X12 278 Health Care Services Review Information - Review (X217)

Beginning of Hierarchical Transaction

Functional Group Header

Transaction Set Header

Utilization Management Organization (UMO) Level Loop

detail

Utilization Management Organization (UMO) Name Loop

Utilization Management Organization (UMO) Name

Requester Supplemental Identification

Requester City, State, ZIP Code

Requester Contact Information

Requester Provider Information

Subscriber Supplemental Identification

Subscriber Level Loop

Subscriber City, State, ZIP Code

Subscriber Demographic Information

Subscriber Relationship

Dependent Supplemental Identification

Dependent City, State, ZIP Code

Dependent Demographic Information

Dependent Relationship

Patient Event Tracking Number

Patient Event Level Loop

Max use 2

0400

Last Menstrual Period Date

Estimated Date of Birth

Onset of Current Symptoms or Illness Date

Ambulance Certification Information

Chiropractic Certification Information

Durable Medical Equipment Information

Oxygen Therapy Certification Information

Functional Limitations Information

Activities Permitted Information

Mental Status Information

Institutional Claim Code

Ambulance Transport Information

Spinal Manipulation Service Information

Home Oxygen Therapy Information

Home Health Care Information

Additional Patient Information

Patient Event Provider Name Loop

Patient Event Provider Name

Patient Event Provider Supplemental Information

Max use 7

Patient Event Provider Address

Patient Event Provider City, State, ZIP Code

Patient Event Provider Contact Information

Patient Event Provider Information

Patient Event Transport Information Loop

Patient Event Transport Information

Patient Event Transport Location Address

Patient Event Transport Location City/State/ZIP Code

Patient Event Other UMO Name Loop

Patient Event Other UMO Name

Other UMO Denial Reason

Other UMO Denial Date

Institutional Service Line

Additional Service Information

Service Provider Name Loop

Service Provider Supplemental Identification

Service Provider Name

Max use 8

Service Provider Address

Service Provider City, State, ZIP Code

Service Provider Contact Information

Service Provider Information

Patient Event Tracking Number

Patient Event Level Loop

Max use 2

0400

Last Menstrual Period Date

Estimated Date of Birth

Onset of Current Symptoms or Illness Date

Ambulance Certification Information

Chiropractic Certification Information

Durable Medical Equipment Information

Oxygen Therapy Certification Information

Functional Limitations Information

Activities Permitted Information

Mental Status Information

Institutional Claim Code

Ambulance Transport Information

Spinal Manipulation Service Information

Home Oxygen Therapy Information

Home Health Care Information

Additional Patient Information

Patient Event Provider Name Loop

Patient Event Provider Name

Patient Event Provider Supplemental Information

Max use 7

Patient Event Provider Address

Patient Event Provider City, State, ZIP Code

Patient Event Provider Contact Information

Patient Event Provider Information

Patient Event Transport Information Loop

Patient Event Transport Information

Patient Event Transport Location Address

Patient Event Transport Location City/State/ZIP Code

Patient Event Other UMO Name Loop

Patient Event Other UMO Name

Other UMO Denial Reason

Other UMO Denial Date

Institutional Service Line

Additional Service Information

Service Provider Name Loop

Service Provider Supplemental Identification

Service Provider Name

Max use 8

Service Provider Address

Service Provider City, State, ZIP Code

Service Provider Contact Information

Service Provider Information

2800

Transaction Set Trailer

Functional Group Trailer

Interchange Control Trailer

IEA

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)

—

HI: Health Care Services Review Information (278)

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)

—

005010X217

Heading

0100

Heading > ST

Transaction Set Header

RequiredMax use 1

—

Usage notes

—

Example

ST-01

143

Transaction Set Identifier Code

Required

Identifier (ID)

—

278: Health Care Services Review Information

ST-02

329

Transaction Set Control Number

Required

Numeric (N)

Min 4Max 9

—

Usage notes

—

ST-03

1705

Implementation Guide Version Name

Required

String (AN)

—

Usage notes

—

005010X217

BHT

0200

Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

—

Example

BHT-01

1005

Hierarchical Structure Code

Required

Identifier (ID)

—

0007: Information Source, Information Receiver, Subscriber, Dependent, Event, Services

BHT-02

353

Transaction Set Purpose Code

Required

Identifier (ID)

—

01: Cancellation
—
13: Request
36: Authority to Deduct (Reply)
—

BHT-03

127

Submitter Transaction Identifier

Required

String (AN)

Min 1Max 50

—

Usage notes

—

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

—

BHT-06

640

Transaction Type Code

Optional

Identifier (ID)

