X12 837 Health Care Claim: Professional (X222A2)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.
For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HC
- Health Care Claim (837)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X222A2
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 837
- Health Care Claim
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
- 005010X222A2
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
- The second example denotes the case where the entire transaction set contains ENCOUNTERS.
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0019
- Information Source, Subscriber, Dependent
Code identifying purpose of transaction set
- BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status.
- 00
- Original
Original transmissions are transmissions which have never been sent to the receiver.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
- This field is limited to 30 characters.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
- This is the date that the original submitter created the claim file from their business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
- This is the time that the original submitter created the claim file from their business application system.
Code specifying the type of transaction
- CH
- Chargeable
Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.
Submitter Name
To supply the full name of an individual or organizational entity
- The submitter is the entity responsible for the creation and formatting of this transaction.
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Established by trading partner agreement
Code identifying a party or other code
CGS will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission. Submitter ID must match the value submitted in ISA06 and GS02.
Submitter EDI Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
- The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
- There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Receiver Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- 40
- Receiver
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
CGS will reject an interchange (transmission) that is not submitted with a valid CGS contractor code. Each individual MAC determines this identifier. Submitter ID must match the value submitted in ISA08 and GS03.
Detail
The Billing Provider Detail Section of this CG contains no unique CMS Medicare requirements that differ from the TR3. Refer to the TR3 specifications for the following Loops: 2000A, 2010AA, 2010AB.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Billing Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when the payer's adjudication is known to be impacted by the provider taxonomy code.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Name
To supply the full name of an individual or organizational entity
- Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
- Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
- The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
- The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration).
- When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
billing provider must be “associated” to the submitter (from a Trading Partner management perspective) in 1000A NM109.
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Billing Provider Address
To specify the location of the named party
- The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
Billing Provider City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Billing Provider Tax Identification
To specify identifying information
- This is the tax identification number (TIN) of the entity to be paid for the submitted services.
Code qualifying the Reference Identification
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
- There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Pay-to Address Name
To supply the full name of an individual or organizational entity
- Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
- The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
Pay-to Address - ADDRESS
To specify the location of the named party
Pay-To Address City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
- P
- Primary
- S
- Secondary
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
For Medicare, the subscriber is always the same as the patient.
- 18
- Self
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
Code identifying the type of insurance policy within a specific insurance program
- 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
Code identifying type of claim
For Medicare, the subscriber is always the same as the patient.
- 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
Use code OF when submitting Medicare Part D claims.
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined
Use Code ZZ when Type of Insurance is not known.
Patient Information
To supply patient information
- Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- PAT06 is the date of death.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- 01
- Actual Pounds
Numeric value of weight
- PAT08 is the patient's weight.
For DME claims only, a maximum of 4 whole numbers and up to 2 decimal positions are allowable.
Code indicating a Yes or No condition or response
- PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant.
- For this implementation, the listed value takes precedence over the semantic note.
- Y
- Yes
Subscriber Name
To supply the full name of an individual or organizational entity
- In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
Code designating the system/method of code structure used for Identification Code (67)
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.
When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Code identifying a party or other code
For the Medicare Beneficiary Identifier (MBI): Must be 11 positions in the format of C A AN N A AN N A A N N where “C” represents a constrained numeric 1 thru 9; “A” represents alphabetic character A – Z but excluding S, L, O, I, B, Z; “N” represents numeric 0 thru 9; “AN” represents either “A” or “N”
Subscriber Address
To specify the location of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Demographic Information
To supply demographic information
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Must not be a future date.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Property and Casualty Claim Number
To specify identifying information
- Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
- This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
- This segment is not a HIPAA requirement as of this writing.
Code qualifying the Reference Identification
- Y4
- Agency Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Property and Casualty Subscriber Contact Information
To identify a person or office to whom administrative communications should be directed
- Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send.
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EX
- Telephone Extension
Complete communications number including country or area code when applicable
Payer Name
To supply the full name of an individual or organizational entity
- This is the destination payer.
- For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- Use code value "PI" when reporting Payor Identification.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:
- Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
OR - Follow an early implementation approach in which the HPID or OEID is sent in NM109.
- PI
- Payor Identification
Payer Address
To specify the location of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Payer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Claim Information
To specify basic data about the claim
- The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
- For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Identifier used to track a claim from creation by the health care provider through payment
- The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
- When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
- The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
Monetary amount
- CLM02 is the total amount of all submitted charges of service segments for this claim.
- The Total Claim Charge Amount must be greater than or equal to zero.
- The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim.
Must be >=0 and <= 99,999.9. When Medicare is primary payer, CLM02 must equal the sum of all SV102 service line charge amounts. When Medicare is Secondary. Total Submitted Charges (CLM02) must equal the sum of all 2320 & 2430 CAS amounts and the 2320 AMT02 (AMT01=D).
