X12 277 Data Reporting Acknowledgment (X364)

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)

• HN: Health Care Information Status Notification (277)

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)

005010X364

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

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

• 277: Health Care Information Status Notification

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)

005010X364

0200 Heading > BHT

BHT Beginning of Hierarchical Transaction

Required · Max use 1

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

• 0085: Information Source, Information Receiver, Provider of Service, Patient

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

• 08: Status

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 Information Source Name Loop Required Max 1

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

NM1 Information Source Name

Required · Max use 1

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

• ACV: Information Source

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

• 2: Non-Person Entity

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

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

• 46: Electronic Transmitter Identification Number (ETIN)

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

2200A Transmission Receipt Control Identifier Loop Required Max 1

0900 Detail > Information Source Level Loop > Transmission Receipt Control Identifier Loop > TRN

TRN Transmission Receipt Control Identifier

Required · Max use 1

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

• 1: Current Transaction Trace Numbers

TRN-02 · 127 · Information Source Application Trace Identifier · Required · String (AN) · Min 1 Max 50

1200 Detail > Information Source Level Loop > Transmission Receipt Control Identifier Loop > DTP

DTP Information Source Receipt Date

Required · Max use 1

Variants (all may be used)

DTPInformation Source Process Date

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

• 050: Received

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Information Source Receipt Date · Required · String (AN) · Min 1 Max 35

1200 Detail > Information Source Level Loop > Transmission Receipt Control Identifier Loop > DTP

DTP Information Source Process Date

Required · Max use 1

Variants (all may be used)

DTPInformation Source Receipt Date

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

• 009: Process

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Information Source Process Date · Required · String (AN) · Min 1 Max 35

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)

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

• 40: Receiver

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

• 2: Non-Person Entity

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

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

• 46: Electronic Transmitter Identification Number (ETIN)

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

2200B Information Receiver Application Trace Identifier Loop Required Max 1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Application Trace Identifier Loop > TRN

TRN Information Receiver Application Trace Identifier

Required · Max use 1

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

• 2: Referenced Transaction Trace Numbers

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

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Application Trace Identifier Loop > STC

STC Information Receiver Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 40: Receiver
• 41: Submitter

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-03 · 306 · Action Code · Required · Identifier (ID)

• U: Reject
• WQ: Accept

STC-04 · 782 · Total Submitted Charges for Unit Work · Required · Decimal number (R) · Min 1 Max 15

STC-10 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-11 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

1210 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Application Trace Identifier Loop > QTY

QTY Total Accepted Quantity

Optional · Max use 1

Variants (all may be used)

QTYTotal Rejected Quantity

QTY-01 · 673 · Quantity Qualifier · Required · Identifier (ID)

• 90: Acknowledged Quantity

QTY-02 · 380 · Total Accepted Quantity · Required · Decimal number (R) · Min 1 Max 15

1210 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Application Trace Identifier Loop > QTY

QTY Total Rejected Quantity

Optional · Max use 1

Variants (all may be used)

QTYTotal Accepted Quantity

QTY-01 · 673 · Quantity Qualifier · Required · Identifier (ID)

• AA: Unacknowledged Quantity

QTY-02 · 380 · Total Rejected Quantity · Required · Decimal number (R) · Min 1 Max 15

1220 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Application Trace Identifier Loop > AMT

AMT Total Accepted Amount

Optional · Max use 1

Variants (all may be used)

AMTTotal Rejected Amount

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

• YU: In Process

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

1220 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Application Trace Identifier Loop > AMT

AMT Total Rejected Amount

Optional · Max use 1

Variants (all may be used)

AMTTotal Accepted Amount

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

• YY: Returned

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

2000C Billing/Service Provider Hierarchical Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical 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)

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

2100C Billing/Service Provider Name Loop Required Max 1

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

NM1 Billing/Service Provider Name

Required · Max use 1

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

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

• 85: Billing Provider

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

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Provider Last or Organization Name · Required · 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 · Optional · Identifier (ID)

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

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

2200C Billing/Service Provider Trace Identifier Loop Optional Max 1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Billing/Service Provider Trace Identifier Loop > TRN

TRN Billing/Service Provider Trace Identifier

Required · Max use 1

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

• 1: Current Transaction Trace Numbers

TRN-02 · 127 · Provider of Service Information Trace Identifier · Required · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Billing/Service Provider Trace Identifier Loop > STC

STC Billing/Service Provider Status Information

Optional · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 85: Billing Provider

STC-03 · 306 · Action Code · Required · Identifier (ID)