—

RU: Medical Services Reservation

Heading end

Detail

2000A Utilization Management Organization (UMO) Level Loop

RequiredMax 1

0100

Detail > Utilization Management Organization (UMO) Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

20: Information Source

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2010A Utilization Management Organization (UMO) Name Loop

RequiredMax 1

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Utilization Management Organization (UMO) Name Loop > NM1

Utilization Management Organization (UMO) Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

2B: Third-Party Administrator
36: Employer
PR: Payer
—
X3: Utilization Management Organization

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
—
2: Non-Person Entity

1035

Utilization Management Organization (UMO) Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Utilization Management Organization (UMO) First Name

Optional

String (AN)

Min 1Max 35

—

1037

Utilization Management Organization (UMO) Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Utilization Management Organization (UMO) Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
PI: Payor Identification
—
XV: Centers for Medicare and Medicaid Services PlanID
—

Utilization Management Organization (UMO) Identifier

Required

String (AN)

Min 2Max 80

—

2010A Utilization Management Organization (UMO) Name Loop end

2000B Requester Level Loop

RequiredMax 1

0100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

21: Information Receiver

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2010B Requester Name Loop

RequiredMax 1

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > NM1

Requester Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

1P: Provider
—
2B: Third-Party Administrator
36: Employer
FA: Facility
—
PR: Payer
—

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Requester Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Requester First Name

Optional

String (AN)

Min 1Max 35

—

1037

Requester Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Requester Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
XV: Centers for Medicare and Medicaid Services PlanID
—
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Requester Identifier

Required

String (AN)

Min 2Max 80

—

REF

1800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > REF

Requester Supplemental Identification

OptionalMax use 8

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
G5: Provider Site Number
—
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Requester Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

2000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > N3

Requester Address

OptionalMax use 1

—

Usage notes

—

Example

166

Requester Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Requester Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > N4

Requester City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Requester 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

Requester City Name

Required

String (AN)

Min 2Max 30

—

156

Requester State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Requester Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > PER

Requester Contact Information

OptionalMax use 1

—

Usage notes

—

Example

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

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

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

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Requester Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Requester Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Requester Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)
—

364

Requester Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

PRV

2400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Requester Name Loop > PRV

Requester Provider Information

OptionalMax use 1

—

Usage notes

—

Example

If either Reference Identification Qualifier (PRV-02) or Provider Taxonomy Code (PRV-03) is present, then the other is required

1221

Provider Code

Required

Identifier (ID)

—

AD: Admitting
AS: Assistant Surgeon
AT: Attending
CO: Consulting
CV: Covering
OP: Operating
OR: Ordering
OT: Other Physician
PC: Primary Care Physician
PE: Performing
RF: Referring

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

127

Provider Taxonomy Code

Optional

String (AN)

Min 1Max 50

—

2010B Requester Name Loop end

2000C Subscriber Level Loop

RequiredMax 1

0100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

22: Subscriber

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.

2010C Subscriber Name Loop

RequiredMax 1

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

IL: Insured or Subscriber

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Subscriber Last Name

Optional

String (AN)

Min 1Max 60

—

1036

Subscriber First Name

Optional

String (AN)

Min 1Max 35

—

1037

Subscriber Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

1038

Subscriber Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Subscriber 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
—

Subscriber Primary Identifier

Required

String (AN)

Min 2Max 80

—

REF

1800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

Subscriber Supplemental Identification

OptionalMax use 9

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1L: Group or Policy Number
—
3L: Branch Identifier
6P: Group Number
DP: Department Number
EJ: Patient Account Number
—
F6: Health Insurance Claim (HIC) Number
—
HJ: Identity Card Number
—
IG: Insurance Policy Number
N6: Plan Network Identification Number
NQ: Medicaid Recipient Identification Number
SY: Social Security Number
—

127

Subscriber Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

2000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1

—

Usage notes

—

Example

166

Subscriber Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Subscriber Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Subscriber City Name

Required

String (AN)

Min 2Max 30

—

156

Subscriber State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Subscriber Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

DMG

2500

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

—

Usage notes

—

Example

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 1Max 35

—

DMG-03

1068

Subscriber Gender Code

Optional

Identifier (ID)

—

F: Female
M: Male
U: Unknown

INS

2600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

Subscriber Relationship

OptionalMax use 1

—

Usage notes

—

Example

INS-01

1073

Insured Indicator

Required

Identifier (ID)

—

Y: Yes

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

—

18: Self

INS-08

584

Employment Status Code

Required

Identifier (ID)

—

Usage notes

—

AO: Active Military - Overseas
AU: Active Military - USA
DI: Deceased
PV: Previous
RU: Retired Military - USA

2010C Subscriber Name Loop end

2000D Dependent Level Loop

OptionalMax 1

Variants (all may be used)