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- B
- Place of Service Codes for Professional or Dental Services
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
- 1
- Original
Code indicating a Yes or No condition or response
- CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
- N
- No
- Y
- Yes
Code indicating whether the provider accepts assignment
- Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
- A
- Assigned
Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. - B
- Assignment Accepted on Clinical Lab Services Only
Required when the provider accepts assignment for Clinical Lab Services only.
- C
- Not Assigned
Required when neither codes
A' norB' apply.
Code indicating a Yes or No condition or response
- CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- The Release of Information response is limited to the information carried in this claim.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
- P
- Signature generated by provider because the patient was not physically present for services
Signature generated by an entity other than the patient according to State or Federal law.
Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.
Code identifying an accompanying cause of an illness, injury or an accident
- AA
- Auto Accident
- EM
- Employment
- OA
- Other Accident
Code identifying an accompanying cause of an illness, injury or an accident
Code (Standard State/Province) as defined by appropriate government agency
- C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
Code indicating the Special Program under which the services rendered to the patient were performed
- 02
- Physically Handicapped Children's Program
This code is used for Medicaid claims only.
- 03
- Special Federal Funding
This code is used for Medicaid claims only.
- 05
- Disability
This code is used for Medicaid claims only.
- 09
- Second Opinion or Surgery
This code is used for Medicaid claims only.
Code indicating the reason why a request was delayed
Data submitted in CLM20 will not be used for processing.
- 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
Date - Accident
To specify any or all of a date, a time, or a time period
- Required when CLM11-1 or CLM11-2 has a value of
AA' orOA'.
OR
Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 439
- Accident
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Acute Manifestation
To specify any or all of a date, a time, or a time period
- Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 453
- Acute Manifestation of a Chronic Condition
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Admission
To specify any or all of a date, a time, or a time period
- Required on all ambulance claims when the patient was known to be admitted to the hospital.
OR
Required on all claims involving inpatient medical visits.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 435
- Admission
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Assumed and Relinquished Care Dates
To specify any or all of a date, a time, or a time period
- Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send.
- Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates.
Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A".
Code specifying type of date or time, or both date and time
- 090
- Report Start
Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care.
- 091
- Report End
Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider.
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Authorized Return to Work
To specify any or all of a date, a time, or a time period
- Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 296
- Initial Disability Period Return To Work
This is the date the provider has authorized the patient to return to work.
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Disability Dates
To specify any or all of a date, a time, or a time period
- Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work.
OR
Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 314
- Disability
Use code 314 when both disability start and end date are being reported.
- 360
- Initial Disability Period Start
Use code 360 if patient is currently disabled and disability end date is unknown.
- 361
- Initial Disability Period End
Use code 361 if patient is no longer disabled and the start date is unknown.
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Use code D8 when DTP01 is 360 or 361.
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use code RD8 when DTP01 is 314.
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Discharge
To specify any or all of a date, a time, or a time period
- Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 096
- Discharge
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Hearing and Vision Prescription Date
To specify any or all of a date, a time, or a time period
- Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 471
- Prescription
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Initial Treatment Date
To specify any or all of a date, a time, or a time period
- Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send.
- Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Code specifying type of date or time, or both date and time
- 454
- Initial Treatment
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Last Menstrual Period
To specify any or all of a date, a time, or a time period
- Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 484
- Last Menstrual Period
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Last Seen Date
To specify any or all of a date, a time, or a time period
- Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.
- This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed.
- Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Code specifying type of date or time, or both date and time
- 304
- Latest Visit or Consultation
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Last Worked
To specify any or all of a date, a time, or a time period
- Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 297
- Initial Disability Period Last Day Worked
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Last X-ray Date
To specify any or all of a date, a time, or a time period
- Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send.
- Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Code specifying type of date or time, or both date and time
- 455
- Last X-Ray
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Onset of Current Illness or Symptom
To specify any or all of a date, a time, or a time period
- Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send.
- This date is the onset of acute symptoms for the current illness or condition.
Code specifying type of date or time, or both date and time
- 431
- Onset of Current Symptoms or Illness
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Property and Casualty Date of First Contact
To specify any or all of a date, a time, or a time period
- Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send.
- This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.
Code specifying type of date or time, or both date and time
- 444
- First Visit or Consultation
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Repricer Received Date
To specify any or all of a date, a time, or a time period
- Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 050
- Received
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Claim Supplemental Information
To identify the type or transmission or both of paperwork or supporting information
- Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.
Code indicating the title or contents of a document, report or supporting item
- 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
Code defining timing, transmission method or format by which reports are to be sent
- BM
- By Mail
- EL
- Electronically Only
Indicates that the attachment is being transmitted in a separate X12 functional group.
- FT
- File Transfer
Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- FX
- By Fax
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
- For the purpose of this implementation, the maximum field length is 50.
Patient Amount Paid
To indicate the total monetary amount
- Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
- Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
Adjusted Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9C
- Adjusted Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Care Plan Oversight
To specify identifying information
- Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send.
- This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished.
Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number.
On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI.
Code qualifying the Reference Identification
- 1J
- Facility ID Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identifier For Transmission Intermediaries
To specify identifying information
- Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
- Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
Code qualifying the Reference Identification
- Number assigned by clearinghouse, van, etc.
