X12 276 Health Care Claim Status Request (X212)

X12 Release 5010

Delimiters

• ~ Segment
• * Element
• > Component
• ^ Repetition

ISA Interchange Control Header

Required · Max use 1

ISA-01 · I01 · Authorization Information Qualifier · Required · Identifier (ID)

• 00: No Authorization Information Present (No Meaningful Information in I02)

ISA-02 · I02 · Authorization Information · Required · String (AN) · Min 10 Max 10

ISA-03 · I03 · Security Information Qualifier · Required · Identifier (ID)

• 00: No Security Information Present (No Meaningful Information in I04)

ISA-04 · I04 · Security Information · Required · String (AN) · Min 10 Max 10

ISA-05 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-06 · I06 · Interchange Sender ID · Required · String (AN) · Min 15 Max 15

ISA-07 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-08 · I07 · Interchange Receiver ID · Required · String (AN) · Min 15 Max 15

ISA-09 · I08 · Interchange Date · Required · Date (DT) · YYMMDD format

ISA-10 · I09 · Interchange Time · Required · Time (TM) · HHMM format

ISA-11 · I65 · Repetition Separator · Required · String (AN) · Min 1 Max 1

• ^: Repetition Separator

ISA-12 · I11 · Interchange Control Version Number · Required · Identifier (ID)

• 00501: Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

ISA-13 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

ISA-14 · I13 · Acknowledgment Requested · Required · Identifier (ID) · Min 1 Max 1

• 0: No Interchange Acknowledgment Requested
• 1: Interchange Acknowledgment Requested (TA1)

ISA-15 · I14 · Interchange Usage Indicator · Required · Identifier (ID) · Min 1 Max 1

• I: Information
• P: Production Data
• T: Test Data

ISA-16 · I15 · Component Element Separator · Required · String (AN) · Min 1 Max 1

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

GS-01 · 479 · Functional Identifier Code · Required · Identifier (ID)

• HR: Health Care Claim Status Request (276)

GS-02 · 142 · Application Sender's Code · Required · String (AN) · Min 2 Max 15

GS-03 · 124 · Application Receiver's Code · Required · String (AN) · Min 2 Max 15

GS-04 · 373 · Date · Required · Date (DT) · CCYYMMDD format

GS-05 · 337 · Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

GS-06 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

GS-07 · 455 · Responsible Agency Code · Required · Identifier (ID) · Min 1 Max 2

• T: Transportation Data Coordinating Committee (TDCC)
• X: Accredited Standards Committee X12

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · String (AN)

005010X212

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

ST-01 · 143 · Transaction Set Identifier Code · Required · Identifier (ID)

• 276: Health Care Claim Status Request

ST-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

ST-03 · 1705 · Version, Release, or Industry Identifier · Required · String (AN)

005010X212

0200 Heading > BHT

BHT Beginning of Hierarchical Transaction

Required · Max use 1

BHT-01 · 1005 · Hierarchical Structure Code · Required · Identifier (ID)

• 0010: Information Source, Information Receiver, Provider of Service, Subscriber, Dependent

BHT-02 · 353 · Transaction Set Purpose Code · Required · Identifier (ID)

• 13: Request

BHT-03 · 127 · Reference Identification · Required · String (AN) · Min 1 Max 50

BHT-04 · 373 · Transaction Set Creation Date · Required · Date (DT) · CCYYMMDD format

BHT-05 · 337 · Transaction Set Creation Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Detail

2000A Information Source Level Loop Required Max >1

0100 Detail > Information Source Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 20: Information Source

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

2100A Payer Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Payer Name Loop > NM1

NM1 Payer Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• PR: Payer

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 2: Non-Person Entity

NM1-03 · 1035 · Payer Name · Required · String (AN) · Min 1 Max 60

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• PI: Payor Identification

NM1-09 · 67 · Payer Identifier · Required · String (AN) · Min 2 Max 80

2000B Information Receiver Level Loop Required Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 21: Information Receiver