Patient Event Level Loop

0100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

23: Dependent

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2010D Dependent Name Loop

RequiredMax 1

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

Dependent Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

QC: Patient

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Dependent Last Name

Optional

String (AN)

Min 1Max 60

—

1036

Dependent First Name

Optional

String (AN)

Min 1Max 35

—

1037

Dependent Middle Name

Optional

String (AN)

Min 1Max 25

—

1039

Dependent Name Suffix

Optional

String (AN)

Min 1Max 10

—

REF

1800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

Dependent Supplemental Identification

OptionalMax use 3

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

EJ: Patient Account Number
—
SY: Social Security Number
—

127

Dependent Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

2000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3

Dependent Address

OptionalMax use 1

—

Usage notes

—

Example

166

Dependent Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Dependent Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4

Dependent City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Dependent City Name

Required

String (AN)

Min 2Max 30

—

156

Dependent State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Dependent Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

DMG

2500

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

Dependent Demographic Information

OptionalMax use 1

—

Usage notes

—

Example

DMG-01

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

1251

Dependent Birth Date

Required

String (AN)

Min 1Max 35

—

DMG-03

1068

Dependent Gender Code

Optional

Identifier (ID)

—

F: Female
M: Male
U: Unknown

INS

2600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

Dependent Relationship

OptionalMax use 1

—

Usage notes

—

Example

INS-01

1073

Insured Indicator

Required

Identifier (ID)

—

N: No

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

—

01: Spouse
19: Child
G8: Other Relationship

INS-17

1470

Birth Sequence Number

Optional

Numeric (N0)

Min 1Max 9

—

2010D Dependent Name Loop end

2000E Patient Event Level Loop

RequiredMax 1

0100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

EV: Event

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.

TRN

0200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > TRN

Patient Event Tracking Number

OptionalMax use 2

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

127

Patient Event Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

0400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > UM

Health Care Services Review Information

RequiredMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

AR: Admission Review
—
HS: Health Services Review
—
IN: Individual
—
SC: Specialty Care Review
—

1322

Certification Type Code

Required

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
I: Initial
N: Reconsideration
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

1: Medical Care
2: Surgical
3: Consultation
4: Diagnostic X-Ray
5: Diagnostic Lab
6: Radiation Therapy
7: Anesthesia
8: Surgical Assistance
11: Used Durable Medical Equipment
12: Durable Medical Equipment Purchase
14: Renal Supplies in the Home
15: Alternate Method Dialysis
16: Chronic Renal Disease (CRD) Equipment
17: Pre-Admission Testing
18: Durable Medical Equipment Rental
20: Second Surgical Opinion
21: Third Surgical Opinion
23: Diagnostic Dental
24: Periodontics
25: Restorative
—
26: Endodontics
27: Maxillofacial Prosthetics
28: Adjunctive Dental Services
33: Chiropractic
35: Dental Care
36: Dental Crowns
37: Dental Accident
38: Orthodontics
39: Prosthodontics
40: Oral Surgery
42: Home Health Care
44: Home Health Visits
45: Hospice
46: Respite Care
54: Long Term Care
56: Medically Related Transportation
61: In-vitro Fertilization
62: MRI/CAT Scan
63: Donor Procedures
64: Acupuncture
65: Newborn Care
66: Pathology
67: Smoking Cessation
68: Well Baby Care
69: Maternity
70: Transplants
71: Audiology Exam
72: Inhalation Therapy
73: Diagnostic Medical
74: Private Duty Nursing
75: Prosthetic Device
76: Dialysis
77: Otological Exam
78: Chemotherapy
79: Allergy Testing
80: Immunizations
82: Family Planning
83: Infertility
84: Abortion
85: AIDS
86: Emergency Services
87: Cancer
88: Pharmacy
93: Podiatry
A4: Psychiatric
A6: Psychotherapy
A9: Rehabilitation
AD: Occupational Therapy
AE: Physical Medicine
AF: Speech Therapy
AG: Skilled Nursing Care
AI: Substance Abuse
AJ: Alcoholism
AK: Drug Addiction
AL: Vision (Optometry)
AR: Experimental Drug Therapy
B1: Burn Care
BB: Partial Hospitalization (Psychiatric)
BC: Day Care (Psychiatric)
BD: Cognitive Therapy
BE: Massage Therapy
BF: Pulmonary Rehabilitation
BG: Cardiac Rehabilitation
BL: Cardiac
BN: Gastrointestinal
BP: Endocrine
BQ: Neurology
BS: Invasive Procedures
BY: Physician Visit - Office: Sick
BZ: Physician Visit - Office: Well
C1: Coronary Care
CQ: Case Management
GY: Allergy
IC: Intensive Care
MH: Mental Health
NI: Neonatal Intensive Care
ON: Oncology
PT: Physical Therapy
PU: Pulmonary
RN: Renal
RT: Residential Psychiatric Treatment
TC: Transitional Care
TN: Transitional Nursery Care

