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: Professional (X222A2)
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Delimiters
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- > Component
- ^ Repetition
EDI samples
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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
PAT
0070
Patient Information
Max use 1
Optional
Subscriber Name Loop
NM1
0150
Subscriber Name
Max use 1
Required
N3
0250
Subscriber Address
Max use 1
Optional
N4
0300
Subscriber City, State, ZIP Code
Max use 1
Optional
DMG
0320
Subscriber Demographic Information
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
PER
0400
Property and Casualty Subscriber Contact Information
Max use 1
Optional
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Acute Manifestation
Max use 1
Optional
DTP
1350
Date - Admission
Max use 1
Optional
DTP
1350
Date - Assumed and Relinquished Care Dates
Max use 2
Optional
DTP
1350
Date - Authorized Return to Work
Max use 1
Optional
DTP
1350
Date - Disability Dates
Max use 1
Optional
DTP
1350
Date - Discharge
Max use 1
Optional
DTP
1350
Date - Hearing and Vision Prescription Date
Max use 1
Optional
DTP
1350
Date - Initial Treatment Date
Max use 1
Optional
DTP
1350
Date - Last Menstrual Period
Max use 1
Optional
DTP
1350
Date - Last Seen Date
Max use 1
Optional
DTP
1350
Date - Last Worked
Max use 1
Optional
DTP
1350
Date - Last X-ray Date
Max use 1
Optional
DTP
1350
Date - Onset of Current Illness or Symptom
Max use 1
Optional
DTP
1350
Date - Property and Casualty Date of First Contact
Max use 1
Optional
DTP
1350
Date - Repricer Received Date
Max use 1
Optional
PWK
1550
Claim Supplemental Information
Max use 10
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Adjusted Repriced Claim Number
Max use 1
Optional
REF
1800
Care Plan Oversight
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
REF
1800
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
1800
Demonstration Project Identifier
Max use 1
Optional
REF
1800
Investigational Device Exemption Number
Max use 1
Optional
REF
1800
Mammography Certification Number
Max use 1
Optional
REF
1800
Medical Record 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
Claim Note
Max use 1
Optional
CR1
1950
Ambulance Transport Information
Max use 1
Optional
CR2
2000
Spinal Manipulation Service Information
Max use 1
Optional
CRC
2200
Ambulance Certification
Max use 3
Optional
CRC
2200
EPSDT Referral
Max use 1
Optional
CRC
2200
Homebound Indicator
Max use 1
Optional
CRC
2200
Patient Condition Information: Vision
Max use 3
Optional
HI
2310
Anesthesia Related Procedure
Max use 1
Optional
HI
2310
Condition Information
Max use 2
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Required
HCP
2410
Claim Pricing/Repricing Information
Max use 1
Optional
Service Facility Location Name Loop
NM1
2500
Service Facility Location Name
Max use 1
Required
N3
2650
Service Facility Location Address
Max use 1
Required
N4
2700
Service Facility Location City, State, ZIP Code
Max use 1
Required
REF
2710
Service Facility Location Secondary Identification
Max use 3
Optional
PER
2750
Service Facility Contact 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
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
3450
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
SV1
3700
Professional Service
Max use 1
Required
SV5
4000
Durable Medical Equipment Service
Max use 1
Optional
PWK
4200
Durable Medical Equipment Certificate of Medical Necessity Indicator
Max use 1
Optional
PWK
4200
Line Supplemental Information
Max use 10
Optional
CR1
4250
Ambulance Transport Information
Max use 1
Optional
CR3
4350
Durable Medical Equipment Certification
Max use 1
Optional
CRC
4500
Ambulance Certification
Max use 3
Optional
CRC
4500
Condition Indicator/Durable Medical Equipment
Max use 1
Optional
CRC
4500
Hospice Employee Indicator
Max use 1
Optional
DTP
4550
Date - Begin Therapy Date
Max use 1
Optional
DTP
4550
DATE - Certification Revision/Recertification Date
Max use 1
Optional
DTP
4550
Date - Initial Treatment Date
Max use 1
Optional
DTP
4550
Date - Last Certification Date
Max use 1
Optional
DTP
4550
Date - Last Seen Date
Max use 1
Optional
DTP
4550
Date - Last X-ray Date
Max use 1
Optional
DTP
4550
Date - Prescription Date
Max use 1
Optional
DTP
4550
Date - Service Date
Max use 1
Required
DTP
4550
Date - Shipped Date
Max use 1
Optional
DTP
4550
Date - Test Date
Max use 2
Optional
QTY
4600
Ambulance Patient Count
Max use 1
Optional
QTY
4600
Obstetric Anesthesia Additional Units
Max use 1
Optional
MEA
4620
Test Result
Max use 5
Optional
REF
4700
Adjusted Repriced Line Item Reference Number
Max use 1
Optional
REF
4700
Clinical Laboratory Improvement Amendment (CLIA) Number
Max use 1
Optional
REF
4700
Immunization Batch Number
Max use 1
Optional
REF
4700
Line Item Control Number
Max use 1
Optional
REF
4700
Mammography Certification Number
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
REF
4700
Referral Number
Max use 5
Optional
REF
4700
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
Max use 1
Optional
REF
4700
Repriced Line Item Reference Number
Max use 1
Optional
AMT
4750
Postage Claimed Amount
Max use 1
Optional
AMT
4750
Sales Tax Amount
Max use 1
Optional
K3
4800
File Information
Max use 10
Optional
NTE
4850
Line Note
Max use 1
Optional
NTE
4850
Third Party Organization Notes
Max use 1
Optional
PS1
4880
Purchased Service 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
Usage notes
—
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)
—
Usage notes
—
- 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
Optional
Identifier (ID)
—
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
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—
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > PAT
Patient Information
OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required
If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required
Optional
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
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
PER
0400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > PER
Property and Casualty Subscriber Contact Information
OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
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 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
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)
—
- P
- Signature generated by provider because the patient was not physically present for services—
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
—
Optional
Identifier (ID)
—
- 02
- Physically Handicapped Children's Program—
- 03
- Special Federal Funding—
- 05
- Disability—
- 09
- Second Opinion or Surgery—
