionalMax use 4
—
Usage notes
—
Example
2310A Attending Provider Name Loop end
2310B Operating Physician Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1
Operating Physician Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > REF
Operating Physician Secondary Identification
OptionalMax use 4
—
Usage notes
—
Example
2310B Operating Physician Name Loop end
2310C Other Operating Physician Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > NM1
Other Operating Physician Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required
Optional
String (AN)
Min 1Max 25
—
Usage notes
—
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > REF
Other Operating Physician Secondary Identification
OptionalMax use 4
—
Usage notes
—
Example
2310C Other Operating Physician Name Loop end
2310D Rendering Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1
Rendering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF
Rendering Provider Secondary Identification
OptionalMax use 4
—
Usage notes
—
Example
2310D Rendering Provider Name Loop end
2310E Service Facility Location Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1
Service Facility Location Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3
Service Facility Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4
Service Facility Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF
Service Facility Location Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310E Service Facility Location Name Loop end
2310F Referring Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1
Referring Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
2310F Referring Provider Name Loop end
2320 Other Subscriber Information Loop
OptionalMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR
Other Subscriber Information
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- A
- Payer Responsibility Four
- B
- Payer Responsibility Five
- C
- Payer Responsibility Six
- D
- Payer Responsibility Seven
- E
- Payer Responsibility Eight
- F
- Payer Responsibility Nine
- G
- Payer Responsibility Ten
- H
- Payer Responsibility Eleven
- P
- Primary
- S
- Secondary
- T
- Tertiary
- U
- Unknown—
Required
Identifier (ID)
—
- 01
- Spouse
- 18
- Self
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Required
Identifier (ID)
—
- 11
- Other Non-Federal Programs
- 12
- Preferred Provider Organization (PPO)
- 13
- Point of Service (POS)
- 14
- Exclusive Provider Organization (EPO)
- 15
- Indemnity Insurance
- 16
- Health Maintenance Organization (HMO) Medicare Risk
- 17
- Dental Maintenance Organization
- AM
- Automobile Medical
- BL
- Blue Cross/Blue Shield
- CH
- Champus
- CI
- Commercial Insurance Co.
- DS
- Disability
- FI
- Federal Employees Program
- HM
- Health Maintenance Organization
- LM
- Liability Medical
- MC
- Medicaid
- OF
- Other Federal Program—
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined—
CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS
Claim Level Adjustments
OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
Required
Identifier (ID)
—
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT
Coordination of Benefits (COB) Payer Paid Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Total Non-Covered AmountAMTRemaining Patient LiabilityAMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT
Coordination of Benefits (COB) Total Non-Covered Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountAMTRemaining Patient LiabilityAMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT
Remaining Patient Liability
OptionalMax use 1
—
Usage notes
—
Example
OI
3100
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI
Other Insurance Coverage Information
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- N
- No
- W
- Not Applicable—
- Y
- Yes
Required
Identifier (ID)
—
Usage notes
—
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes—
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim—
MIA
3150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA
Inpatient Adjudication Information
OptionalMax use 1
—
Usage notes
—
Example
MOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA
Outpatient Adjudication Information
OptionalMax use 1
—
Usage notes
—
Example
2330A Other Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Other Payer Name LoopNM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1
Other Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number—
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3
Other Subscriber Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4
Other Subscriber City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF
Other Subscriber Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
Variants (all may be used)
Other Subscriber Name LoopNM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1
Other Payer Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3
Other Payer Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4
Other Payer City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
DTP
3500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP
Claim Check or Remittance Date
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Claim Adjustment Indicator
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Claim Control Number
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Prior Authorization Number
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Referral Number
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Secondary Identifier
OptionalMax use 2
—
Usage notes
—
Example
2330B Other Payer Name Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 999
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX
Service Line Number
RequiredMax use 1
—
Usage notes
—
Example
SV2
3750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV2
Institutional Service Line
RequiredMax use 1
—
Example
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes
—
Required