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

UM-05

C024

Related Causes Information

OptionalMax use 1

To identify one or more related causes and associated state or country information

Usage notes

—

C024-01

1362

Related Causes Code

Required

Identifier (ID)

—

Usage notes

—

AA: Auto Accident
AP: Another Party Responsible
EM: Employment

C024-02

1362

Related Causes Code

Optional

Identifier (ID)

—

AP: Another Party Responsible
EM: Employment

C024-03

1362

Related Causes Code

Optional

Identifier (ID)

—

AP: Another Party Responsible

C024-04

156

State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

C024-05

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

UM-06

1338

Level of Service Code

Optional

Identifier (ID)

—

03: Emergency
E: Elective
U: Urgent

UM-07

1213

Current Health Condition Code

Optional

Identifier (ID)

—

1: Acute
2: Stable
3: Chronic
4: Systemic
5: Localized
6: Mild Disease
7: Normal, Healthy
8: Severe Systemic disease
9: Severe Systemic Disease that is a Constant Threat to Life
E: Excellent
F: Fair
G: Good
P: Poor

UM-08

923

Prognosis Code

Optional

Identifier (ID)

—

1: Poor
2: Guarded
3: Fair
4: Good
5: Very Good
6: Excellent
7: Less than 6 Months to Live
8: Terminal

UM-09

1363

Release of Information Code

Optional

Identifier (ID)

—

Usage notes

—

M: The Provider has Limited or Restricted Ability to Release Data Related to a Claim
—
Y: Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

UM-10

1514

Delay Reason Code

Optional

Identifier (ID)

—

1: Proof of Eligibility Unknown or Unavailable
2: Litigation
3: Authorization Delays
4: Delay in Certifying Provider
7: Third Party Processing Delay
8: Delay in Eligibility Determination
10: Administration Delay in the Prior Approval Process
11: Other
15: Natural Disaster
16: Lack of Information
17: No response to initial request

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

Previous Review Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date

127

Previous Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Accident Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

439: Accident

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date

1251

Accident Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Last Menstrual Period Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

484: Last Menstrual Period

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date

1251

Last Menstrual Period Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Estimated Date of Birth

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

ABC: Estimated Date of Birth

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPEvent Date DTPAdmission Date DTPDischarge Date

1251

Estimated Birth Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Onset of Current Symptoms or Illness Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

431: Onset of Current Symptoms or Illness

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPAdmission Date DTPDischarge Date

1251

Onset Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Event Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

AAH: Event

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPDischarge Date

1251

Proposed or Actual Event Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Admission Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

435: Admission

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date

1251

Proposed or Actual Admission Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

Discharge Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

096: Discharge

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Proposed or Actual Discharge Date

Required

String (AN)

Min 1Max 35

—

0800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HI

Patient Diagnosis

OptionalMax use 1

—

Usage notes

—

Example

HI-01

C022

Health Care Code Information

RequiredMax use 1

To send health care codes and their associated dates, amounts and quantities

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
ABJ: International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ: International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
BK: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-02

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
ABJ: International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ: International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-03

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-04

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-05

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-06

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-07

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-08

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-09

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-10

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-11

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-12

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HSD

0900

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

CRCChiropractic Certification Information CRCDurable Medical Equipment Information CRCOxygen Therapy Certification Information CRCFunctional Limitations Information CRCActivities Permitted Information CRCMental Status Information

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Ambulance Certification Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

07: Ambulance Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

01: Patient was admitted to a hospital
02: Patient was bed confined before the ambulance service
03: Patient was bed confined after the ambulance service
04: Patient was moved by stretcher
05: Patient was unconscious or in shock
5A: Treatment is rendered related to the terminal illness
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
9D: Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
60: Transportation Was To the Nearest Facility

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCDurable Medical Equipment Information CRCOxygen Therapy Certification Information CRCFunctional Limitations Information CRCActivities Permitted Information CRCMental Status Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Chiropractic Certification Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

08: Chiropractic Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
12: Patient is confined to a bed or chair
14: Ambulation is Impaired and Walking Aid is Used for Mobility
24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
25: Item has been prescribed as part of a planned regimen of treatment in patient home
27: Patient or a care-giver has been instructed in use of equipment
30: Without the equipment, the patient would require surgery

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCChiropractic Certification Information CRCOxygen Therapy Certification Information CRCFunctional Limitations Information CRCActivities Permitted Information CRCMental Status Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Durable Medical Equipment Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