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The value carried in this element is limited to a maximum of 20 positions.
Clinical Laboratory Improvement Amendment (CLIA) Number
To specify identifying information
- Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send.
- If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
- In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400.
Code qualifying the Reference Identification
- X4
- Clinical Laboratory Improvement Amendment Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Demonstration Project Identifier
To specify identifying information
- Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- P4
- Project Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Investigational Device Exemption Number
To specify identifying information
- Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- LX
- Qualified Products List
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Mammography Certification Number
To specify identifying information
- Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EW
- Mammography Certification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Medical Record Number
To specify identifying information
- Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EA
- Medical Record Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Prior Authorization
To specify identifying information
- Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
- Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
- Required when an authorization number is assigned by the payer or UMO
AND
the services on this claim were preauthorized.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
AND
a referral is involved.
If not required by this implementation guide, do not send. - Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9A
- Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Authorization Exception Code
To specify identifying information
- Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 4N
- Special Payment Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Allowable values for this element are:
1 Immediate/Urgent Care
2 Services Rendered in a Retroactive Period
3 Emergency Care
4 Client has Temporary Medicaid
5 Request from County for Second Opinion to Determine
if Recipient Can Work
6 Request for Override Pending
7 Special Handling
File Information
To transmit a fixed-format record or matrix contents
- Required when ALL of the following conditions are met:
- A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement; - The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement - X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send. - At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. - Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
- X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Data in fixed format agreed upon by sender and receiver
Claim Note
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
If not required by this implementation guide, do not send. - Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300.
- The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Code identifying the functional area or purpose for which the note applies
- ADD
- Additional Information
- CER
- Certification Narrative
- DCP
- Goals, Rehabilitation Potential, or Discharge Plans
- DGN
- Diagnosis Description
- TPO
- Third Party Organization Notes
A free-form description to clarify the related data elements and their content
Ambulance Transport Information
To supply information related to the ambulance service rendered to a patient
- Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send.
- The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- LB
- Pound
Numeric value of weight
- CR102 is the weight of the patient at time of transport.
A maximum of 4 whole numbers and up to 2 decimal positions are allowable.
Patient weight in excess of 9,999.99 pounds will be rejected.
Code indicating the reason for ambulance transport
- A
- Patient was transported to nearest facility for care of symptoms, complaints, or both
Can be used to indicate that the patient was transferred to a residential facility.
- 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
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DH
- Miles
Numeric value of quantity
- CR106 is the distance traveled during transport.
- 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
Must not exceed 4 digits. Transport distance in excess of 9,999 miles will be rejected.
A free-form description to clarify the related data elements and their content
- CR109 is the purpose for the round trip ambulance service.
A free-form description to clarify the related data elements and their content
- CR110 is the purpose for the usage of a stretcher during ambulance service.
Spinal Manipulation Service Information
To supply information related to the chiropractic service rendered to a patient
- Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.
Code indicating the nature of a patient's condition
- A
- Acute Condition
- C
- Chronic Condition
- D
- Non-acute
- E
- Non-Life Threatening
- F
- Routine
- G
- Symptomatic
- M
- Acute Manifestation of a Chronic Condition
A free-form description to clarify the related data elements and their content
- CR210 is a description of the patient's condition.
A free-form description to clarify the related data elements and their content
- CR211 is an additional description of the patient's condition.
Ambulance Certification
To supply information on conditions
- Required when the claim involves ambulance transport services
AND
when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. - The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01.
- Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 07
- Ambulance Certification
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- The codes for CRC03 also can be used for CRC04 through CRC07.
- 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
Use code 12 to indicate patient was bedridden during transport.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
EPSDT Referral
To supply information on conditions
- Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- ZZ
- Mutually Defined
EPSDT Screening referral information.
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- The response answers the question: Was an EPSDT referral given to the patient?
- N
- No
If no, then choose "NU" in CRC03 indicating no referral given.
- Y
- Yes
Code indicating a condition
- The codes for CRC03 also can be used for CRC04 through CRC05.
- AV
- Available - Not Used
Patient refused referral.
- NU
- Not Used
This conditioner indicator must be used when the submitter answers "N" in CRC02.
- S2
- Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health problem.
- ST
- New Services Requested
Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
OR
Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).;
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Homebound Indicator
To supply information on conditions
- Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 75
- Functional Limitations
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- Y
- Yes
Code indicating a condition
- IH
- Independent at Home
Patient Condition Information: Vision
To supply information on conditions
- Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- E1
- Spectacle Lenses
- E2
- Contact Lenses
- E3
- Spectacle Frames
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 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
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Anesthesia Related Procedure
To supply information related to the delivery of health care
- Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BP
- Health Care Financing Administration Common Procedural Coding System Principal Procedure
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BO
- Health Care Financing Administration Common Procedural Coding System
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Condition Information
To supply information related to the delivery of health care
- Required when condition information applies to the claim.