• U: Reject
• WQ: Accept

STC-04 · 782 · Total Submitted Charges for Unit Work · Required · Decimal number (R) · Min 1 Max 15

STC-10 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-11 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Billing/Service Provider Trace Identifier Loop > REF

REF Billing/Service Provider Secondary Identifier

Optional · Max use 5

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

• 0B: State License Number
• 1J: Facility ID Number
• G2: Provider Commercial Number
• LU: Location Number
• TJ: Federal Taxpayer's Identification Number

REF-02 · 127 · Billing Provider Additional Identifier · Required · String (AN) · Min 1 Max 50

1210 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Billing/Service Provider Trace Identifier Loop > QTY

QTY Total Accepted Quantity

Optional · Max use 1

Variants (all may be used)

QTYTotal Rejected Quantity

QTY-01 · 673 · Quantity Qualifier · Required · Identifier (ID)

• QA: Quantity Approved

QTY-02 · 380 · Total Accepted Quantity · Required · Decimal number (R) · Min 1 Max 15

1210 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Billing/Service Provider Trace Identifier Loop > QTY

QTY Total Rejected Quantity

Optional · Max use 1

Variants (all may be used)

QTYTotal Accepted Quantity

QTY-01 · 673 · Quantity Qualifier · Required · Identifier (ID)

• QC: Quantity Disapproved

QTY-02 · 380 · Total Rejected Quantity · Required · Decimal number (R) · Min 1 Max 15

1220 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Billing/Service Provider Trace Identifier Loop > AMT

AMT Total Accepted Amount

Optional · Max use 1

Variants (all may be used)

AMTTotal Rejected Amount

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

• YU: In Process

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

1220 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Billing/Service Provider Trace Identifier Loop > AMT

AMT Total Rejected Amount

Optional · Max use 1

Variants (all may be used)

AMTTotal Accepted Amount

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

• YY: Returned

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

2000D Patient Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient 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)

• PT: Patient

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

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

2100D Patient Name Loop Required Max 1

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Patient Name Loop > NM1

NM1 Patient Name

Required · Max use 1

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

• QC: Patient

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

• 1: Person

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

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

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

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

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

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

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

2200D Claim Status Tracking Number Loop Required Max >1

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient 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)

• 2: Referenced Transaction Trace Numbers

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

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > STC

STC Claim Level Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 40: Receiver
• 41: Submitter
• 45: Drop-off Location
• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• 77: Service Location
• 82: Rendering Provider
• 85: Billing Provider
• DK: Ordering Physician
• DN: Referring Provider
• DQ: Supervising Physician
• IL: Insured or Subscriber
• P3: Primary Care Provider
• PR: Payer
• PRP: Primary Payer
• PW: Pickup Address
• QB: Purchase Service Provider
• QC: Patient
• SEP: Secondary Payer
• SJ: Service Provider
• TTP: Tertiary Payer
• ZD: Party to Receive Reports
• ZZ: Mutually Defined

STC-02 · 373 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

STC-03 · 306 · Status Information Action Code · Required · Identifier (ID)

• EZ: Exception Occurred
• U: Reject
• WQ: Accept

STC-04 · 782 · Total Claim Charge Amount · Required · Decimal number (R) · Min 1 Max 15

STC-10 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-11 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-12 · 933 · Free Form Message Text · Optional · String (AN) · Min 1 Max 264

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > REF

REF Data Receiver Claim Control Number

Optional · Max use 1

Variants (all may be used)

REFPayer Claim Control NumberREFClaim Identifier For Transmission Intermediaries

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

• F8: Original Reference Number

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > REF

REF Payer Claim Control Number

Optional · Max use 1

Variants (all may be used)

REFData Receiver Claim Control NumberREFClaim Identifier For Transmission Intermediaries

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

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > REF

REF Claim Identifier For Transmission Intermediaries

Optional · Max use 1

Variants (all may be used)

REFData Receiver Claim Control NumberREFPayer Claim Control 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

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > DTP

DTP Claim Level Service 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 · Claim Service Period · Required · String (AN) · Min 1 Max 35

2220D Service Line Information Loop Optional Max >1

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient 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 · Procedure Code · Required · Identifier (ID)

• AD: American Dental Association Codes
• ER: Jurisdiction Specific Procedure and Supply Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
• NU: National Uniform Billing Committee (NUBC) UB92 Codes
• WK: Advanced Billing Concepts (ABC) 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 · Original Units of Service Count · Optional · Decimal number (R) · Min 1 Max 15

1900 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > STC

STC Service Line Level Status Information

Required · Max use >1

STC-01 · C043 · Health Care Claim Status · Required Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID)