09: Durable Medical Equipment Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

01: Patient was admitted to a hospital
02: Patient was bed confined before the ambulance service
03: Patient was bed confined after the ambulance service
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
9D: Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
9H: Patient Requires Intensive IV Therapy
9J: Patient Requires Protective Isolation
9K: Patient Requires Frequent Monitoring
10: Patient is ambulatory
11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
12: Patient is confined to a bed or chair
13: Patient is Confined to a Room or an Area Without Bathroom Facilities
14: Ambulation is Impaired and Walking Aid is Used for Mobility
15: Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
17: Patient's Ability to Breathe is Severely Impaired
18: Patient condition requires frequent and/or immediate changes in body positions
19: Patient can operate controls
20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
21: Patient owns equipment
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
25: Item has been prescribed as part of a planned regimen of treatment in patient home
26: Patient is highly susceptible to decubitus ulcers
27: Patient or a care-giver has been instructed in use of equipment
29: A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds
30: Without the equipment, the patient would require surgery
31: Patient has had a total knee replacement
32: Patient has intractable lymphedema of the extremities
33: Patient is in a nursing home
35: This Feeding is the Only Form of Nutritional Intake for This Patient
37: Oxygen delivery equipment is stationary
38: Certification signed by the physician is on file at the supplier's office
40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
42: Patient Requires Leg Elevation for Edema or Body Alignment
43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
44: Patient Requires Reclining Function of a Wheelchair
45: Patient is Unable to Operate a Wheelchair Manually
46: Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
58: Durable Medical Equipment (DME) Purchased New
59: Durable Medical Equipment (DME) Is Under Warranty
60: Transportation Was To the Nearest Facility
IH: Independent at Home
LB: Legally Blind
SL: Speech Limitations

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCChiropractic Certification Information CRCDurable Medical Equipment Information CRCFunctional Limitations Information CRCActivities Permitted Information CRCMental Status Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Oxygen Therapy Certification Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

11: Oxygen Therapy Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

5A: Treatment is rendered related to the terminal illness
06: Patient was transported in an emergency situation
9J: Patient Requires Protective Isolation
9K: Patient Requires Frequent Monitoring
16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
17: Patient's Ability to Breathe is Severely Impaired
25: Item has been prescribed as part of a planned regimen of treatment in patient home
33: Patient is in a nursing home
37: Oxygen delivery equipment is stationary
39: Patient Has Mobilizing Respiratory Tract Secretions
DY: Dyspnea with Minimal Exertion

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCChiropractic Certification Information CRCDurable Medical Equipment Information CRCOxygen Therapy Certification Information CRCActivities Permitted Information CRCMental Status Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Functional Limitations Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

75: Functional Limitations

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

02: Patient was bed confined before the ambulance service
03: Patient was bed confined after the ambulance service
04: Patient was moved by stretcher
05: Patient was unconscious or in shock
5A: Treatment is rendered related to the terminal illness
06: Patient was transported in an emergency situation
9E: Sudden Onset of Disorientation
9F: Sudden Onset of Severe, Incapacitating Pain
9H: Patient Requires Intensive IV Therapy
11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
12: Patient is confined to a bed or chair
14: Ambulation is Impaired and Walking Aid is Used for Mobility
15: Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
17: Patient's Ability to Breathe is Severely Impaired
18: Patient condition requires frequent and/or immediate changes in body positions
19: Patient can operate controls
20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
21: Patient owns equipment
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
25: Item has been prescribed as part of a planned regimen of treatment in patient home
26: Patient is highly susceptible to decubitus ulcers
27: Patient or a care-giver has been instructed in use of equipment
28: Patient has poor diabetic control
30: Without the equipment, the patient would require surgery
31: Patient has had a total knee replacement
32: Patient has intractable lymphedema of the extremities
35: This Feeding is the Only Form of Nutritional Intake for This Patient
37: Oxygen delivery equipment is stationary
39: Patient Has Mobilizing Respiratory Tract Secretions
40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
42: Patient Requires Leg Elevation for Edema or Body Alignment
43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
44: Patient Requires Reclining Function of a Wheelchair
45: Patient is Unable to Operate a Wheelchair Manually
46: Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
68: Severe
69: Moderate
AA: Amputation
AL: Ambulation Limitations
BL: Bowel Limitations, Bladder Limitations, or both (Incontinence)
BPD: Beneficiary is Partially Dependent
BTD: Beneficiary is Totally Dependent
CA: Cane Required
CB: Complete Bedrest
CNJ: Cumulative Injury
CO: Contracture
DY: Dyspnea with Minimal Exertion
EL: Endurance Limitations
EP: Exercises Prescribed
HL: Hearing Limitations
LB: Legally Blind
LE: Lethargic
OL: Other Limitation
PA: Paralysis
PW: Partial Weight Bearing
SL: Speech Limitations
TNJ: Traumatic Injury
WA: Walker Required
WR: Wheelchair Required