If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- BG
- Condition
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Health Care Diagnosis Code
To supply information related to the delivery of health care
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
All diagnosis codes submitted on a claim must be valid codes per the qualified code source. Claims that contain invalid diagnosis codes (pointed to or not) will be rejected.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
ICD-9 Codes
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Claim Pricing/Repricing Information
To specify pricing or repricing information about a health care claim or line item
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code specifying pricing methodology at which the claim or line item has been priced or repriced
- Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
- 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
Monetary amount
- HCP02 is the allowed amount.
Monetary amount
- HCP03 is the savings amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP04 is the repricing organization identification number.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Rate expressed in the standard monetary denomination for the currency specified
- HCP05 is the pricing rate associated with per diem or flat rate repricing.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP06 is the approved DRG code.
- HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Monetary amount
- HCP07 is the approved DRG amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code assigned by issuer to identify reason for rejection
- HCP13 is the rejection message returned from the third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 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
Code specifying policy compliance
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 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
Code specifying the exception reason for consideration of out-of-network health care services
- HCP15 is the exception reason generated by a third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 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
Referring Provider Name
To supply the full name of an individual or organizational entity
- Required when this claim involves a referral. If not required by this implementation guide, do not send.
- When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
- When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Use on the first iteration of this loop. Use if loop is used only once.
- P3
- Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Referring Provider Secondary Identification
To specify identifying information
- The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider.
If not required by this implementation guide, do not send. - Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
- The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Facility Location Name
To supply the full name of an individual or organizational entity
- Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
If not required by this implementation guide, do not send. - When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
- The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Service Facility Location Address
To specify the location of the named party
- If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Facility Contact Information
To identify a person or office to whom administrative communications should be directed
- Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter.
If not required by this implementation guide, do not send. - When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EX
- Telephone Extension
Complete communications number including country or area code when applicable
Supervising Provider Name
To supply the full name of an individual or organizational entity
- Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Supervising Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Ambulance Pick-up Location
To supply the full name of an individual or organizational entity
- Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Ambulance Pick-up Location Address
To specify the location of the named party
- If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Ambulance Pick-up Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Ambulance Drop-off Location
To supply the full name of an individual or organizational entity
- Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 45
- Drop-off Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Ambulance Drop-off Location Address
To specify the location of the named party
Ambulance Drop-off Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Other Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
- Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
- All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
2320 SBR01 = ”P” must be present when 2000B SBR01 = ”S”
- 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
This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
- 01
- Spouse
- 18
- Self
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
Code identifying the type of insurance policy within a specific insurance program
- 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
Code identifying type of claim
- 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
Use code OF when submitting Medicare Part D claims.
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined
Use Code ZZ when Type of Insurance is not known.
Claim Level Adjustments
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
- Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
- Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
- Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Code identifying the general category of payment adjustment
CAS segment must not be present when 2000B SBR01 = “P”
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Coordination of Benefits (COB) Payer Paid Amount
To indicate the total monetary amount
- Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
If not required by this implementation guide, do not send.;
Code to qualify amount
Medicare requires one occurrence of 2320 loop with an AMT segment AMT01 = ”D” must be present when 2000B SBR01 = ”S”.
- D
- Payor Amount Paid
Monetary amount
- It is acceptable to show "0" as the amount paid.
- When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
Coordination of Benefits (COB) Total Non-Covered Amount
To indicate the total monetary amount
- Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
- When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Remaining Patient Liability
To indicate the total monetary amount
- Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
OR
Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
If not required by this implementation guide, do not send. - In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
- This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
Other Insurance Coverage Information
To specify information associated with other health insurance coverage
- All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Code indicating a Yes or No condition or response
- OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This is a crosswalk from CLM08 when doing COB.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
- This is a crosswalk from CLM10 when doing COB.
- P
- Signature generated by provider because the patient was not physically present for services
Signature generated by an entity other than the patient according to State or Federal law.
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- This is a crosswalk from CLM09 when doing COB.
- The Release of Information response is limited to the information carried in this claim.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
Outpatient Adjudication Information
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
- Required when outpatient adjudication information is reported in the remittance advice
OR
Required when it is necessary to report remark codes.
If not required by this implementation guide, do not send.
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
- MOA01 is the reimbursement rate.
Monetary amount
- MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA03 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA04 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA05 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA06 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA07 is the Claim Payment Remark Code. See Code Source 411.
Monetary amount
- MOA08 is the End Stage Renal Disease (ESRD) payment amount.
Monetary amount
- MOA09 is the professional component amount billed but not payable.
Other Subscriber Name
To supply the full name of an individual or organizational entity
- If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
- If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.
When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Code identifying a party or other code
Other Subscriber Address
To specify the location of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Other Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Other Subscriber Secondary Identification
To specify identifying information
- Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Must be 9 digits with no punctuation.
First 3 digits cannot be higher than “272”.
Digits 1-3, 4-5, and 6-9 cannot be zeros (0).
Other Payer Name
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- Use code value "PI" when reporting Payor Identification.
Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:
- Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).
OR - Follow an early implementation approach in which the HPID or OEID is sent in NM109.