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
Date - Accident
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Acute Manifestation
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Admission
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Assumed and Relinquished Care Dates
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Authorized Return to Work
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Disability Dates
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateRequired
Identifier (ID)
—
- 314
- Disability—
- 360
- Initial Disability Period Start—
- 361
- Initial Disability Period End—
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD—
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD—
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Discharge
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Hearing and Vision Prescription Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Initial Treatment Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Menstrual Period
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Seen Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last Worked
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Last X-ray Date
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Onset of Current Illness or Symptom
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Property and Casualty Date of First ContactDTPDate - Repricer Received DateDTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP
Date - Property and Casualty Date of First Contact
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Repricer Received DateDTP
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
Variants (all may be used)
DTPDate - AccidentDTPDate - Acute ManifestationDTPDate - AdmissionDTPDate - Assumed and Relinquished Care DatesDTPDate - Authorized Return to WorkDTPDate - Disability DatesDTPDate - DischargeDTPDate - Hearing and Vision Prescription DateDTPDate - Initial Treatment DateDTPDate - Last Menstrual PeriodDTPDate - Last Seen DateDTPDate - Last WorkedDTPDate - Last X-ray DateDTPDate - Onset of Current Illness or SymptomDTPDate - Property and Casualty Date of First ContactPWK
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 Amount Paid
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)
REFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Care Plan Oversight
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record 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 NumberREFCare Plan OversightREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Clinical Laboratory Improvement Amendment (CLIA) Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record 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 NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record 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 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFMammography Certification NumberREFMedical Record NumberREFPrior AuthorizationREFReferral NumberREFRepriced Claim NumberREFService Authorization Exception CodeREF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF
Mammography Certification Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Claim NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMedical Record 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 NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification 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 NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record 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 NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record 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 NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record 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 NumberREFCare Plan OversightREFClaim Identifier For Transmission IntermediariesREFClinical Laboratory Improvement Amendment (CLIA) NumberREFDemonstration Project IdentifierREFInvestigational Device Exemption NumberREFMammography Certification NumberREFMedical Record 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
Claim Note
OptionalMax use 1
—
Usage notes
—
Example
CR1
1950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CR1
Ambulance Transport Information
OptionalMax use 1
—
Usage notes
—
Example
If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required
Required
Identifier (ID)
—
- A
- Patient was transported to nearest facility for care of symptoms, complaints, or both—
- B
- Patient was transported for the benefit of a preferred physician
- C
- Patient was transported for the nearness of family members
- D
- Patient was transported for the care of a specialist or for availability of specialized equipment
- E
- Patient Transferred to Rehabilitation Facility
CR2
2000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CR2
Spinal Manipulation Service Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- A
- Acute Condition
- C
- Chronic Condition
- D
- Non-acute
- E
- Non-Life Threatening
- F
- Routine
- G
- Symptomatic
- M
- Acute Manifestation of a Chronic Condition
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC
Ambulance Certification
OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
CRCEPSDT ReferralCRCHomebound IndicatorCRCPatient Condition Information: VisionRequired
Identifier (ID)
—
Usage notes
—
- 01
- Patient was admitted to a hospital
- 04
- Patient was moved by stretcher
- 05
- Patient was unconscious or in shock
- 06
- Patient was transported in an emergency situation
- 07
- Patient had to be physically restrained
- 08
- Patient had visible hemorrhaging
- 09
- Ambulance service was medically necessary
- 12
- Patient is confined to a bed or chair—
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC
EPSDT Referral
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
CRCAmbulance CertificationCRCHomebound IndicatorCRCPatient Condition Information: VisionRequired
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—
CRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC
Homebound Indicator
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
CRCAmbulance CertificationCRCEPSDT ReferralCRCPatient Condition Information: VisionCRC
2200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC
Patient Condition Information: Vision
OptionalMax use 3
—
Usage notes
—
Example
Required
Identifier (ID)
—
- L1
- General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
- L2
- Replacement Due to Loss or Theft
- L3
- Replacement Due to Breakage or Damage
- L4
- Replacement Due to Patient Preference
- L5
- Replacement Due to Medical Reason
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Anesthesia Related Procedure
OptionalMax use 1
—
Usage notes
—
Example