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCChiropractic Certification Information CRCDurable Medical Equipment Information CRCOxygen Therapy Certification Information CRCFunctional Limitations Information CRCMental Status Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Activities Permitted Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

76: Activities Permitted

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

10: Patient is ambulatory
13: Patient is Confined to a Room or an Area Without Bathroom Facilities
19: Patient can operate controls
21: Patient owns equipment
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
27: Patient or a care-giver has been instructed in use of equipment
31: Patient has had a total knee replacement
40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
BR: Bedrest BRP (Bathroom Privileges)
CA: Cane Required
CB: Complete Bedrest
CR: Crutches Required
EL: Endurance Limitations
EP: Exercises Prescribed
IH: Independent at Home
NR: No Restrictions
PA: Paralysis
PW: Partial Weight Bearing
TR: Transfer to Bed, or Chair, or Both
UT: Up as Tolerated
WA: Walker Required
WR: Wheelchair Required

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCChiropractic Certification Information CRCDurable Medical Equipment Information CRCOxygen Therapy Certification Information CRCFunctional Limitations Information CRCActivities Permitted Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CRC

Mental Status Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

77: Mental Status

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

01: Patient was admitted to a hospital
05: Patient was unconscious or in shock
5A: Treatment is rendered related to the terminal illness
07: Patient had to be physically restrained
9E: Sudden Onset of Disorientation
9F: Sudden Onset of Severe, Incapacitating Pain
9J: Patient Requires Protective Isolation
9K: Patient Requires Frequent Monitoring
13: Patient is Confined to a Room or an Area Without Bathroom Facilities
20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
26: Patient is highly susceptible to decubitus ulcers
33: Patient is in a nursing home
34: Patient is conscious
68: Severe
69: Moderate
AG: Agitated
BPD: Beneficiary is Partially Dependent
BTD: Beneficiary is Totally Dependent
CB: Complete Bedrest
CM: Comatose
DI: Disoriented
DP: Depressed
FO: Forgetful
HO: Hostile
LE: Lethargic
MC: Other Mental Condition
OT: Oriented
UN: Uncooperative

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CL1

1100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CL1

Institutional Claim Code

OptionalMax use 1

—

Usage notes

—

Example

CL1-01

1315

Admission Type Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-02

1314

Admission Source Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-03

1352

Patient Status Code

Optional

Identifier (ID)

Min 1Max 2

—

CL1-04

1345

Nursing Home Residential Status Code

Optional

Identifier (ID)

—

1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
2: Newly Admitted
3: Newly Eligible
4: No Longer Eligible
5: Still a Resident
6: Temporary Absence - Hospital
7: Temporary Absence - Other
8: Transferred to Intermediate Care Facility - Level II (ICF II)
9: Other

CR1

1200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR1

Ambulance Transport Information

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required

If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required

CR1-01

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

KG: Kilogram
LB: Pound

CR1-02

Patient Weight

Optional

Decimal number (R)

Min 1Max 10

—

CR1-03

1316

Ambulance Transport Code

Required

Identifier (ID)

—

I: Initial Trip
R: Return Trip
T: Transfer Trip
X: Round Trip

CR1-04

1317

Ambulance Transport Reason Code

Optional

Identifier (ID)

—

A: Patient was transported to nearest facility for care of symptoms, complaints, or both
B: Patient was transported for the benefit of a preferred physician
C: Patient was transported for the nearness of family members
D: Patient was transported for the care of a specialist or for availability of specialized equipment
E: Patient Transferred to Rehabilitation Facility
F: Patient Transferred to Residential Facility

CR1-05

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DH: Miles
DK: Kilometers

CR1-06

380

Transport Distance

Optional

Decimal number (R)

Min 1Max 15

—

CR1-09

352

Round Trip Purpose Description

Optional

String (AN)

Min 1Max 80

—

CR1-10

352

Stretcher Purpose Description

Optional

String (AN)

Min 1Max 80

—

CR2

1300

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR2

Spinal Manipulation Service Information

OptionalMax use 1

—

Usage notes

—

Example

If either Treatment Series Number (CR2-01) or Treatment Count (CR2-02) is present, then the other is required

If Subluxation Level Code (CR2-04) is present, then Subluxation Level Code (CR2-03) is required

CR2-01

609

Treatment Series Number

Optional

Numeric (N0)

Min 1Max 9

—

CR2-02

380

Treatment Count

Optional

Decimal number (R)