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Code identifying a party or other code
- When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
Other Payer Address
To specify the location of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Other Payer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Claim Check or Remittance Date
To specify any or all of a date, a time, or a time period
- Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Other Payer Claim Adjustment Indicator
To specify identifying information
- Required when the claim is being sent in the payer-to-payer COB model,
AND
the destination payer is secondary to the payer identified in this Loop ID-2330B,
AND
the payer identified in this Loop ID-2330B has re-adjudicated the claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- T4
- Signal Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The only valid value for this element is `Y'.
Other Payer Claim Control Number
To specify identifying information
- Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
OR
Required when the Other Payer's Claim Control Number is available.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- F8
- Original Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Prior Authorization Number
To specify identifying information
- Required when the payer identified in this loop has assigned a prior authorization number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Referral Number
To specify identifying information
- Required when the payer identified in this loop has assigned a referral number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Secondary Identifier
To specify identifying information
- Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
This code is only allowed when the qualifier XV is reported in NM108 of this loop.
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
- FY
- Claim Office Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Number
To reference a line number in a transaction set
- The LX functions as a line counter.
- The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
- LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Number assigned for differentiation within a transaction set
Professional Service
To specify the service line item detail for a health care professional
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID-2410 only.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
For DME only: These segments cannot have a value of “EX.”
For DME only: When billing for capped rentals and pen pumps with 2 units of service, one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “RT” and one of one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “LT”.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
For DME only: These segments cannot have a value of “EX.”
For DME only: When billing for capped rentals and pen pumps with 2 units of service, one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “RT” and one of one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “LT”.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
For DME only: These segments cannot have a value of “EX.”
For DME only: When billing for capped rentals and pen pumps with 2 units of service, one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “RT” and one of one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “LT”.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
For DME only: These segments cannot have a value of “EX.”
For DME only: When billing for capped rentals and pen pumps with 2 units of service, one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “RT” and one of one of SV101-3, SV101-4, SV101-5, SV101-6 must have a value of “LT”.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Monetary amount
- SV102 is the submitted service line item amount.
- This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments.
- Zero "0" is an acceptable value for this element.
SV102 must be greater than 0. SV102’s decimal positions are limited to 0, 1, or 2.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
SV103 must be “UN” for DME claims.
SV103 must be "MJ" when SV101-3, SV101-4, SV101-5, or SV101-6 is an
anesthesia modifier (AA, AD, QK, QS, QX, QY or QZ).
Otherwise, must be "UN".
- MJ
- Minutes
Required for Anesthesia claims.
Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel.
- UN
- Unit
Numeric value of quantity
- Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Anesthesia claims must be submitted with minutes (qualifier MJ). The max value cannot exceed 4 bytes numeric.
Must be > 0 with maximum of 4 whole numbers and 1 decimal position (cannot exceed 9999.9).
For DME only: SV104 must be “1” or “2” for capped rentals and pen pumps.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
- SV105 is the place of service.
- See CODE SOURCE 237: Place of Service Codes for Professional Claims
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
- This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
Code indicating a Yes or No condition or response
- SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related.
- For this implementation, the listed value takes precedence over the semantic note.
Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions.
- Y
- Yes
Code indicating a Yes or No condition or response
- SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
- For this implementation, the listed value takes precedence over the semantic note.
- When this element is used, this service is not the screening service.
- Y
- Yes
Code indicating a Yes or No condition or response
- SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement.
- For this implementation, the listed value takes precedence over the semantic note.
- Y
- Yes
Code indicating whether or not co-payment requirements were met on a line by line basis
- 0
- Copay exempt
Durable Medical Equipment Service
To specify the claim service detail for durable medical equipment
- Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- This value must be the same as that reported in SV101-2.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
Numeric value of quantity
- SV503 is the length of medical treatment required.
DME Only: Must be greater than 0 with a maximum of 3 whole numbers (must not exceed 999).
Monetary amount
- SV504 is the rental price.
DME Only: Must be greater than 0 with maximum of 7 digits – inclusive of up to 3 decimal positions.
Monetary amount
- SV505 is the purchase price.
DME Only: Must be greater than 0 with maximum of 7 digits – inclusive of up to 3 decimal positions.
Code indicating frequency or type of activities or actions being reported
- SV506 is the frequency at which the rental equipment is billed.
- 1
- Weekly
- 4
- Monthly
- 6
- Daily
Durable Medical Equipment Certificate of Medical Necessity Indicator
To identify the type or transmission or both of paperwork or supporting information
- Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.;
Code indicating the title or contents of a document, report or supporting item
DME only.
Must not be present on Part B claims.
- CT
- Certification
Code defining timing, transmission method or format by which reports are to be sent
- Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- 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
NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.
Line Supplemental Information
To identify the type or transmission or both of paperwork or supporting information
- Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.
Code indicating the title or contents of a document, report or supporting item
- 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
Code defining timing, transmission method or format by which reports are to be sent
- Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- AA
- Available on Request at Provider Site
This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.