RequiredMax 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
—
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI
Condition Information
OptionalMax use 2
—
Usage notes
—
Example
RequiredMax 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
Health Care Diagnosis Code
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax 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
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
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
- 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
Decimal number (R)
Min 1Max 15
—
Usage notes
—
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 Referring Provider Name Loop
OptionalMax 2
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
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF
Referring Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310A Referring Provider Name Loop end
2310B 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
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV
Rendering Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
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
2310B Rendering Provider Name Loop end
2310C 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
PER
2750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > PER
Service Facility Contact Information
OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
2310C Service Facility Location Name Loop end
2310D Supervising Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1
Supervising Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising 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 > Supervising Provider Name Loop > REF
Supervising Provider Secondary Identification
OptionalMax use 4
—
Usage notes
—
Example
2310D Supervising Provider Name Loop end
2310E Ambulance Pick-up Location Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > NM1
Ambulance Pick-up Location
RequiredMax use 1
—
Usage notes
—
Example
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N3
Ambulance Pick-up Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N4
Ambulance Pick-up Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Ambulance Pick-up 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
2310E Ambulance Pick-up Location Loop end
2310F Ambulance Drop-off Location Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > NM1
Ambulance Drop-off Location
RequiredMax use 1
—
Usage notes
—
Example
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > N3
Ambulance Drop-off Location Address
RequiredMax use 1
—
Example
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > N4
Ambulance Drop-off Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Ambulance Drop-off 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
2310F Ambulance Drop-off Location 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
Optional
Identifier (ID)
—
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
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)
—
Usage notes
—
- 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
Optional
Identifier (ID)
—
Usage notes
—
- P
- Signature generated by provider because the patient was not physically present for services—
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—
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 Subscriber 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
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 1
—
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 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
DTP
3450
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 50
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
SV1
3700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV1
Professional Service
RequiredMax use 1
—
Example
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Required
Identifier (ID)
—
Usage notes
—
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
RequiredMax use 1
To identify one or more diagnosis code pointers
SV5
4000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV5
Durable Medical Equipment Service
OptionalMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
PWK
4200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK
Durable Medical Equipment Certificate of Medical Necessity Indicator
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
PWKLine Supplemental InformationRequired
Identifier (ID)
—
Usage notes
—
- AB
- Previously Submitted to Payer
- AD
- Certification Included in this Claim
- AF
- Narrative Segment Included in this Claim
- AG
- No Documentation is Required
- NS
- Not Specified—
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
Variants (all may be used)
PWKDurable Medical Equipment Certificate of Medical Necessity IndicatorIf 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)
—
Usage notes
—
- AA
- Available on Request at Provider Site—
- BM
- By Mail
- EL
- Electronically Only—
- EM
- FT
- File Transfer
- FX
- By Fax
CR1
4250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR1
Ambulance Transport Information
OptionalMax use 1
—
Usage notes
—
Example
If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required
Required
Identifier (ID)
—
- A
- Patient was transported to nearest facility for care of symptoms, complaints, or both
- B
- Patient was transported for the benefit of a preferred physician
- C
- Patient was transported for the nearness of family members
- D
- Patient was transported for the care of a specialist or for availability of specialized equipment
- E
- Patient Transferred to Rehabilitation Facility
CR3
4350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR3
Durable Medical Equipment Certification
OptionalMax use 1
—
Usage notes
—
Example
CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC
Ambulance Certification
OptionalMax use 3
—
Usage notes
—
Example
Variants (all may be used)
CRCCondition Indicator/Durable Medical EquipmentCRCHospice Employee IndicatorRequired
Identifier (ID)
—
Usage notes
—
- 01
- Patient was admitted to a hospital
- 04
- Patient was moved by stretcher
- 05
- Patient was unconscious or in shock
- 06
- Patient was transported in an emergency situation
- 07
- Patient had to be physically restrained
- 08
- Patient had visible hemorrhaging
- 09
- Ambulance service was medically necessary
- 12
- Patient is confined to a bed or chair—
CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC
Condition Indicator/Durable Medical Equipment
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 09
- Durable Medical Equipment Certification
Required
Identifier (ID)
—
- 38
- Certification signed by the physician is on file at the supplier's office
- ZV
- Replacement Item
CRC
4500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC
Hospice Employee Indicator