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

2100B Information Receiver Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

NM1 Information Receiver Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 41: Submitter

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Information Receiver Last or Organization Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Information Receiver First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Information Receiver Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• 46: Electronic Transmitter Identification Number (ETIN)

NM1-09 · 67 · Information Receiver Identification Number · Required · String (AN) · Min 2 Max 80

2000C Service Provider Level Loop Required Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 19: Provider of Service

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

2100C Provider Name Loop Required Max 2

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Provider Name Loop > NM1

NM1 Provider Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 1P: Provider

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Provider Last or Organization Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Provider First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Provider Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Provider Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• SV: Service Provider Number
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Provider Identifier · Required · String (AN) · Min 2 Max 80

2000D Subscriber Level Loop Required Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 22: Subscriber

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > DMG

DMG Subscriber Demographic Information

Optional · Max use 1

DMG-01 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Subscriber Birth Date · Required · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Subscriber Gender Code · Optional · Identifier (ID)

• F: Female
• M: Male

2100D Subscriber Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

NM1 Subscriber Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• IL: Insured or Subscriber

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Subscriber Last Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Subscriber First Name · Required · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Subscriber Middle Name or Initial · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Subscriber Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• MI: Member Identification Number

NM1-09 · 67 · Subscriber Identifier · Required · String (AN) · Min 2 Max 80

2200D Claim Status Tracking Number Loop Optional Max >1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > TRN

TRN Claim Status Tracking Number

Required · Max use 1

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 1: Current Transaction Trace Numbers

TRN-02 · 127 · Current Transaction Trace Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Application or Location System Identifier

Optional · Max use 1

Variants (all may be used)

REFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFGroup NumberREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• LU: Location Number

REF-02 · 127 · Application or Location System Identifier · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

Optional · Max use 1

Variants (all may be used)

REFApplication or Location System IdentifierREFGroup NumberREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• D9: Claim Number

REF-02 · 127 · Clearinghouse Trace Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Group Number

Optional · Max use 1

Variants (all may be used)

REFApplication or Location System IdentifierREFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 6P: Group Number

REF-02 · 127 · Group Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Institutional Bill Type Identification

Optional · Max use 1

Variants (all may be used)

REFApplication or Location System IdentifierREFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFGroup NumberREFPatient Control NumberREFPayer Claim Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• BLT: Billing Type

REF-02 · 127 · Bill Type Identifier · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Patient Control Number

Optional · Max use 1

Variants (all may be used)

REFApplication or Location System IdentifierREFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFGroup NumberREFInstitutional Bill Type IdentificationREFPayer Claim Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• EJ: Patient Account Number

REF-02 · 127 · Patient Control Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Payer Claim Control Number

Optional · Max use 1

Variants (all may be used)

REFApplication or Location System IdentifierREFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFGroup NumberREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPharmacy Prescription Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1K: Payor's Claim Number

REF-02 · 127 · Payer Claim Control Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > REF

REF Pharmacy Prescription Number

Optional · Max use 1

Variants (all may be used)

REFApplication or Location System IdentifierREFClaim Identification Number For Clearinghouses and Other Transmission IntermediariesREFGroup NumberREFInstitutional Bill Type IdentificationREFPatient Control NumberREFPayer Claim Control Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• XZ: Pharmacy Prescription Number

REF-02 · 127 · Pharmacy Prescription Number · Required · String (AN) · Min 1 Max 50

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > AMT

AMT Claim Submitted Charges

Optional · Max use 1

AMT-01 · 522 · Amount Qualifier Code · Required · Identifier (ID)

• T3: Total Submitted Charges

AMT-02 · 782 · Total Claim Charge Amount · Required · Decimal number (R) · Min 1 Max 15