- BM
- By Mail
- EL
- Electronically Only
Indicates that the attachment is being transmitted in a separate X12 functional group.
- EM
- FT
- File Transfer
- FX
- By Fax
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
- For the purpose of this implementation, the maximum field length is 50.
Ambulance Transport Information
To supply information related to the ambulance service rendered to a patient
- Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- LB
- Pound
Numeric value of weight
- CR102 is the weight of the patient at time of transport.
Must not exceed 4 whole numbers and 2 decimals.
Patient weight in excess of 9,999.99 pounds will be rejected.
Code indicating the reason for ambulance transport
- 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
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DH
- Miles
Numeric value of quantity
- CR106 is the distance traveled during transport.
- 0 (zero) is a valid value when ambulance services do not include a charge for mileage.
Must not exceed 4 digits.
Transport distance in excess of 9,999 miles will be rejected.
A free-form description to clarify the related data elements and their content
- CR109 is the purpose for the round trip ambulance service.
A free-form description to clarify the related data elements and their content
- CR110 is the purpose for the usage of a stretcher during ambulance service.
Durable Medical Equipment Certification
To supply information regarding a physician's certification for durable medical equipment
- Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line.
If not required by this implementation guide, do not send.
Code indicating the type of certification
- I
- Initial
- R
- Renewal
- S
- Revised
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- CR302 and CR303 specify the time period covered by this certification.
- MO
- Months
Numeric value of quantity
- Length of time DME equipment is needed.
DME Only: Must not exceed 2 digits.
DME Only: Must be greater than 0 unless 2400 L02 = “08.02”.
Ambulance Certification
To supply information on conditions
- The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
- Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 07
- Ambulance Certification
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- The codes for CRC03 also can be used for CRC04 through CRC07.
- 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
Use code 12 to indicate patient was bedridden during transport.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Code indicating a condition
- Use the codes listed in CRC03.
Condition Indicator/Durable Medical Equipment
To supply information on conditions
- Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication.
If not required by this implementation guide, do not send. - The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
- The first example shows a case where an item billed was not a replacement item.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
DME Only: When CRC Condition Indicator (CRC01 = “09”) is submitted, either CRC03 or CRC04 must be “38”.
- 09
- Durable Medical Equipment Certification
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 38
- Certification signed by the physician is on file at the supplier's office
- ZV
- Replacement Item
Code indicating a condition
- Use the codes listed in CRC03.
Hospice Employee Indicator
To supply information on conditions
- Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send.
- The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
- The example shows the method used to indicate whether the rendering provider is an employee of the hospice.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 70
- Hospice
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice.
- N
- No
- Y
- Yes
Code indicating a condition
- 65
- Open
This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement.
Date - Begin Therapy Date
To specify any or all of a date, a time, or a time period
- Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 463
- Begin Therapy
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
DME only: Must not be a future date.
Must not be present on a Part B claim.
DATE - Certification Revision/Recertification Date
To specify any or all of a date, a time, or a time period
- Required when CR301 (DMERC Certification) = "R" or "S". If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 607
- Certification Revision
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
DME only: Must not be a future date.
Must not be present on a Part B claim.
Date - Initial Treatment Date
To specify any or all of a date, a time, or a time period
- Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 454
- Initial Treatment
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Last Certification Date
To specify any or all of a date, a time, or a time period
- Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.
- This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF).
Code specifying type of date or time, or both date and time
- 461
- Last Certification
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
DME only: Must not be a future date.
Must not be present on a Part B claim.
Date - Last Seen Date
To specify any or all of a date, a time, or a time period
- Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.;
Code specifying type of date or time, or both date and time
- 304
- Latest Visit or Consultation
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Segment must not be present for DME claims.
Part B only: Must not be a future date
Date - Last X-ray Date
To specify any or all of a date, a time, or a time period
- Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 455
- Last X-Ray
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Segment must not be present for DME claims.
Part B only: Must not be a future date.
Date - Prescription Date
To specify any or all of a date, a time, or a time period
- Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 471
- Prescription
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Date - Service Date
To specify any or all of a date, a time, or a time period
- In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
DME only:
Must not be a single date of service when modifier RR is reported with more than 1 unit of service.
When a Service Date range extends into the future, the procedure code must equate to an Inexpensive Supply, PEN Amino Acid, PEN Enteral, PEN
Immunosuppressant Drug, PEN Kit/Supply, PEN Lipid, PEN Pump, PEN Special Parenteral, or PEN Dextrose/Home Mix.
Must be a single DOS when procedure code is NOT “E0935” or “E0936” and the procedure code is not considered a Glucose Monitoring or Inexpensive Supply, and the procedure code is categorized as Frequently Serviced DME, Inexpensive or Routinely Purchased DME, Capped Rental DME, Stationary Liquid and Portable Oxygen Equipment, Oxygen Concentrators, Gaseous Oxygen Equipment, Liquid Oxygen Equipment, or Portable Oxygen Equipment.