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
CRCAmbulance CertificationCRCCondition Indicator/Durable Medical EquipmentDTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Begin Therapy Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
DATE - Certification Revision/Recertification Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Initial Treatment Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Last Certification Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Last Seen Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Last X-ray Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Prescription Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Service Date
RequiredMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Shipped Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Test Date
OptionalMax use 2
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 738
- Most Recent Hemoglobin or Hematocrit or Both
- 739
- Most Recent Serum Creatine
Required
Identifier (ID)
—
- D8
- Date Expressed in Format CCYYMMDD
QTY
4600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY
Ambulance Patient Count
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
QTYObstetric Anesthesia Additional UnitsQTY
4600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY
Obstetric Anesthesia Additional Units
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
QTYAmbulance Patient CountMEA
4620
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > MEA
Test Result
OptionalMax use 5
—
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
Variants (all may be used)
REFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Clinical Laboratory Improvement Amendment (CLIA) Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Immunization Batch Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREF
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 NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Mammography Certification Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Prior Authorization
OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberOptionalMax 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
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Referral Number
OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationREFRepriced Line Item Reference NumberOptionalMax 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
—
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
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
Repriced Line Item Reference Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFAdjusted Repriced Line Item Reference NumberREFClinical Laboratory Improvement Amendment (CLIA) NumberREFImmunization Batch NumberREFLine Item Control NumberREFMammography Certification NumberREFPrior AuthorizationREFReferral NumberREFReferring Clinical Laboratory Improvement Amendment (CLIA) Facility IdentificationAMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT
Postage Claimed Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTSales Tax AmountAMT
4750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT
Sales Tax Amount
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTPostage Claimed AmountK3
4800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3
File Information
OptionalMax use 10
—
Usage notes
—
Example
NTE
4850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE
Line Note
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
NTEThird Party Organization NotesNTE
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
Variants (all may be used)
NTELine NotePS1
4880
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1
Purchased Service Information
OptionalMax use 1
—
Usage notes
—
Example
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 Rendering Provider Name Loop
OptionalMax 1
NM1
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
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV
Rendering Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
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
—
2420A Rendering Provider Name Loop end
2420B Purchased Service Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1
Purchased Service Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Purchased Service 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 > Purchased Service Provider Name Loop > REF
Purchased Service 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
—
2420B Purchased Service Provider Name Loop end
2420C Service Facility Location Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N3
Service Facility Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF
Service Facility Location Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 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 Service Facility Location Name Loop end
2420D Supervising Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1
Supervising Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising 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 > Supervising Provider Name Loop > REF
Supervising 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
—
2420D Supervising Provider Name Loop end
2420E Ordering Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1
Ordering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Ordering 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
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3
Ordering Provider Address
OptionalMax use 1
—
Usage notes
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N4
Ordering Provider City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Ordering 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
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > REF
Ordering 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
—
PER
5300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > PER
Ordering Provider Contact Information
OptionalMax use 1
—
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
2420E Ordering Provider Name Loop end
2420F Referring Provider Name Loop
OptionalMax 2
NM1
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
—
2420F Referring Provider Name Loop end
2420G Ambulance Pick-up Location Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > NM1
Ambulance Pick-up Location
RequiredMax use 1
—
Usage notes
—
Example
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N3
Ambulance Pick-up Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Pick-up Location Loop > N4
Ambulance Pick-up Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Ambulance Pick-up 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
2420G Ambulance Pick-up Location Loop end
2420H Ambulance Drop-off Location Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > NM1
Ambulance Drop-off Location
