X12 275 Patient Information (X210)

Payer Contact Information

Functional Group Header

275 Transaction Header

Submitter Information Loop

Optional

NM1

0500

Submitter Information

Provider Name Information Loop

NM1

0500

Provider Name Information

Provider Taxonomy Information

Provider Secondary Identification

Provider Identification Loop

Optional

NX1

1100

Provider Identification

Provider City, State, ZIP Code

Patient Control Number

Institutional Type Of Bill

Medical Record Identification Number

Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

Payer Claim Control Number/Provider Attachment Control Number

Service Line Item Identification

Procedure or Revenue Code

Procedure Code Modifier

Service Line Date of Service Loop

Optional

DTP

0600

Service Line Date of Service

Additional Information Submission Date Loop

DTP

0600

Additional Information Submission Date

Category of Patient Information Service

Electronic Format Identification Loop

EFI

0900

Electronic Format Identification

275 Transaction Set Trailer

Functional Group Trailer

Interchange Control Trailer

IEA

Submitter Information Loop Provider Name Information Loop Patient Name Loop

ISA

Interchange Control Header

RequiredMax use 1

—

Example

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 10Max 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 10Max 10

—

ISA-05

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 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 15Max 15

—

ISA-07

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 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 15Max 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 1Max 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 9Max 9

—

ISA-14

I13

Acknowledgment Requested

Required

Identifier (ID)

Min 1Max 1

—

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

ISA-15

I14

Interchange Usage Indicator

Required

Identifier (ID)

Min 1Max 1

—

I: Information
P: Production Data
T: Test Data

ISA-16

I15

Component Element Separator

Required

String (AN)

Min 1Max 1

—

>: Component Element Separator

Functional Group Header

RequiredMax use 1

—

Example

GS-01

479

Functional Identifier Code

Required

Identifier (ID)

—

PI: Patient Information (275)

GS-02

142

Application Sender's Code

Required

String (AN)

Min 2Max 15

—

GS-03

124

Application Receiver's Code

Required

String (AN)

Min 2Max 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

Group Control Number

Required

Numeric (N0)

Min 1Max 9

—

GS-07

455

Responsible Agency Code

Required

Identifier (ID)

Min 1Max 2

—

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

GS-08

480

Version / Release / Industry Identifier Code

Required

String (AN)

—

005010X210

Heading

0100

Heading > ST

275 Transaction Header

RequiredMax use 1

—

Example

ST-01

143

Transaction Set Identifier Code

Required

Identifier (ID)

—

Usage notes

—

275: Patient Information

ST-02

329

Transaction Set Control Number

Required

Numeric (N)

Min 4Max 9

—

Usage notes

—

ST-03

1705

Version, Release, or Industry Identifier

Required

String (AN)

—

Usage notes

—

005010X210

BGN

0200

Heading > BGN

Beginning Segment

RequiredMax use 1

—

Example

BGN-01

353

Transaction Set Purpose Code

Required

Identifier (ID)

—

02: Add
—
11: Response
—

BGN-02

127

Transaction Set Reference Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

BGN-03

373

Transaction Set Creation Date

Required

Date (DT)

CCYYMMDD format

—

1000A Payer Name Loop

RequiredMax 1

Variants (all may be used)

NM1

0500

Heading > Payer Name Loop > NM1

Payer Name

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

PR: Payer

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Payer Name

Required

String (AN)

Min 1Max 60

—

Identification Code Qualifier

Required

Identifier (ID)

—

PI: Payor Identification
XV: Centers for Medicare and Medicaid Services PlanID

Payer Name Loop Provider Name Information Loop Patient Name Loop

Payer Identifier

Required

String (AN)

Min 2Max 80

—

PER

0900

Heading > Payer Name Loop > PER

Payer Contact Information

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required

PER-01

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

PER-02

Payer Contact Name

Optional

String (AN)

Min 1Max 60

—

PER-03

365

Communication Number Qualifier

Optional

Identifier (ID)

—

ED: Electronic Data Interchange Access Number
EM: Electronic Mail
FX: Facsimile
TE: Telephone