Identifier (ID)
—
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK
Line Supplemental Information
OptionalMax use 10
—
Usage notes
—
Example
If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
Required
Identifier (ID)
—
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
- AS
- Admission Summary
- B2
- Prescription
- B3
- Physician Order
- B4
- Referral Form
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
- CK
- Consent Form(s)
- CT
- Certification
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- MT
- Models
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- OZ
- Support Data for Claim
- P4
- Pathology Report
- P5
- Patient Medical History Document
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Required
Identifier (ID)
—
- AA
- Available on Request at Provider Site—
- BM
- By Mail
- EL
- Electronically Only—
- EM
- FT
- File Transfer—
- FX
- By Fax
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Service Date
OptionalMax use 1
—
Usage notes
—
Example
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Adjusted Repriced Line Item Reference Number
OptionalMax use 1
—
Usage notes
—
Example
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Line Item Control Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFRepriced Line Item Reference NumberREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Repriced Line Item Reference Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFLine Item Control NumberAMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT
Facility Tax Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTService Tax AmountAMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT
Service Tax Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTFacility Tax AmountNTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE
Third Party Organization Notes
OptionalMax use 1
—
Usage notes
—
Example
HCP
4920
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP
Line Pricing/Repricing Information
OptionalMax use 1
—
Usage notes
—
Example
If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required
If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required
Required
Identifier (ID)
—
Usage notes
—
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Optional
Identifier (ID)
—
- ER
- Jurisdiction Specific Procedure and Supply Codes—
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code—
- WK
- Advanced Billing Concepts (ABC) Codes—
Optional
Identifier (ID)
—
Usage notes
—
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Optional
Identifier (ID)
—
Usage notes
—
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Optional
Identifier (ID)
—
Usage notes
—
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
2410 Drug Identification Loop
OptionalMax 1
LIN
4930
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN
Drug Identification
RequiredMax use 1
—
Usage notes
—
Example
CTP
4940
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP
Drug Quantity
RequiredMax use 1
—
Example
REF
4950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF
Prescription or Compound Drug Association Number
OptionalMax use 1
—
Usage notes
—
Example
2410 Drug Identification Loop end
2420A Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Other Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name LoopNM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > NM1
Operating Physician Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF
Operating Physician Secondary Identification
OptionalMax use 20
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 0B
- State License Number
- 1G
- Provider UPIN Number—
- G2
- Provider Commercial Number—
- LU
- Location Number
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier
- REF04 contains data relating to the value cited in REF02.
Usage notes
—
2420A Operating Physician Name Loop end
2420B Other Operating Physician Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopRendering Provider Name LoopReferring Provider Name LoopNM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > NM1
Other Operating Physician Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required
Optional
String (AN)
Min 1Max 25
—
Usage notes
—
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > REF
Other Operating Physician Secondary Identification
OptionalMax use 20
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 0B
- State License Number
- 1G
- Provider UPIN Number—
- G2
- Provider Commercial Number—
- LU
- Location Number
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier
- REF04 contains data relating to the value cited in REF02.
Usage notes
—
2420B Other Operating Physician Name Loop end
2420C Rendering Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopReferring Provider Name LoopNM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1
Rendering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF
Rendering Provider Secondary Identification
OptionalMax use 20
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 0B
- State License Number
- 1G
- Provider UPIN Number—
- G2
- Provider Commercial Number—
- LU
- Location Number
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier
- REF04 contains data relating to the value cited in REF02.
Usage notes
—
2420C Rendering Provider Name Loop end
2420D Referring Provider Name Loop
OptionalMax 1
Variants (all may be used)
Operating Physician Name LoopOther Operating Physician Name LoopRendering Provider Name LoopNM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1
Referring Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF
Referring Provider Secondary Identification
OptionalMax use 20
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 0B
- State License Number
- 1G
- Provider UPIN Number—
- G2
- Provider Commercial Number—
OptionalMax use 1
To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier
- REF04 contains data relating to the value cited in REF02.