Date - Shipped Date
To specify any or all of a date, a time, or a time period
- Required when billing or reporting shipped products. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 011
- Shipped
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Test Date
To specify any or all of a date, a time, or a time period
- Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 738
- Most Recent Hemoglobin or Hematocrit or Both
- 739
- Most Recent Serum Creatine
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Ambulance Patient Count
To specify quantity information
- Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send.
- The QTY02 is the only place to report the number of patients when there are multiple patients transported.
Obstetric Anesthesia Additional Units
To specify quantity information
- Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time.
If not required by this implementation guide, do not send.
Numeric value of quantity
- The number of additional units reported by an anesthesia provider to reflect additional complexity of services.
Does not apply to DME.
Must be between 1 and 99.
Test Result
To specify physical measurements or counts, including dimensions, tolerances, variances, and weights
(See Figures Appendix for example of use of C001)
- Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results.
OR
Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier.
If not required by this implementation guide, do not send.
Code identifying the broad category to which a measurement applies
- OG
- Original
Use OG to report Starting Dosage.
- TR
- Test Results
Code identifying a specific product or process characteristic to which a measurement applies
- HT
- Height
- R1
- Hemoglobin
- R2
- Hematocrit
- R3
- Epoetin Starting Dosage
- R4
- Creatinine
The value of the measurement
Must not exceed 2 whole numbers and 1 decimal position.
Must be a value greater than or equal to 0 and less than or equal to 99.9.
Adjusted Repriced Line Item Reference Number
To specify identifying information
- Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9D
- Adjusted Repriced Line Item Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Clinical Laboratory Improvement Amendment (CLIA) Number
To specify identifying information
- Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.;
Code qualifying the Reference Identification
- X4
- Clinical Laboratory Improvement Amendment Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Immunization Batch Number
To specify identifying information
- Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BT
- Batch Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Line Item Control Number
To specify identifying information
- Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
- The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
- Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
Code qualifying the Reference Identification
- 6R
- Provider Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The maximum number of characters to be supported for this field is
30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
Mammography Certification Number
To specify identifying information
- Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EW
- Mammography Certification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Prior Authorization
To specify identifying information
- Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300).
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Referral Number
To specify identifying information
- Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300).
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Referral Number reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification
To specify identifying information
- Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- F4
- Facility Certification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Repriced Line Item Reference Number
To specify identifying information
- Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9B
- Repriced Line Item Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Postage Claimed Amount
To indicate the total monetary amount
- Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send.
- When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount.
Sales Tax Amount
To indicate the total monetary amount
- Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
- When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount.
File Information
To transmit a fixed-format record or matrix contents
- Required when ALL of the following conditions are met:
- A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement; - The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement - X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send. - At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. - Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
- X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Data in fixed format agreed upon by sender and receiver
Line Note
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
If not required by this implementation guide, do not send. - Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description.
Code identifying the functional area or purpose for which the note applies
- ADD
- Additional Information
- DCP
- Goals, Rehabilitation Potential, or Discharge Plans
A free-form description to clarify the related data elements and their content
Third Party Organization Notes
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send.
Purchased Service Information
To specify the information about services that are purchased
- Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source.
OR
Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses.
If not required by this implementation guide, do not send.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- PS101 is provider identification number.
- This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109.
Monetary amount
- PS102 is cost of the purchased service.
Drug Identification
To specify basic item identification data
- Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers.
OR
Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.
OR
Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners.
OR
Required when government regulation mandates that medical and surgical supplies are reported with UPN's.
If not required by this implementation guide, do not send.
- Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU.
- At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation.
- N4
- National Drug Code in 5-4-2 Format
Identifying number for a product or service
Must be exactly 11 alphanumeric positions.
Drug Quantity
To specify pricing information
Numeric value of quantity
Must be greater than 0 and less than or equal to 9,999,999.999.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
For DME claims only:
Must be “UN” when 2410 LIN03 NDC is found on Medicare file as associated to an Oral Cancer Drug HCPCS code.
- F2
- International Unit
- GR
- Gram
- ME
- Milligram
- ML
- Milliliter
- UN
- Unit
Prescription or Compound Drug Association Number
To specify identifying information
- Required when dispensing of the drug has been done with an assigned prescription number.
OR
Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number.
If not required by this implementation guide, do not send. - In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
- For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.
Code qualifying the Reference Identification
If service line (SV1) includes Modifier J1, REF01 = “XZ” must be present.
- VY
- Link Sequence Number
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
- Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider.
OR
Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider.
If not required by this implementation guide, do not send.;
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
The first position must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Purchased Service Provider Name
To supply the full name of an individual or organizational entity
- Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send.
- Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations.
Code identifying an organizational entity, a physical location, property or an individual
- The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
- QB
- Purchase Service Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Purchased Service Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Service Facility Location Name
To supply the full name of an individual or organizational entity
- When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
- Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.
- The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.;
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Service Facility Location Address
To specify the location of the named party
- If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Supervising Provider Name
To supply the full name of an individual or organizational entity
- Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
First position of Supervising Provider Middle Name must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Supervising Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Ordering Provider Name
To supply the full name of an individual or organizational entity
- Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line.