• 45: Drop-off Location
• 72: Operating Physician
• 77: Service Location
• 82: Rendering Provider
• DD: Assistant Surgeon
• DK: Ordering Physician
• DN: Referring Provider
• DQ: Supervising Physician
• P3: Primary Care Provider
• PW: Pickup Address
• QB: Purchase Service Provider
• ZZ: Mutually Defined

STC-03 · 306 · Action Code · Required · Identifier (ID)

• EZ: Exception Occurred
• U: Reject

STC-10 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-11 · C043 · Health Care Claim Status · Optional Max 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 1 Max 30

C043-02 · 1271 · Health Care Claim Status Code · Required · String (AN) · Min 1 Max 30

C043-03 · 98 · Entity Identifier Code · Optional · Identifier (ID) · Min 2 Max 3

STC-12 · 933 · Free Form Message Text · Optional · String (AN) · Min 1 Max 264

2000 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

REF Line Item Control Number

Required · Max use 1

Variants (all may be used)

REFPharmacy Prescription Number

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

• 6R: Provider Control Number

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

2000 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > REF

REF Pharmacy Prescription Number

Optional · Max use 1

Variants (all may be used)

REFLine Item 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

2100 Detail > Information Source Level Loop > Information Receiver Level Loop > Billing/Service Provider Hierarchical Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > DTP

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

2700 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

ST*277*0003*005010X364~
BHT*0085*08*0000221*20190221*1025~
HL*1**20*1~
NM1*ACV*2*ALL PAYER CLAIMS DATABASE*****46*APCD01~
TRN*1*ABC12345~
DTP*050*D8*20190220~
DTP*009*D8*20190221~
HL*2*1*21*1~
NM1*40*2*YOUR INSURANCE COMPANY*****46*S00003~
TRN*2*206438976580901~
STC*DR02>20*20190221*WQ*365.5~
QTY*90*3~
QTY*AA*2~
AMT*YU*200.5~
AMT*YY*165~
HL*3*2*19*1~
NM1*85*1*JONES*HARRY*B**MD*XX*1546326897~
HL*4*3*PT~
NM1*QC*1*PATIENT*FEMALE****MI*2222222222~
TRN*2*PATIENT22222~
STC*DR02>20>PR*20190221*WQ*100~
REF*F8*IC847502~
REF*1K*220216359803X~
DTP*472*D8*20190214~
HL*5*3*PT~
NM1*QC*1*PATIENT*MALE****MI*3333333333~
TRN*2*PATIENT33333~
STC*DR06>21*20190221*U*65******DR06>255~
REF*F8*IC429783~
REF*1K*220216359954X~
DTP*472*D8*20190121~
HL*6*3*PT~
NM1*QC*1*JONES*LARRY****MI*4444444444~
TRN*2*JONES44444~
STC*DR03>26>77*20190221*U*100~
REF*F8*IC429805~
REF*1K*220216359964X~
DTP*472*D8*20190211~
HL*7*2*19*1~
NM1*85*1*SMITH*JOHN*C**MD*XX*1546326780~
TRN*1*0~
REF*LU*AB142~
QTY*QA*2~
AMT*YU*100.5~
HL*8*7*PT~
NM1*QC*1*JOHNSON*MARY****MI*5555555555~
TRN*2*JOHNSON55555~
STC*DR08>20>PR*20190221*EZ*50.5~
REF*F8*IC429888~
REF*1K*220216359806X~
DTP*472*D8*20190210~
SVC*HC>G9938*50.5*****1~
STC*DR08>475**EZ~
REF*6R*1~
DTP*472*D8*20190210~
HL*9*7*PT~
NM1*QC*1*MILLS*HARRIETT****MI*6666666666~
TRN*2*MILLS66666~
STC*DR02>20>PR*20190221*WQ*50~
REF*F8*IC429956~
REF*1K*220216359807X~
DTP*472*D8*20190205~
SE*63*0003~

Example 2

ST*277*0002*005010X364~
BHT*0085*08*123456789*20190201*0405~
HL*1**20*1~
NM1*ACV*2*STATE ENCOUNTER SYSTEM*****46*STATE01~
TRN*1*20201312005S00002XYZABC~
DTP*050*D8*20190131~
DTP*009*D8*20190201~
HL*2*1*21*0~
NM1*40*2*ABC PAYER*****46*S00002~
TRN*2*2020131052389~
STC*DR03>24>41*20190201*U*800~
QTY*AA*3~
AMT*YY*800~
SE*14*0002~