PER-04

364

Payer Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-05

365

Communication Number Qualifier

Optional

Identifier (ID)

—

ED: Electronic Data Interchange Access Number
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

PER-06

364

Payer Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

PER-07

365

Communication Number Qualifier

Optional

Identifier (ID)

—

ED: Electronic Data Interchange Access Number
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

PER-08

364

Payer Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

1000A Payer Name Loop end

1000B Submitter Information Loop

RequiredMax 1

Variants (all may be used)

NM1

0500

Heading > Submitter Information Loop > NM1

Submitter Information

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

41: Submitter

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Submitter Last or Organization Name

Required

String (AN)

Min 1Max 60

—

NM1-04

1036

Submitter First Name

Optional

String (AN)

Min 1Max 35

—

NM1-05

1037

Submitter Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

Identification Code Qualifier

Required

Identifier (ID)

—

46: Electronic Transmitter Identification Number (ETIN)

Payer Name Loop Submitter Information Loop Patient Name Loop

Submitter Identifier

Required

String (AN)

Min 2Max 80

—

1000B Submitter Information Loop end

1000C Provider Name Information Loop

RequiredMax 1

Variants (all may be used)

NM1

0500

Heading > Provider Name Information Loop > NM1

Provider Name Information

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Provider Identifier (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

1P: Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Provider Last or Organization Name

Required

String (AN)

Min 1Max 60

—

NM1-04

1036

Provider First Name

Optional

String (AN)

Min 1Max 35

—

NM1-05

1037

Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

NM1-07

1039

Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Provider Identifier

Optional

String (AN)

Min 2Max 80

—

PRV

0800

Heading > Provider Name Information Loop > PRV

Provider Taxonomy Information

OptionalMax use 1

—

Usage notes

—

Example

PRV-01

1221

Provider Code

Required

Identifier (ID)

—

BI: Billing

PRV-02

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

PRV-03

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

REF

1000

Heading > Provider Name Information Loop > REF

Provider Secondary Identification

OptionalMax use 1

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
G2: Provider Commercial Number
—
LU: Location Number

Payer Name Loop Submitter Information Loop Provider Name Information Loop

127

Provider Secondary Identifier

Required

String (AN)

Min 1Max 50

—

1100C Provider Identification Loop

RequiredMax 1

NX1

1100

Heading > Provider Name Information Loop > Provider Identification Loop > NX1

Provider Identification

RequiredMax use 1

—

Usage notes

—

Example

NX1-01

Entity Identifier Code

Required

Identifier (ID)

—

1P: Provider

1200

Heading > Provider Name Information Loop > Provider Identification Loop > N3

Provider Address

RequiredMax use 1

—

Example

N3-01

166

Provider Address Line

Required

String (AN)

Min 1Max 55

—

N3-02

166

Provider Address Line

Optional

String (AN)

Min 1Max 55

—

1300

Heading > Provider Name Information Loop > Provider Identification Loop > N4

Provider City, State, ZIP Code

RequiredMax use 1

—

Example

Only one of Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01

Provider City Name

Required

String (AN)

Min 2Max 30

—

N4-02

156

Provider State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

N4-03

116

Postal Code

Optional

Identifier (ID)

Min 3Max 15

—

N4-04

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

N4-07

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

1100C Provider Identification Loop end

1000C Provider Name Information Loop end

1000D Patient Name Loop

RequiredMax 1

Variants (all may be used)

NM1

0500

Heading > Patient Name Loop > NM1

Patient Name

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

QC: Patient

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Patient Last Name

Required

String (AN)

Min 1Max 60

—

NM1-04

1036

Patient First Name

Optional

String (AN)

Min 1Max 35

—

NM1-05

1037

Patient Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

NM1-07

1039

Patient Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

II: Standard Unique Health Identifier for each Individual in the United States
—
MI: Member Identification Number
—

REFInstitutional Type Of Bill REFMedical Record Identification Number REFClaim Identification Number for Clearinghouses and Other Transmission Intermediaries

Patient Primary Identifier

Required

String (AN)