RequiredMax use 1
—
Usage notes
—
Example
N3
5140
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3
Ambulance Drop-off Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
5200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N4
Ambulance Drop-off Location City, State, ZIP Code
RequiredMax use 1
—
Example
Only one of Ambulance Drop-off 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
2420H Ambulance Drop-off Location 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
RequiredMax 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.
Required
Identifier (ID)
—
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes—
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
2440 Form Identification Code Loop
OptionalMax >1
LQ
5510
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > LQ
Form Identification Code
RequiredMax use 1
—
Usage notes
—
Example
FRM
5520
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM
Supporting Documentation
RequiredMax use 99
—
Usage notes
—
Example
At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required
2440 Form Identification Code 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 1: Commercial Health Insurance
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0214*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*021452*000000001*X*005010X222A2~
ST*837*0021*005010X222A2~
BHT*0019*00*244579*20061015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222*EX*231~
NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*203BF0100Y~
NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*1~
SBR*P**2222-SJ******CI~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
CLM*26463774*100***11>B>1*Y*A*Y*I~
REF*D9*17312345600006351~
HI*BK>0340*BF>V7389~
LX*1~
SV1*HC>99213*40*UN*1***1~
DTP*472*D8*20061003~
LX*2~
SV1*HC>87070*15*UN*1***1~
DTP*472*D8*20061003~
LX*3~
SV1*HC>99214*35*UN*1***2~
DTP*472*D8*20061010~
LX*4~
SV1*HC>86663*10*UN*1***2~
DTP*472*D8*20061010~
SE*35*0021~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*021452*000000001*X*005010X222A2~
ST*837*0021*005010X222A2~
BHT*0019*00*244579*20061015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222*EX*231~
NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*203BF0100Y~
NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*1~
SBR*P**2222-SJ******CI~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
CLM*26463774*100***11>B>1*Y*A*Y*I~
REF*D9*17312345600006351~
HI*BK>0340*BF>V7389~
LX*1~
SV1*HC>99213*40*UN*1***1~
DTP*472*D8*20061003~
LX*2~
SV1*HC>87070*15*UN*1***1~
DTP*472*D8*20061003~
LX*3~
SV1*HC>99214*35*UN*1***2~
DTP*472*D8*20061010~
LX*4~
SV1*HC>86663*10*UN*1***2~
DTP*472*D8*20061010~
SE*35*0021~
GE*1*000000001~
IEA*1*000000001~
Example 10a: Drug administered in the Physician Office
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0215*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*021535*000000001*X*005010X222A2~
ST*837*0711*005010X222A2~
BHT*0019*00*0013*20040801*1200*CH~
NM1*41*2*Associates in Medicine*****46*587654321~
PER*IC*Bud Holly*TE*8017268899~
NM1*40*2*XYZ Receiver*****46*369852758~
HL*1**20*1~
NM1*85*2*Associates in Medicine*****XX*587654321~
N3*1313 Las Vegas Boulevard~
N4*Las Vegas*NV*89109~
REF*EI*587654321~
HL*2*1*22*0~
SBR*P*18*GRP01020102******CI~
NM1*IL*1*Vaughn*Steve*R***MI*MBRID12345~
N3*236 Diamond ST~
N4*Las Vegas*NV*89109~
DMG*D8*19430501*M~
NM1*PR*2*R&R Health Plan*****PI*PLANID12345~
CLM*CLMNO12345*103.37***11>B>1*Y*A*Y*Y~
HI*BK>03591~
NM1*82*1*Hendrix*Jim****XX*1122333341~
PRV*PE*PXC*208D00000X~
LX*1~
SV1*HC>90782*50*UN*1*11**1~
DTP*472*D8*20040711~
LX*2~
SV1*HC>J1550*53.37*UN*1*11**1~
DTP*472*D8*20040711~
AMT*T*3.37~
LIN**N4*00026063512~
CTP****10*ML~
SE*31*0711~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*021535*000000001*X*005010X222A2~
ST*837*0711*005010X222A2~
BHT*0019*00*0013*20040801*1200*CH~
NM1*41*2*Associates in Medicine*****46*587654321~
PER*IC*Bud Holly*TE*8017268899~
NM1*40*2*XYZ Receiver*****46*369852758~
HL*1**20*1~
NM1*85*2*Associates in Medicine*****XX*587654321~
N3*1313 Las Vegas Boulevard~
N4*Las Vegas*NV*89109~
REF*EI*587654321~
HL*2*1*22*0~
SBR*P*18*GRP01020102******CI~
NM1*IL*1*Vaughn*Steve*R***MI*MBRID12345~
N3*236 Diamond ST~
N4*Las Vegas*NV*89109~
DMG*D8*19430501*M~
NM1*PR*2*R&R Health Plan*****PI*PLANID12345~
CLM*CLMNO12345*103.37***11>B>1*Y*A*Y*Y~
HI*BK>03591~
NM1*82*1*Hendrix*Jim****XX*1122333341~
PRV*PE*PXC*208D00000X~
LX*1~
SV1*HC>90782*50*UN*1*11**1~
DTP*472*D8*20040711~
LX*2~
SV1*HC>J1550*53.37*UN*1*11**1~
DTP*472*D8*20040711~
AMT*T*3.37~
LIN**N4*00026063512~
CTP****10*ML~
SE*31*0711~
GE*1*000000001~
IEA*1*000000001~
Example 11: PPO Repriced Claim
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0222*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*022242*000000001*X*005010X222A2~
ST*837*1002*005010X222A2~
BHT*0019*00*1002*20050620*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*EXTRA HEALTHY INSURANCE*****46*112244~
HL*1**20*1~
NM1*85*2*HAPPY DOCTORS GROUP PRACTICE*****XX*1234567890~
N3*P O BOX 123~
N4*FORT WAYNE*IN*462540000~
REF*EI*555512345~
PER*IC*SUE BILLINGSWORTH*TE*8881231234~
HL*2*1*22*0~
SBR*P*18*123XYZ******CI~
NM1*IL*1*RING*DIAMOND*D***MI*00124A089~
N3*123 EXAMPLE DRIVE~
N4*INDIANAPOLIS*IN*462290000~
DMG*D8*19401229*F~
NM1*PR*2*EXTRA HEALTHY INSURANCE*****PI*12345~
CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P~
REF*9A*0902352342~
REF*D9*061505501749388~
HI*BK>496*BF>25000~
HCP*03*26.75*2*908231234~
NM1*DN*1*DOE*JOHN****XX*9988776655~
NM1*82*1*ANTHONY*SUSAN*B***XX*1122334455~
NM1*77*2*HAPPY DOCTORS GROUP~
N3*123 FEEL GOOD ROAD~
N4*WASHINGTON*IN*475010000~
LX*1~
SV1*HC>E0570>RR*25*UN*1***1>2~
DTP*472*D8*20050514~
LX*2~
SV1*HC>A7003>NU*3.75*UN*1***1~
DTP*472*D8*20050514~
SE*35*1002~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*022242*000000001*X*005010X222A2~
ST*837*1002*005010X222A2~
BHT*0019*00*1002*20050620*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*EXTRA HEALTHY INSURANCE*****46*112244~
HL*1**20*1~
NM1*85*2*HAPPY DOCTORS GROUP PRACTICE*****XX*1234567890~
N3*P O BOX 123~
N4*FORT WAYNE*IN*462540000~
REF*EI*555512345~
PER*IC*SUE BILLINGSWORTH*TE*8881231234~
HL*2*1*22*0~
SBR*P*18*123XYZ******CI~
NM1*IL*1*RING*DIAMOND*D***MI*00124A089~
N3*123 EXAMPLE DRIVE~
N4*INDIANAPOLIS*IN*462290000~
DMG*D8*19401229*F~
NM1*PR*2*EXTRA HEALTHY INSURANCE*****PI*12345~
CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P~
REF*9A*0902352342~
REF*D9*061505501749388~
HI*BK>496*BF>25000~
HCP*03*26.75*2*908231234~
NM1*DN*1*DOE*JOHN****XX*9988776655~
NM1*82*1*ANTHONY*SUSAN*B***XX*1122334455~
NM1*77*2*HAPPY DOCTORS GROUP~
N3*123 FEEL GOOD ROAD~
N4*WASHINGTON*IN*475010000~
LX*1~
SV1*HC>E0570>RR*25*UN*1***1>2~
DTP*472*D8*20050514~
LX*2~
SV1*HC>A7003>NU*3.75*UN*1***1~
DTP*472*D8*20050514~