Usage notes
—
2420D Referring Provider Name Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD
Line Adjudication Information
RequiredMax use 1
—
Usage notes
—
Example
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
- SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
Usage notes
—
Required
Identifier (ID)
—
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS
Line Adjustment
OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
Required
Identifier (ID)
—
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP
Line Check or Remittance Date
RequiredMax use 1
—
Example
AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT
Remaining Patient Liability
OptionalMax use 1
—
Usage notes
—
Example
2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000B Subscriber Hierarchical Level Loop end
2000A Billing Provider Hierarchical Level Loop end
SE
5550
Detail > SE
Transaction Set Trailer
RequiredMax use 1
—
Example
Detail end
GE
Functional Group Trailer
RequiredMax use 1
—
Example
IEA
Interchange Control Trailer
RequiredMax use 1
—
Example
EDI Samples
Example 1a: Institutional Claim
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231031*0142*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231031*014228*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*MEDICARE*****46*00120~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
REF*G2*330127~
CLM*756048Q*89.93***14>A>1**A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
HI*BH>A1>D8>19261111*BH>A2>D8>19911101*BH>B1>D8>19261111*BH>B2>D8>19870101~
HI*BE>A2>>>15.31~
HI*BG>09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC>93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*43*987654~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231031*014228*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*MEDICARE*****46*00120~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
REF*G2*330127~
CLM*756048Q*89.93***14>A>1**A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
HI*BH>A1>D8>19261111*BH>A2>D8>19911101*BH>B1>D8>19261111*BH>B2>D8>19870101~
HI*BE>A2>>>15.31~
HI*BG>09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC>93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*43*987654~
GE*1*000000001~
IEA*1*000000001~
Example 1b: Two Claims for the Same Provider
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231031*0142*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231031*014255*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*20050630*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*1112223333~
NM1*40*2*TRICARE*****46*99999~
HL*1**20*1~
PRV*BI*PXC*282N00000X~
NM1*85*2*JONES HOSPITAL*****XX*1234567890~
N3*225 MAIN STREET~
N4*ANYWHERE*PA*17111~
REF*EI*123456789~
HL*2*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*DOE*JOHN*T***MI*030005074~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19681111*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756048Q*89.95***13>A>1**C*Y*Y~
DTP*434*RD8*20050315-20050315~
CL1*1**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
NM1*71*1*JONES*JOHN*J***XX*1122334455~
REF*1G*U12345~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*20050315~
LX*2~
SV2*0730*HC>93010*76.56*UN*3~
DTP*472*D8*20050315~
HL*3*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*SMITH*JOE****MI*123405074~
N3*5 MAIN STREET~
N4*ANYWHERE*PA*17111~
DMG*D8*19621210*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756049Q*50***13>A>1**C*Y*Y~
DTP*434*RD8*20050401-20050401~
CL1*1**01~
HI*BK>30000~
NM1*71*1*JONES*JUDY*J***XX*9999999999~
PRV*AT*PXC*363LP0200N~
LX*1~
SV2*0300*HC>85087*50*UN*1~
DTP*472*D8*20050401~
SE*48*987654~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231031*014255*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*20050630*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*1112223333~