Min 1Max 15

—

CR2-03

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR2-04

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR2-08

1342

Patient Condition Code

Required

Identifier (ID)

—

A: Acute Condition
C: Chronic Condition
D: Non-acute
E: Non-Life Threatening
F: Routine
G: Symptomatic
M: Acute Manifestation of a Chronic Condition

CR2-09

1073

Complication Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

CR2-10

352

Patient Condition Description

Optional

String (AN)

Min 1Max 80

—

CR2-11

352

Patient Condition Description

Optional

String (AN)

Min 1Max 80

—

CR2-12

1073

X-ray Availability Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

CR5

1400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR5

Home Oxygen Therapy Information

OptionalMax use 1

—

Usage notes

—

Example

CR5-03

1348

Oxygen Equipment Type Code

Required

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-04

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-05

352

Equipment Reason Description

Optional

String (AN)

Min 1Max 80

—

CR5-06

380

Oxygen Flow Rate

Required

Decimal number (R)

Min 1Max 15

—

CR5-07

380

Daily Oxygen Use Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-08

380

Oxygen Use Period Hour Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-09

352

Respiratory Therapist Order Text

Optional

String (AN)

Min 1Max 80

—

CR5-10

380

Arterial Blood Gas Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CR5-11

380

Oxygen Saturation Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CR5-12

1349

Oxygen Test Condition Code

Optional

Identifier (ID)

—

E: Exercising
N: No special conditions for test
O: On oxygen
R: At rest on room air
S: Sleeping
W: Walking
X: Other

CR5-13

1350

Oxygen Test Findings Code

Optional

Identifier (ID)

—

1: Dependent edema suggesting congestive heart failure
2: "P" Pulmonale on Electrocardiogram (EKG)
3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-14

1350

Oxygen Test Findings Code

Optional

Identifier (ID)

—

1: Dependent edema suggesting congestive heart failure
2: "P" Pulmonale on Electrocardiogram (EKG)
3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-15

1350

Oxygen Test Findings Code

Optional

Identifier (ID)

—

1: Dependent edema suggesting congestive heart failure
2: "P" Pulmonale on Electrocardiogram (EKG)
3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-16

380

Portable Oxygen System Flow Rate

Optional

Decimal number (R)

Min 1Max 15

—

CR5-17

1382

Oxygen Delivery System Code

Required

Identifier (ID)

—

A: Nasal Cannula
B: Oxygen Conserving Device
C: Oxygen Conserving Device with Oxygen Pulse System
D: Oxygen Conserving Device with Reservoir System
E: Transtracheal Catheter

CR5-18

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR6

1500

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > CR6

Home Health Care Information

OptionalMax use 1

—

Usage notes

—

Example

If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required

If either Surgery Date (CR6-09), Product or Service ID Qualifier (CR6-10) or Surgical Procedure Code (CR6-11) are present, then the others are required

If either Date Time Period Format Qualifier (CR6-15), Last Admission Period (CR6-16) or Patient Location Code (CR6-17) are present, then the others are required

CR6-01

923

Prognosis Code

Required

Identifier (ID)

—

1: Poor
2: Guarded
3: Fair
4: Good
5: Very Good
6: Excellent
7: Less than 6 Months to Live
8: Terminal

CR6-02

373

Home Health Start Date

Required

Date (DT)

CCYYMMDD format

—

CR6-03

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

CR6-04

1251

Home Health Certification Period

Optional

String (AN)

Min 1Max 35

—

CR6-07

1073

Medicare Coverage Indicator

Required

Identifier (ID)

—

W: Not Applicable

CR6-08

1322

Certification Type Code

Required

Identifier (ID)

—

Usage notes

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
6: Verification
—
I: Initial
R: Renewal
—
S: Revised
—

CR6-09

373

Surgery Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-10

235

Product or Service ID Qualifier

Optional

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CR6-11

1137

Surgical Procedure Code

Optional

String (AN)

Min 1Max 15

—

CR6-12

373

Physician Order Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-13

373

Last Visit Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-14

373

Physician Contact Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-15

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

CR6-16

1251

Last Admission Period

Optional

String (AN)

Min 1Max 35

—

CR6-17

1384

Patient Location Code

Optional

Identifier (ID)

—

A: Acute Care Facility
B: Boarding Home
C: Hospice
D: Intermediate Care Facility
E: Long-term or Extended Care Facility
F: Not Specified
G: Nursing Home
H: Sub-acute Care Facility
L: Other Location
M: Rehabilitation Facility
O: Outpatient Facility
P: Private Home
R: Residential Treatment Facility
S: Skilled Nursing Home
T: Rest Home