SE*35*1002~
GE*1*000000001~
IEA*1*000000001~
Example 12: Out of Network Repriced Claim
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0223*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*022316*000000001*X*005010X222A2~
ST*837*1024*005010X222A2~
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*EMERGENCY PHYSICIANS GROUP*****XX*1122334455~
N3*7423 SUPER STREET~
N4*BILLINGS*MO*919910000~
REF*EI*111002222~
HL*2*1*22*1~
SBR*P**232AA******CI~
NM1*IL*1*SMITH*MATTHEW*R***MI*57976235C~
N3*5698 SOUTH STREET~
N4*BILLINGS*MO*919910000~
DMG*D8*19561015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*00123~
CLM*TS234H3*252.71***23>B>1*Y*A*Y*Y*P~
REF*9A*0902345406~
REF*D9*687534234346~
HI*BK>9951~
HCP*00*0**333001234*********T1~
NM1*82*1*BLUE*JACKIE*D***XX*1112223336~
SBR*S*18*56567******CI~
OI***Y***Y~
NM1*IL*1*SMITH*TOM*E***MI*23424570~
N3*5698 SOUTH STREET~
N4*BILLINGS*MO*919910000~
NM1*PR*2*SECONDARY INSURANCE COMPANY*****PI*95645~
LX*1~
SV1*HC>99284*252.71*UN*1***1~
DTP*472*D8*20050506~
SE*33*1024~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*022316*000000001*X*005010X222A2~
ST*837*1024*005010X222A2~
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*EMERGENCY PHYSICIANS GROUP*****XX*1122334455~
N3*7423 SUPER STREET~
N4*BILLINGS*MO*919910000~
REF*EI*111002222~
HL*2*1*22*1~
SBR*P**232AA******CI~
NM1*IL*1*SMITH*MATTHEW*R***MI*57976235C~
N3*5698 SOUTH STREET~
N4*BILLINGS*MO*919910000~
DMG*D8*19561015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*00123~
CLM*TS234H3*252.71***23>B>1*Y*A*Y*Y*P~
REF*9A*0902345406~
REF*D9*687534234346~
HI*BK>9951~
HCP*00*0**333001234*********T1~
NM1*82*1*BLUE*JACKIE*D***XX*1112223336~
SBR*S*18*56567******CI~
OI***Y***Y~
NM1*IL*1*SMITH*TOM*E***MI*23424570~
N3*5698 SOUTH STREET~
N4*BILLINGS*MO*919910000~
NM1*PR*2*SECONDARY INSURANCE COMPANY*****PI*95645~
LX*1~
SV1*HC>99284*252.71*UN*1***1~
DTP*472*D8*20050506~
SE*33*1024~
GE*1*000000001~
IEA*1*000000001~
Example 2: Encounter
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0223*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*022349*000000001*X*005010X222A2~
ST*837*0021*005010X222A2~
BHT*0019*00*0123*20061015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222*EX*231~
NM1*40*2*AHLIC*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*203BF0100Y~
NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*0~
SBR*P*18*12312-A******HM~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*M~
NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~
CLM*26462967*100***11>B>1*Y*A*Y*I~
DTP*431*D8*19981003~
REF*D9*17312345600006351~
HI*BK>0340*BF>V7389~
NM1*77*2*KILDARE ASSOCIATES*****XX*5812345679~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
LX*1~
SV1*HC>99213*40*UN*1***1~
DTP*472*D8*20061003~
LX*2~
SV1*HC>87072*15*UN*1***1~
DTP*472*D8*20061003~
LX*3~
SV1*HC>99214*35*UN*1***2~
DTP*472*D8*20061010~
LX*4~
SV1*HC>86663*10*UN*1***2~
DTP*472*D8*20061010~
SE*41*0021~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*022349*000000001*X*005010X222A2~
ST*837*0021*005010X222A2~
BHT*0019*00*0123*20061015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222*EX*231~
NM1*40*2*AHLIC*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*203BF0100Y~
NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*0~
SBR*P*18*12312-A******HM~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*M~
NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~
CLM*26462967*100***11>B>1*Y*A*Y*I~
DTP*431*D8*19981003~
REF*D9*17312345600006351~
HI*BK>0340*BF>V7389~
NM1*77*2*KILDARE ASSOCIATES*****XX*5812345679~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
LX*1~
SV1*HC>99213*40*UN*1***1~
DTP*472*D8*20061003~
LX*2~
SV1*HC>87072*15*UN*1***1~
DTP*472*D8*20061003~
LX*3~
SV1*HC>99214*35*UN*1***2~
DTP*472*D8*20061010~
LX*4~
SV1*HC>86663*10*UN*1***2~
DTP*472*D8*20061010~
SE*41*0021~
GE*1*000000001~
IEA*1*000000001~
Example 3a: Claim from Billing Provider to Payer A
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0228*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*022802*000000001*X*005010X222A2~
ST*837*0021*005010X222A2~
BHT*0019*00*0123*20051015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222~
NM1*40*2*XYZ REPRICER*****46*66783JJT~
HL*1**20*1~
NM1*85*1*KILDARE*BEN****XX*1999996666~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*123456789~
PER*IC*CONNIE*TE*3055551234~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
N3*3333 OCEAN ST~
N4*SOUTH MIAMI*FL*33000~
CLM*26407789*79.04***11>B>1*Y*A*Y*I*P~
HI*BK>4779*BF>2724*BF>2780*BF>53081~
NM1*82*1*KILDARE*BEN****XX*1999996666~
PRV*PE*PXC*204C00000X~
REF*G2*KA6663~
NM1*77*2*KILDARE ASSOCIATES*****XX*1581234567~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
SBR*S*01*******CI~
OI***Y*P**Y~
NM1*IL*1*SMITH*JACK****MI*T55TY666~
N3*236 N MAIN ST~
N4*MIAMI*FL*33111~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
LX*1~
SV1*HC>99213*43*UN*1***1>2>3>4~
DTP*472*D8*20051003~
LX*2~
SV1*HC>90782*15*UN*1***1>2~
DTP*472*D8*20051003~
LX*3~
SV1*HC>J3301*21.04*UN*1***1>2~
DTP*472*D8*20051003~
SE*45*0021~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*022802*000000001*X*005010X222A2~
ST*837*0021*005010X222A2~
BHT*0019*00*0123*20051015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222~
NM1*40*2*XYZ REPRICER*****46*66783JJT~
HL*1**20*1~
NM1*85*1*KILDARE*BEN****XX*1999996666~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*123456789~
PER*IC*CONNIE*TE*3055551234~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
N3*3333 OCEAN ST~
N4*SOUTH MIAMI*FL*33000~
CLM*26407789*79.04***11>B>1*Y*A*Y*I*P~
HI*BK>4779*BF>2724*BF>2780*BF>53081~
NM1*82*1*KILDARE*BEN****XX*1999996666~
PRV*PE*PXC*204C00000X~
REF*G2*KA6663~
NM1*77*2*KILDARE ASSOCIATES*****XX*1581234567~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
SBR*S*01*******CI~
OI***Y*P**Y~
NM1*IL*1*SMITH*JACK****MI*T55TY666~
N3*236 N MAIN ST~
N4*MIAMI*FL*33111~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
LX*1~
SV1*HC>99213*43*UN*1***1>2>3>4~
DTP*472*D8*20051003~
LX*2~
SV1*HC>90782*15*UN*1***1>2~
DTP*472*D8*20051003~
LX*3~
SV1*HC>J3301*21.04*UN*1***1>2~
DTP*472*D8*20051003~
SE*45*0021~
GE*1*000000001~
IEA*1*000000001~
Example 4: Medicare Secondary Payer (COB)
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0230*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*023015*000000001*X*005010X222A2~
ST*837*0002*005010X222A2~
BHT*0019*00*000001142*20050214*115101*CH~
NM1*41*2*SPECIALISTS*****46*1111111~
PER*IC*SUE*TE*8005558888~
NM1*40*2*MEDICARE PENNSYLVANIA*****46*10234~
HL*1**20*1~
NM1*85*2*SPECIALISTS*****XX*0100000090~
N3*5 MAP COURT~
N4*MAYNE*PA*17111~
REF*EI*890123456~
HL*2*1*22*0~
SBR*S*18*MEDICARE*12*****MB~
NM1*IL*1*MEDYUM*WAYNE*M***MI*102200221B1~
N3*1010 THOUSAND OAK LANE~
N4*MAYN*PA*17089~