NM1*40*2*TRICARE*****46*99999~
HL*1**20*1~
PRV*BI*PXC*282N00000X~
NM1*85*2*JONES HOSPITAL*****XX*1234567890~
N3*225 MAIN STREET~
N4*ANYWHERE*PA*17111~
REF*EI*123456789~
HL*2*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*DOE*JOHN*T***MI*030005074~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19681111*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756048Q*89.95***13>A>1**C*Y*Y~
DTP*434*RD8*20050315-20050315~
CL1*1**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
NM1*71*1*JONES*JOHN*J***XX*1122334455~
REF*1G*U12345~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*20050315~
LX*2~
SV2*0730*HC>93010*76.56*UN*3~
DTP*472*D8*20050315~
HL*3*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*SMITH*JOE****MI*123405074~
N3*5 MAIN STREET~
N4*ANYWHERE*PA*17111~
DMG*D8*19621210*M~
NM1*PR*2*TRICARE*****PI*99999~
CLM*756049Q*50***13>A>1**C*Y*Y~
DTP*434*RD8*20050401-20050401~
CL1*1**01~
HI*BK>30000~
NM1*71*1*JONES*JUDY*J***XX*9999999999~
PRV*AT*PXC*363LP0200N~
LX*1~
SV2*0300*HC>85087*50*UN*1~
DTP*472*D8*20050401~
SE*48*987654~
GE*1*000000001~
IEA*1*000000001~
Example 1c: PPO Repriced Claim
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0220*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*022053*000000001*X*005010X223A3~
ST*837*1002*005010X223A3~
BHT*0019*00*1002*20050721*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*LOCAL INSURANCE COMPANY*****46*54334452~
HL*1**20*1~
NM1*85*2*GOOD HEALTH HOSPITAL*****XX*1257234346~
N3*592 NORTH ELM STREET~
N4*EDGEWOOD*AZ*860015590~
REF*EI*344232321~
HL*2*1*22*1~
SBR*P**46522567AW******CI~
NM1*IL*1*JONES*JENNY****MI*345U8423H~
N3*4512 WEST AVENUE~
N4*EVANSVILLE*AZ*863030000~
DMG*D8*19690731*F~
NM1*PR*2*LOCAL INSURANCE COMPANY*****PI*7452723~
CLM*456DFH43*237.5***13>A>1**A*Y*Y~
DTP*434*RD8*20050706-20050706~
DTP*435*DT*200507060800~
CL1*1*2*01~
AMT*F3*237.5~
REF*9A*09459034092~
REF*D9*04566877634343456~
HI*BK>38181~
HI*BF>38900~
HI*BH>11>D8>20050706~
HCP*03*182.88*54.62*123456789~
NM1*71*1*JOHNSON*SIMON****XX*5544332211~
SBR*S*19**T&T PLUMBING COMPANY*****CI~
OI***Y***Y~
NM1*IL*1*JONES*GEORGE****MI*56454566~
NM1*PR*2*OTHER COVERAGE COMPANY*****PI*534524~
LX*1~
SV2*0471*HC>92557*178*UN*1~
DTP*472*D8*20050706~
HCP*03*137.06*40.94~
LX*2~
SV2*0471*HC>92567*59.5*UN*1~
DTP*472*D8*20050706~
HCP*03*45.82*13.68~
SE*42*1002~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*022053*000000001*X*005010X223A3~
ST*837*1002*005010X223A3~
BHT*0019*00*1002*20050721*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*LOCAL INSURANCE COMPANY*****46*54334452~
HL*1**20*1~
NM1*85*2*GOOD HEALTH HOSPITAL*****XX*1257234346~
N3*592 NORTH ELM STREET~
N4*EDGEWOOD*AZ*860015590~
REF*EI*344232321~
HL*2*1*22*1~
SBR*P**46522567AW******CI~
NM1*IL*1*JONES*JENNY****MI*345U8423H~
N3*4512 WEST AVENUE~
N4*EVANSVILLE*AZ*863030000~
DMG*D8*19690731*F~
NM1*PR*2*LOCAL INSURANCE COMPANY*****PI*7452723~
CLM*456DFH43*237.5***13>A>1**A*Y*Y~
DTP*434*RD8*20050706-20050706~
DTP*435*DT*200507060800~
CL1*1*2*01~
AMT*F3*237.5~
REF*9A*09459034092~
REF*D9*04566877634343456~
HI*BK>38181~
HI*BF>38900~
HI*BH>11>D8>20050706~
HCP*03*182.88*54.62*123456789~
NM1*71*1*JOHNSON*SIMON****XX*5544332211~
SBR*S*19**T&T PLUMBING COMPANY*****CI~
OI***Y***Y~
NM1*IL*1*JONES*GEORGE****MI*56454566~
NM1*PR*2*OTHER COVERAGE COMPANY*****PI*534524~
LX*1~
SV2*0471*HC>92557*178*UN*1~
DTP*472*D8*20050706~
HCP*03*137.06*40.94~
LX*2~
SV2*0471*HC>92567*59.5*UN*1~
DTP*472*D8*20050706~
HCP*03*45.82*13.68~
SE*42*1002~
GE*1*000000001~
IEA*1*000000001~
Example 1d: Out of Network Repriced Claim
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231031*0143*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231031*014349*000000001*X*005010X223A3~