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > DTP

DTP Claim Service Date

Optional · Max use 1

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 472: Service

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

DTP-03 · 1251 · Claim Service Period · Required · String (AN) · Min 1 Max 35

2210D Service Line Information Loop Optional Max >1

1300 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

SVC Service Line Information

Required · Max use 1

SVC-01 · C003 · Composite Medical Procedure Identifier · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
• N4: National Drug Code in 5-4-2 Format
• NU: National Uniform Billing Committee (NUBC) UB92 Codes

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

SVC-02 · 782 · Line Item Charge Amount · Required · Decimal number (R) · Min 1 Max 15

SVC-04 · 234 · Revenue Code · Optional · String (AN) · Min 1 Max 48

SVC-07 · 380 · Units of Service Count · Required · Decimal number (R) · Min 1 Max 15

1400 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

REF Service Line Item Identification

Optional · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• FJ: Line Item Control Number

REF-02 · 127 · Line Item Control Number · Required · String (AN) · Min 1 Max 50

1500 Detail > Information Source Level Loop > Information Receiver Level Loop > Service Provider Level Loop > Subscriber Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

DTP Service Line Date

Required · Max use 1

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 472: Service

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

DTP-03 · 1251 · Service Line Date · Required · String (AN) · Min 1 Max 35

1600 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

SE-01 · 96 · Transaction Segment Count · Required · Numeric (N0) · Min 1 Max 10

SE-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

GE Functional Group Trailer

Required · Max use 1

GE-01 · 97 · Number of Transaction Sets Included · Required · Numeric (N0) · Min 1 Max 6

GE-02 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

IEA Interchange Control Trailer

Required · Max use 1

IEA-01 · I16 · Number of Included Functional Groups · Required · Numeric (N0) · Min 1 Max 5

IEA-02 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

EDI Samples

Example 1: Claim Level Status

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231108*0216*^*00501*000000001*0*T*>~
GS*HR*SENDERGS*RECEIVERGS*20231108*021658*000000001*X*005010X212~
ST*276*0001*005010X212~
BHT*0010*13*ABC276XXX*20050915*1425~
HL*1**20*1~
NM1*PR*2*ABC INSURANCE*****PI*12345~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
DMG*D8*19301210*M~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*1*ABCXYZ1~
REF*BLT*111~
REF*EJ*SM123456~
AMT*T3*8513.88~
DTP*472*RD8*20050831-20050906~
HL*5*3*22*0~
DMG*D8*19301115*F~
NM1*IL*1*JONES*MARY****MI*234567890A~
TRN*1*ABCXYZ2~
REF*BLT*111~
REF*EJ*JO234567~
AMT*T3*7599~
DTP*472*RD8*20050731-20050809~
HL*6*2*19*1~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~
HL*7*6*22*1~
NM1*IL*1*MANN*JOHN****MI*345678901~
TRN*1*ABCXYZ3~
REF*EJ*MA345678~
SVC*HC>99203*150*****1~
DTP*472*D8*20050501~
SE*33*0001~
GE*1*000000001~
IEA*1*000000001~

Example 2: Provider Level Status

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231108*0217*^*00501*000000001*0*T*>~
GS*HR*SENDERGS*RECEIVERGS*20231108*021710*000000001*X*005010X212~
ST*276*0001*005010X212~
BHT*0010*13*ABC276XXX*20050915*1425~
HL*1**20*1~
NM1*PR*2*ABC INSURANCE*****PI*12345~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
DMG*D8*19301210*M~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*1*ABCXYZ1~
REF*BLT*111~
REF*EJ*SM123456~
AMT*T3*8513.88~
DTP*472*RD8*20050831-20050906~
HL*5*2*19*1~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*6166666666~
HL*6*5*22*1~
NM1*IL*1*MANN*JOHN****MI*345678901~
TRN*1*ABCXYZ3~
REF*EJ*MA345678~
SVC*HC>99203*150*****1~
DTP*472*D8*20050501~
SE*25*0001~
GE*1*000000001~
IEA*1*000000001~