DMG*D8*19560110*M~
NM1*PR*2*MEDICARE PENNSYLVANIA*****PI*10234~
N3*5232 MAYNE AVENUE~
N4*LYGHT*PA*17009~
CLM*101KEN6055*120***11>B>1*Y*A*Y*Y*P~
HI*BK>71516*BF>71906~
NM1*DN*1*BRYHT*LEE*T~
REF*1G*B01010~
NM1*82*1*HENZES*JACK****XX*9090909090~
PRV*PE*PXC*207X00000X~
REF*G2*110102CCC~
SBR*P*01**COMMERCE*****CI~
AMT*D*80~
AMT*A8*15~
OI***Y*P**Y~
NM1*IL*1*MEDYUM*CAROL****MI*COM188-404777~
N3*PO BOX 45~
N4*MAYN*PA*17089~
NM1*PR*2*COMMERCE*****PI*59999~
LX*1~
SV1*HC>99203>25*120*UN*1***1>2~
DTP*472*D8*20050119~
SVD*59999*80*HC>99203>25**1~
CAS*CO*42*25~
CAS*PR*2*15~
DTP*573*D8*20050128~
SE*42*0002~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*023015*000000001*X*005010X222A2~
ST*837*0002*005010X222A2~
BHT*0019*00*000001142*20050214*115101*CH~
NM1*41*2*SPECIALISTS*****46*1111111~
PER*IC*SUE*TE*8005558888~
NM1*40*2*MEDICARE PENNSYLVANIA*****46*10234~
HL*1**20*1~
NM1*85*2*SPECIALISTS*****XX*0100000090~
N3*5 MAP COURT~
N4*MAYNE*PA*17111~
REF*EI*890123456~
HL*2*1*22*0~
SBR*S*18*MEDICARE*12*****MB~
NM1*IL*1*MEDYUM*WAYNE*M***MI*102200221B1~
N3*1010 THOUSAND OAK LANE~
N4*MAYN*PA*17089~
DMG*D8*19560110*M~
NM1*PR*2*MEDICARE PENNSYLVANIA*****PI*10234~
N3*5232 MAYNE AVENUE~
N4*LYGHT*PA*17009~
CLM*101KEN6055*120***11>B>1*Y*A*Y*Y*P~
HI*BK>71516*BF>71906~
NM1*DN*1*BRYHT*LEE*T~
REF*1G*B01010~
NM1*82*1*HENZES*JACK****XX*9090909090~
PRV*PE*PXC*207X00000X~
REF*G2*110102CCC~
SBR*P*01**COMMERCE*****CI~
AMT*D*80~
AMT*A8*15~
OI***Y*P**Y~
NM1*IL*1*MEDYUM*CAROL****MI*COM188-404777~
N3*PO BOX 45~
N4*MAYN*PA*17089~
NM1*PR*2*COMMERCE*****PI*59999~
LX*1~
SV1*HC>99203>25*120*UN*1***1>2~
DTP*472*D8*20050119~
SVD*59999*80*HC>99203>25**1~
CAS*CO*42*25~
CAS*PR*2*15~
DTP*573*D8*20050128~
SE*42*0002~
GE*1*000000001~
IEA*1*000000001~
Example 5: Ambulance
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0232*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*023243*000000001*X*005010X222A2~
ST*837*000017712*005010X222A2~
BHT*0019*00*000017712*20050208*1112*CH~
NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369~
PER*IC*LISA SMITH*TE*3037752536~
NM1*40*2*MEDICARE B*****46*123245~
HL*1**20*1~
PRV*BI*PXC*3416L0300X~
NM1*85*2*AAA AMBULANCE SERVICE*****XX*2366554859~
N3*12202 AIRPORT WAY~
N4*BROOMFIELD*CO*800210021~
REF*EI*376985369~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*JONES*SARAH*A***MI*012345678A~
N3*1129 REINDEER ROAD~
N4*CARR*CO*80612~
DMG*D8*19630729*F~
NM1*PR*2*MEDICARE PART B*****PI*123245~
N3*PO BOX 3543~
N4*BALTIMORE*MD*666013543~
CLM*051068*766.50***41>B>1*Y*A*Y*Y*P*OA~
DTP*439*D8*20050208~
CR1*LB*275**A*DH*21****PATIENT IMOBILIZED~
CRC*07*Y*04*06*09~
CRC*07*N*05*07*08~
HI*BK>8628*BF>E8888*BF>9592*BF>8540~
NM1*PW*2~
N3*1129 REINDEER ROAD~
N4*CARR*CO*80612~
NM1*45*2~
N3*10005 BANNOCK ST~
N4*CHEYENNE*WY*82009~
LX*1~
SV1*HC>A0427>RH*700*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
QTY*PT*2~
REF*6R*1001~
NTE*ADD*CARDIAC EMERGENCY~
LX*2~
SV1*HC>A0425>RH*8.20*UN*21***1>2>3>4**Y~
DTP*472*D8*20050208~
QTY*PT*2~
REF*6R*1002~
LX*3~
SV1*HC>A0422>RH*46*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
REF*6R*1003~
LX*4~
SV1*HC>A0382>RH*12.30*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
REF*6R*1004~
SE*52*000017712~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*023243*000000001*X*005010X222A2~
ST*837*000017712*005010X222A2~
BHT*0019*00*000017712*20050208*1112*CH~
NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369~
PER*IC*LISA SMITH*TE*3037752536~
NM1*40*2*MEDICARE B*****46*123245~
HL*1**20*1~
PRV*BI*PXC*3416L0300X~
NM1*85*2*AAA AMBULANCE SERVICE*****XX*2366554859~
N3*12202 AIRPORT WAY~
N4*BROOMFIELD*CO*800210021~
REF*EI*376985369~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*JONES*SARAH*A***MI*012345678A~
N3*1129 REINDEER ROAD~
N4*CARR*CO*80612~
DMG*D8*19630729*F~
NM1*PR*2*MEDICARE PART B*****PI*123245~
N3*PO BOX 3543~
N4*BALTIMORE*MD*666013543~
CLM*051068*766.50***41>B>1*Y*A*Y*Y*P*OA~
DTP*439*D8*20050208~
CR1*LB*275**A*DH*21****PATIENT IMOBILIZED~
CRC*07*Y*04*06*09~
CRC*07*N*05*07*08~
HI*BK>8628*BF>E8888*BF>9592*BF>8540~
NM1*PW*2~
N3*1129 REINDEER ROAD~
N4*CARR*CO*80612~
NM1*45*2~
N3*10005 BANNOCK ST~
N4*CHEYENNE*WY*82009~
LX*1~
SV1*HC>A0427>RH*700*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
QTY*PT*2~
REF*6R*1001~
NTE*ADD*CARDIAC EMERGENCY~
LX*2~
SV1*HC>A0425>RH*8.20*UN*21***1>2>3>4**Y~
DTP*472*D8*20050208~
QTY*PT*2~
REF*6R*1002~
LX*3~
SV1*HC>A0422>RH*46*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
REF*6R*1003~
LX*4~
SV1*HC>A0382>RH*12.30*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
REF*6R*1004~
SE*52*000017712~
GE*1*000000001~
IEA*1*000000001~
Example 6: Chiropractic
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0234*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*023446*000000001*X*005010X222A2~
ST*837*3701*005010X222A2~
BHT*0019*00*007227*20050215*075420*CH~
NM1*41*2*DAVID GREEN*****46*S01057~
PER*IC*KATHY SMITH*TE*4105558888~
NM1*40*2*MEDICARE PART B MARYLAND*****46*12345~
HL*1**20*1~
NM1*85*1*GREENE*DAVID*M***XX*1234567890~
N3*1264 OAKWOOD AVE~
N4*BALTIMORE*MD*21236~
REF*EI*987654321~
PER*IC*DR*TE*4105551212~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*WILLIAMSON*MATTHEW*J***MI*123456789A~
N3*128 BROADCREEK~
N4*BALTIMORE*MD*21234~
DMG*D8*19250110*M~
NM1*PR*2*MEDICARE PART B MARYLAND*****PI*C12345~
CLM*125WILL*145.5***11>B>1*Y*A*Y*Y~
DTP*454*D8*20050115~
DTP*453*D8*20050110~
DTP*455*D8*20050113~
CR2********A**CHRONIC PAIN AND DISCOMFORT~
HI*BK>7215~
LX*1~
SV1*HC>98940*145.5*UN*1***1~
DTP*472*D8*20050215~
REF*6R*01~
SE*29*3701~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*023446*000000001*X*005010X222A2~
ST*837*3701*005010X222A2~
BHT*0019*00*007227*20050215*075420*CH~
NM1*41*2*DAVID GREEN*****46*S01057~
PER*IC*KATHY SMITH*TE*4105558888~
NM1*40*2*MEDICARE PART B MARYLAND*****46*12345~
HL*1**20*1~
NM1*85*1*GREENE*DAVID*M***XX*1234567890~
N3*1264 OAKWOOD AVE~
N4*BALTIMORE*MD*21236~
REF*EI*987654321~
PER*IC*DR*TE*4105551212~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*WILLIAMSON*MATTHEW*J***MI*123456789A~
N3*128 BROADCREEK~
N4*BALTIMORE*MD*21234~
DMG*D8*19250110*M~
NM1*PR*2*MEDICARE PART B MARYLAND*****PI*C12345~
CLM*125WILL*145.5***11>B>1*Y*A*Y*Y~
DTP*454*D8*20050115~
DTP*453*D8*20050110~
DTP*455*D8*20050113~
CR2********A**CHRONIC PAIN AND DISCOMFORT~
HI*BK>7215~
LX*1~
SV1*HC>98940*145.5*UN*1***1~
DTP*472*D8*20050215~
REF*6R*01~
SE*29*3701~
GE*1*000000001~
IEA*1*000000001~
Example 7: Oxygen
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0235*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*023520*000000001*X*005010X222A2~
ST*837*0001*005010X222A2~
BHT*0019*00*16*20050326*1036*CH~
NM1*41*2*OXYGEN SUPPLY COMPANY*****46*ABC11111~
PER*IC*BONNIE*TE*8125551111*EM*HELPDESK@OXYGEN.COM~
NM1*40*2*DMERC CARRIER*****46*99999~