Min 2Max 80

—

REF

1000

Heading > Patient Name Loop > REF

Patient Control Number

RequiredMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

EJ: Patient Account Number

REFPatient Control Number REFMedical Record Identification Number REFClaim Identification Number for Clearinghouses and Other Transmission Intermediaries

127

Patient Control Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

REF

1000

Heading > Patient Name Loop > REF

Institutional Type Of Bill

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BLT: Billing Type

REFPatient Control Number REFInstitutional Type Of Bill REFClaim Identification Number for Clearinghouses and Other Transmission Intermediaries

127

Bill Type Identifier

Required

String (AN)

Min 1Max 50

—

Usage notes

—

REF

1000

Heading > Patient Name Loop > REF

Medical Record Identification Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

EA: Medical Record Identification Number

REFPatient Control Number REFInstitutional Type Of Bill REFMedical Record Identification Number

127

Medical Record Identification Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

REF

1000

Heading > Patient Name Loop > REF

Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

D9: Claim Number

REFProcedure or Revenue Code REFProcedure Code Modifier

127

Clearinghouse Trace Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

DTP

1050

Heading > Patient Name Loop > DTP

Claim Service Date

OptionalMax use 1

—

Usage notes

—

Example

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 1Max 35

—

1000D Patient Name Loop end

Heading end

Detail

2000A Assigned Number Loop

RequiredMax >1

0100

Detail > Assigned Number Loop > LX

Assigned Number

RequiredMax use 1

—

Usage notes

—

Example

LX-01

554

Assigned Number

Required

Numeric (N0)

Min 1Max 6

—

Usage notes

—

TRN

0150

Detail > Assigned Number Loop > TRN

Payer Claim Control Number/Provider Attachment Control Number

RequiredMax use 1

—

Usage notes

—

Example

TRN-01

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers
—
2: Referenced Transaction Trace Numbers
—

TRN-02

127

Payer Claim Control Number or Provider Attachment Control Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

STC

0175

Detail > Assigned Number Loop > STC

Status Information

OptionalMax use 1

—

Usage notes

—

Example

STC-01

C043

Health Care Claim Status

RequiredMax use 1

Used to convey status of the entire claim or a specific service line

C043-01

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

C043-02

1271

Additional Information Request Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

C043-04

1270

Code List Qualifier Code

Required

Identifier (ID)

—

LOI: Logical Observation Identifier Names and Codes (LOINC<190>) Codes

STC-10

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

C043-01

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

C043-02

1271

Additional Information Request Modifier

Required

String (AN)

Min 1Max 30

—

Usage notes

—

C043-04

1270

Code List Qualifier Code

Required

Identifier (ID)

—

LOI: Logical Observation Identifier Names and Codes (LOINC<190>) Codes

STC-11

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

C043-01

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

C043-02

1271

Additional Information Request Modifier

Required

String (AN)

Min 1Max 30

—

Usage notes

—

C043-04

1270

Code List Qualifier Code

Required

Identifier (ID)

—

LOI: Logical Observation Identifier Names and Codes (LOINC<190>) Codes

REF

0500

Detail > Assigned Number Loop > REF

Service Line Item Identification

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

6R: Provider Control Number
—
FJ: Line Item Control Number
—

REFService Line Item Identification REFProcedure Code Modifier

127

Line Item Control Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

REF

0500

Detail > Assigned Number Loop > REF

Procedure or Revenue Code

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

CPT: Current Procedural Terminology Code
—
F8: Original Reference Number
—
FO: Drug Formulary Number
—
PRT: Product Type
—
RB: Rate code number
—
VP: Vendor Product Number
—
YJ: Revenue Source
—
ZZ: Mutually Defined
—

REFService Line Item Identification REFProcedure or Revenue Code

127

Procedure Code

Required

String (AN)

Min 1Max 50

—

Usage notes

—

REF-04

C040

Reference Identifier

OptionalMax use 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02.

Usage notes

—

C040-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

YJ: Revenue Source
—

C040-02

127

Revenue Code

Required

String (AN)

Min 1Max 50

—

REF

0500

Detail > Assigned Number Loop > REF

Procedure Code Modifier

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

SK: Service Change Number
—