If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
- DK
- Ordering Physician
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
First position of Ordering Provider Middle Name must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Ordering Provider Address
To specify the location of the named party
- Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.
Ordering Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Ordering Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Ordering Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send.
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Referring Provider Name
To supply the full name of an individual or organizational entity
- When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
- When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
- Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Use on the first iteration of this loop. Use if loop is used only once.
- P3
- Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
First position of Referring Provider Middle Name must be alphabetic (A-Z).
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Referring Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Ambulance Pick-up Location
To supply the full name of an individual or organizational entity
- Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.;
Ambulance Pick-up Location Address
To specify the location of the named party
- If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Ambulance Pick-up Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Ambulance Drop-off Location
To supply the full name of an individual or organizational entity
- Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 45
- Drop-off Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Ambulance Drop-off Location Address
To specify the location of the named party
- If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Ambulance Drop-off Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Line Adjudication Information
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
- Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
- To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Code identifying a party or other code
- SVD01 is the payer identification code.
- This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
Monetary amount
- SVD02 is the amount paid for this service line.
- Zero "0" is an acceptable value for this element.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Numeric value of quantity
- SVD05 is the paid units of service.
- This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Must not exceed 4 whole numbers and one decimal position.
Must be a value greater than or equal to 0 and less than or equal to 9999.9
Number assigned for differentiation within a transaction set
- SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
Must be an integer (no decimals).
Line Adjustment
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Code identifying the general category of payment adjustment
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
- See CODE SOURCE 139: Claim Adjustment Reason Code
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Line Check or Remittance Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Must not be a future date.
Remaining Patient Liability
To indicate the total monetary amount
- In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
- Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
- This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
Form Identification Code
To identify standard industry codes
- Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send.
- Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used.
- An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services.
Code identifying a specific industry code list
- UT
- Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms
Code indicating a code from a specific industry code list
Supporting Documentation
To specify information in response to a codified questionnaire document
- The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair.
The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02~).
Alphanumeric characters assigned for differentiation within a transaction set
- FRM01 is the question number on a questionnaire or codified form.
DME claims only.
When LQ02=’484.03’ and FRM01=’6A’ or ‘6B’, an occurrence of FRM01 with the value of ‘6C’ is required.
DME claims only.
When LQ02=’484.03’ and FRM01=’6C’, an occurrence of FRM01 with the value of ‘6A’ or ‘6B’ is required.
DME claims only.
FRM01 Question number must be valid for the LQ02 CMN/DIF number.
DME claims only.
When LQ02 = ‘484.03”, occurrences of FRM01 = “1A” or “1B”, and FRM01 = “1C”, and FRM01 = “05” must be present.
DME claims only.
When LQ02 = ‘484.03” and FRM01 = “1A”, and FRM03 is greater than or equal to “55.5” and less than or equal to “59.4”, occurrences of FRM01 = “07”, “08” and “09” must be present.
DME claims only.
When LQ02 = ‘484.03” and FRM01 = “1B”, and FRM05 is greater than or equal to “88.5” and less than or equal to “89.4”, occurrences of FRM01 = “07”, “08” and “09” must be present.
Code indicating a Yes or No condition or response
- FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01.
DME claims only.
When LQ02 = ‘484.03” and FRM with FRM01 = “04”, “07”, “08” or “09” is present, then FRM02 must be present.
- N
- No
- W
- Not Applicable
- Y
- Yes
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
DME claims only.
When LQ02 = “04.04” and FRM01 = “07B”, “09B”, “10B” or “10C”, FRM03 must be present.
DME claims Only.
When LQ02 = “06.03” and FRM01 = “02” or “03”, FRM03 must be present.
DME claims Only.
When LQ02 = “09.03” and FRM01 = “01”, “01A”, “01B”, “01C”, “02”, “02A”, “02B”, “02C”, “03” or “04”, FRM03 must be present.
DME claims Only.
When LQ02 = “10.03” and FRM01 = “03”, “03A”, “03B”, “04”, “04A”, “04B”, “05”, “06”, “08A”, “08C”, “08D”, “08F”, “08G” or “09”, FRM03 must be present.
DME claims Only.
When LQ02 = ‘484.03” and FRM with FRM01 = “1A”, “1B”, “02”, “03” or “05” is present, then FRM03 must be present.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
DME claims Only.
Must not be a future date.
DME claims Only.
When LQ02 = “484.03” and FRM with FRM01 = “1C” or “6C” is present, then FRM04 must be present.
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
DME claims Only.
When LQ02 = “10.03” and FRM01 = “08B”, “08E” or “08H”, FRM05 must be present.
DME claims Only.
When LQ02 = ”484.03” and FRM01 = “1B” or “6B”, FRM05 must be present.
DME claims Only.
Must be between 0 and 100 and can contain up to one decimal place
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1: Commercial Health Insurance
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
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
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
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
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
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)
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
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
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
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
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
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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