HL*1**20*1~
NM1*85*2*OXYGEN SUPPLY COMPANY*****XX*9992233334~
N3*1800 EAST RIDGE DRIVE~
N4*RICHMOND*IN*46224~
REF*EI*389999999~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*SMITH*TERRY****MI*111222333A~
N3*121 SOUTH ST~
N4*RICHMOND*IN*46236~
DMG*D8*19380105*F~
NM1*PR*2*DMERC CARRIER*****PI*99999~
CLM*R03996273 #01*520.24***11>B>1*Y*A*Y*Y~
HI*BK>496*BF>51881*BF>2859~
LX*1~
SV1*HC>E1390>RR*461.1*UN*1***1>2~
PWK*CT*AD~
CR3*R*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*607*D8*20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
NM1*DK*1*WILSON*LARRY****XX*5555511111~
N3*1212 NORTH MERIDIAN~
N4*RICHMOND*IN*46223~
REF*1G*X99999~
PER*IC*LEE*TE*5554446666~
LQ*UT*04.03~
FRM*1A**056~
FRM*1C**20050228~
FRM*2**1~
FRM*3**1~
FRM*4*Y~
FRM*5**2~
FRM*7*Y~
FRM*8*N~
FRM*9*Y~
LX*2~
SV1*HC>E0431>RR*59.14*UN*1***1>2~
PWK*CT*AD~
CR3*R*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*607*D8*20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
NM1*DK*1*WILSON*LARRY****XX*5555511111~
N3*1212 NORTH MERIDIAN~
N4*RICHMOND*IN*46223~
REF*1G*X99999~
PER*IC*LEE*TE*5554446666~
LQ*UT*04.03~
FRM*1A**056~
FRM*1C**20050228~
FRM*2**1~
FRM*3**1~
FRM*4*Y~
FRM*5**2~
FRM*7*Y~
FRM*8*N~
FRM*9*Y~
SE*66*0001~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*023520*000000001*X*005010X222A2~
ST*837*0001*005010X222A2~
BHT*0019*00*16*20050326*1036*CH~
NM1*41*2*OXYGEN SUPPLY COMPANY*****46*ABC11111~
PER*IC*BONNIE*TE*8125551111*EM*HELPDESK@OXYGEN.COM~
NM1*40*2*DMERC CARRIER*****46*99999~
HL*1**20*1~
NM1*85*2*OXYGEN SUPPLY COMPANY*****XX*9992233334~
N3*1800 EAST RIDGE DRIVE~
N4*RICHMOND*IN*46224~
REF*EI*389999999~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*SMITH*TERRY****MI*111222333A~
N3*121 SOUTH ST~
N4*RICHMOND*IN*46236~
DMG*D8*19380105*F~
NM1*PR*2*DMERC CARRIER*****PI*99999~
CLM*R03996273 #01*520.24***11>B>1*Y*A*Y*Y~
HI*BK>496*BF>51881*BF>2859~
LX*1~
SV1*HC>E1390>RR*461.1*UN*1***1>2~
PWK*CT*AD~
CR3*R*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*607*D8*20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
NM1*DK*1*WILSON*LARRY****XX*5555511111~
N3*1212 NORTH MERIDIAN~
N4*RICHMOND*IN*46223~
REF*1G*X99999~
PER*IC*LEE*TE*5554446666~
LQ*UT*04.03~
FRM*1A**056~
FRM*1C**20050228~
FRM*2**1~
FRM*3**1~
FRM*4*Y~
FRM*5**2~
FRM*7*Y~
FRM*8*N~
FRM*9*Y~
LX*2~
SV1*HC>E0431>RR*59.14*UN*1***1>2~
PWK*CT*AD~
CR3*R*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*607*D8*20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
NM1*DK*1*WILSON*LARRY****XX*5555511111~
N3*1212 NORTH MERIDIAN~
N4*RICHMOND*IN*46223~
REF*1G*X99999~
PER*IC*LEE*TE*5554446666~
LQ*UT*04.03~
FRM*1A**056~
FRM*1C**20050228~
FRM*2**1~
FRM*3**1~
FRM*4*Y~
FRM*5**2~
FRM*7*Y~
FRM*8*N~
FRM*9*Y~
SE*66*0001~
GE*1*000000001~
IEA*1*000000001~
Example 8: Wheelchair
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0238*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*023843*000000001*X*005010X222A2~
ST*837*112233*005010X222A2~
BHT*0019*00*16*20050326*1036*CH~
NM1*41*2*XYZ WHEELCHAIRS INC*****46*ABC55~
PER*IC*JANE*TE*2225551111~
NM1*40*2*DMERC CARRIER*****46*99999~
HL*1**20*1~
NM1*85*2*XYZ WHEELCHAIR INC*****XX*7778889999~
N3*1440 NORTH STREET~
N4*LAFAYETTE*IN*47904~
REF*EI*123567989~
HL*2*1*22*0~
SBR*P*18*******MB~
PAT*******01*155~
NM1*IL*1*SMITH*JAMES****MI*987654321A~
N3*12 MAIN ST~
N4*FRANKFORT*IN*46209~
DMG*D8*19201023*M~
NM1*PR*2*DMERC CARRIER*****PI*99999~
CLM*SMI123*75***12>B>1*Y*A*Y*Y~
HI*BK>436*BF>3449~
LX*1~
SV1*HC>K0001>RR>KH>BR*75*UN*1***1>2~
PWK*CT*AD~
CR3*I*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
MEA*TR*HT*70~
NM1*DK*1*WILSON*RANDALL****XX*1111155555~
N3*1226 WEST RAILROAD STREET~
N4*LAFAYETTE*IN*47905~
REF*1G*M12345~
PER*IC*LEE*TE*7659259999~
LQ*UT*02.03B~
FRM*1*Y~
FRM*2*N~
FRM*3*N~
FRM*4*N~
FRM*5**8~
FRM*8*N~
FRM*9*Y~
SE*42*112233~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*023843*000000001*X*005010X222A2~
ST*837*112233*005010X222A2~
BHT*0019*00*16*20050326*1036*CH~
NM1*41*2*XYZ WHEELCHAIRS INC*****46*ABC55~
PER*IC*JANE*TE*2225551111~
NM1*40*2*DMERC CARRIER*****46*99999~
HL*1**20*1~
NM1*85*2*XYZ WHEELCHAIR INC*****XX*7778889999~
N3*1440 NORTH STREET~
N4*LAFAYETTE*IN*47904~
REF*EI*123567989~
HL*2*1*22*0~
SBR*P*18*******MB~
PAT*******01*155~
NM1*IL*1*SMITH*JAMES****MI*987654321A~
N3*12 MAIN ST~
N4*FRANKFORT*IN*46209~
DMG*D8*19201023*M~
NM1*PR*2*DMERC CARRIER*****PI*99999~
CLM*SMI123*75***12>B>1*Y*A*Y*Y~
HI*BK>436*BF>3449~
LX*1~
SV1*HC>K0001>RR>KH>BR*75*UN*1***1>2~
PWK*CT*AD~
CR3*I*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
MEA*TR*HT*70~
NM1*DK*1*WILSON*RANDALL****XX*1111155555~
N3*1226 WEST RAILROAD STREET~
N4*LAFAYETTE*IN*47905~
REF*1G*M12345~
PER*IC*LEE*TE*7659259999~
LQ*UT*02.03B~
FRM*1*Y~
FRM*2*N~
FRM*3*N~
FRM*4*N~
FRM*5**8~
FRM*8*N~
FRM*9*Y~
SE*42*112233~
GE*1*000000001~
IEA*1*000000001~
Example 9: Anesthesia
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231108*0240*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231108*024052*000000001*X*005010X222A2~
ST*837*0001*005010X222A2~
BHT*0019*00*0123*20050117*1023*CH~
NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~
PER*IC*NINA*TE*6155551212*EX*911~
NM1*40*2*ABC PAYER*****46*05440~
HL*1**20*1~
NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~
N3*1234 WEST END AVE~
N4*NASHVILLE*TN*37232~
REF*EI*756473826~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*JONES*MARGARET****MI*123456789A~
N3*123 RAINBOW ROAD~
N4*NASHVILLE*TN*37232~
DMG*D8*19740303*F~
NM1*PR*2*ABC PAYER*****PI*05440~
CLM*153829140*827***22>B>1*Y*A*Y*Y~
HI*BK>36616~
NM1*82*1*TOWNSEND*JACOB*E***XX*5678912345~
PRV*PE*PXC*207L00000X~
REF*G2*9741234~
NM1*77*2*PROVIDER OP HOSP*****XX*432198765~
N3*345 MAIN DRIVE~
N4*NASHVILLE*TN*37232~
LX*1~
SV1*HC>00142>QK>QS>P1*827*MJ*61***1~
DTP*472*D8*20050112~
SE*29*0001~
GE*1*000000001~
IEA*1*000000001~
GS*HC*SENDERGS*RECEIVERGS*20231108*024052*000000001*X*005010X222A2~
ST*837*0001*005010X222A2~
BHT*0019*00*0123*20050117*1023*CH~
NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~
PER*IC*NINA*TE*6155551212*EX*911~
NM1*40*2*ABC PAYER*****46*05440~
HL*1**20*1~
NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~
N3*1234 WEST END AVE~
N4*NASHVILLE*TN*37232~
REF*EI*756473826~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*JONES*MARGARET****MI*123456789A~
N3*123 RAINBOW ROAD~
N4*NASHVILLE*TN*37232~
DMG*D8*19740303*F~
NM1*PR*2*ABC PAYER*****PI*05440~
CLM*153829140*827***22>B>1*Y*A*Y*Y~
HI*BK>36616~
NM1*82*1*TOWNSEND*JACOB*E***XX*5678912345~
PRV*PE*PXC*207L00000X~
REF*G2*9741234~
NM1*77*2*PROVIDER OP HOSP*****XX*432198765~
N3*345 MAIN DRIVE~
N4*NASHVILLE*TN*37232~
LX*1~
SV1*HC>00142>QK>QS>P1*827*MJ*61***1~
DTP*472*D8*20050112~
SE*29*0001~
GE*1*000000001~
IEA*1*000000001~
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