ST*837*1024*005010X223A3~
BHT*0019*00*1024*20050711*1335*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~
HL*1**20*1~
NM1*85*2*LOCAL HOSPITAL*****XX*1122334455~
N3*3423 SMALL STREET~
N4*COLUMBUS*OH*432150000~
REF*EI*111002222~
HL*2*1*22*0~
SBR*P*18*34561W******CI~
NM1*IL*1*SMITH*JAMES*A***MI*34902390F~
N3*934 NORTH STREET~
N4*COLUMBUS*OH*432150000~
DMG*D8*19621015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*0012~
CLM*W392-49141*14.84***13>A>1**A*Y*Y~
DTP*434*RD8*20050617-20050617~
DTP*435*DT*200506170800~
CL1*1*1*01~
AMT*F3*14.84~
REF*9A*459804390823~
REF*D9*32423466233~
HI*BK>53081~
HCP*00*0**333001234*********T1~
NM1*71*1*RIVERS*DAWN****XX*2244224455~
LX*1~
SV2*0301*HC>82270*14.84*UN*1~
DTP*472*D8*20050617~
SE*31*1024~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231031*014349*000000001*X*005010X223A3~
ST*837*1024*005010X223A3~
BHT*0019*00*1024*20050711*1335*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~
HL*1**20*1~
NM1*85*2*LOCAL HOSPITAL*****XX*1122334455~
N3*3423 SMALL STREET~
N4*COLUMBUS*OH*432150000~
REF*EI*111002222~
HL*2*1*22*0~
SBR*P*18*34561W******CI~
NM1*IL*1*SMITH*JAMES*A***MI*34902390F~
N3*934 NORTH STREET~
N4*COLUMBUS*OH*432150000~
DMG*D8*19621015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*0012~
CLM*W392-49141*14.84***13>A>1**A*Y*Y~
DTP*434*RD8*20050617-20050617~
DTP*435*DT*200506170800~
CL1*1*1*01~
AMT*F3*14.84~
REF*9A*459804390823~
REF*D9*32423466233~
HI*BK>53081~
HCP*00*0**333001234*********T1~
NM1*71*1*RIVERS*DAWN****XX*2244224455~
LX*1~
SV2*0301*HC>82270*14.84*UN*1~
DTP*472*D8*20050617~
SE*31*1024~
GE*1*000000001~
IEA*1*000000001~
Example 2a: Automobile Accident
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0222*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*022219*000000001*X*005010X223A3~
ST*837*557766*005010X223A3~
BHT*0019*00*0324*20051111*1800*CH~
NM1*41*2*HALL OF FAME MEMORIAL HOSPITAL*****46*737373737~
PER*IC*KATE CASEY*TE*7152569877~
NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*HALL OF FAME MEMORIAL HOSPITAL*****XX*2365259638~
N3*1 CANTON ROAD~
N4*BROKEN FIELD*CA*99998~
REF*EI*737373737~
HL*2*1*22*1~
SBR*P********AM~
NM1*IL*1*HOWLING*HAL****MI*B999777791G~
NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~
CLM*67236695521*545***13>A>1**A*Y*Y~
DTP*434*RD8*20051031-20051101~
CL1*3*7*1~
REF*LU*CA~
HI*BK>8842~
HI*PR>8842~
HI*BN>E9750*BN>E9860~
NM1*71*1*LOMBARDO*VINCENT****XX*2533698543~
LX*1~
SV2*0450*HC>98765*150*UN*1~
DTP*472*D8*20051031~
LX*2~
SV2*0360*HC>26591*75*UN*1~
DTP*472*D8*20051031~
LX*3~
SV2*0312*HC>86225*100*UN*2~
DTP*472*D8*20051031~
LX*4~
SV2*0360*HC>99283*220*UN*1~
DTP*472*D8*20051031~
SE*36*557766~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*022219*000000001*X*005010X223A3~
ST*837*557766*005010X223A3~
BHT*0019*00*0324*20051111*1800*CH~
NM1*41*2*HALL OF FAME MEMORIAL HOSPITAL*****46*737373737~
PER*IC*KATE CASEY*TE*7152569877~
NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*HALL OF FAME MEMORIAL HOSPITAL*****XX*2365259638~
N3*1 CANTON ROAD~
N4*BROKEN FIELD*CA*99998~
REF*EI*737373737~
HL*2*1*22*1~
SBR*P********AM~
NM1*IL*1*HOWLING*HAL****MI*B999777791G~
NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~
CLM*67236695521*545***13>A>1**A*Y*Y~
DTP*434*RD8*20051031-20051101~
CL1*3*7*1~
REF*LU*CA~
HI*BK>8842~
HI*PR>8842~
HI*BN>E9750*BN>E9860~
NM1*71*1*LOMBARDO*VINCENT****XX*2533698543~
LX*1~
SV2*0450*HC>98765*150*UN*1~
DTP*472*D8*20051031~
LX*2~
SV2*0360*HC>26591*75*UN*1~
DTP*472*D8*20051031~
LX*3~
SV2*0312*HC>86225*100*UN*2~
DTP*472*D8*20051031~
LX*4~
SV2*0360*HC>99283*220*UN*1~
DTP*472*D8*20051031~
SE*36*557766~
GE*1*000000001~
IEA*1*000000001~
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