PWK

1550

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > PWK

Additional Patient Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
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
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
—
P7: Periodontal Reports
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
QC: Cause and Corrective Action Report
QR: Quality Report
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

756

Report Transmission Code

Required

Identifier (ID)

—

AA: Available on Request at Provider Site
—
BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

MSG

1600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

Patient Event Transport Information Loop Patient Event Other UMO Name Loop

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010EA Patient Event Provider Name Loop

OptionalMax 14

Variants (all may be used)

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

Patient Event Provider Name

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

71: Attending Physician
72: Operating Physician
73: Other Physician
77: Service Location
AAJ: Admitting Services
DD: Assistant Surgeon
DK: Ordering Physician
DN: Referring Provider
—
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Patient Event Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Patient Event Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Patient Event Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Patient Event Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Patient Event Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Patient Event Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

Patient Event Provider Supplemental Information

OptionalMax use 7

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Patient Event Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

2000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N3

Patient Event Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Patient Event Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N4

Patient Event Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Patient Event Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Patient Event Provider State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Patient Event Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PER

Patient Event Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

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

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

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

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Patient Event Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

Usage notes

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

PRV

2400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

Patient Event Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AD: Admitting
—
AS: Assistant Surgeon
—
AT: Attending
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—
RF: Referring
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

Patient Event Provider Name Loop Patient Event Other UMO Name Loop

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

2010EA Patient Event Provider Name Loop end

2010EB Patient Event Transport Information Loop

OptionalMax 5

Variants (all may be used)

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > NM1

Patient Event Transport Information

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

45: Drop-off Location
FS: Final Scheduled Destination
ND: Next Destination
PW: Pickup Address
R3: Next Scheduled Destination

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Patient Event Transport Location Name

Optional

String (AN)

Min 1Max 60

—

2000

Patient Event Transport Location Address

RequiredMax use 1

—

Example

166

Patient Event Transport Location Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Transport Location Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Patient Event Transport Location City/State/ZIP Code

RequiredMax use 1

—

Usage notes

—

Example

Patient Event Transport Location City Name

Optional

String (AN)

Min 2Max 30

—

156

Patient Event Transport Location State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

Patient Event Provider Name Loop Patient Event Transport Information Loop

116

Patient Event Transport Location Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

2010EB Patient Event Transport Information Loop end

2010EC Patient Event Other UMO Name Loop

OptionalMax 3

Variants (all may be used)

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > NM1

Patient Event Other UMO Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

00: Alternate Insurer
—
CA: Carrier
—
GG: Intermediary
—

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Other UMO Name

Optional

String (AN)

Min 1Max 60

—

REF

1800

Other UMO Denial Reason

RequiredMax use 1

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

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

—

If either Reference Identification Qualifier (C040-03) or Other UMO Denial Reason (C040-04) is present, then the other is required

If either Reference Identification Qualifier (C040-05) or Reference Identification (C040-06) is present, then the other is required

C040-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-02

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

C040-03

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-04

127

Other UMO Denial Reason

Optional

String (AN)

Min 1Max 50

—

C040-05

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-06

127

Reference Identification

Optional

String (AN)

Min 1Max 50

—

DTP

2700

Other UMO Denial Date

RequiredMax use 1

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

598: Rejected

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Other UMO Denial Date

Required

String (AN)

Min 1Max 35

—

2010EC Patient Event Other UMO Name Loop end

2000F Service Level Loop

OptionalMax >1

0100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

SS: Services

736

Hierarchical Child Code

Optional

Identifier (ID)

—

0: No Subordinate HL Segment in This Hierarchical Structure.

TRN

0200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TRN

Service Trace Number

OptionalMax use 2

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

127

Service Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

0400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > UM

Health Care Services Review Information

OptionalMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

HS: Health Services Review
—
SC: Specialty Care Review
—

1322

Certification Type Code

Optional

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
I: Initial
N: Reconsideration
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

Usage notes

—

1: Medical Care
2: Surgical
3: Consultation
4: Diagnostic X-Ray
5: Diagnostic Lab
6: Radiation Therapy
7: Anesthesia
8: Surgical Assistance
11: Used Durable Medical Equipment
12: Durable Medical Equipment Purchase
14: Renal Supplies in the Home
15: Alternate Method Dialysis
16: Chronic Renal Disease (CRD) Equipment
17: Pre-Admission Testing
18: Durable Medical Equipment Rental
20: Second Surgical Opinion
21: Third Surgical Opinion
23: Diagnostic Dental
24: Periodontics
25: Restorative
—
26: Endodontics
27: Maxillofacial Prosthetics
28: Adjunctive Dental Services
33: Chiropractic
35: Dental Care
36: Dental Crowns
37: Dental Accident
38: Orthodontics
39: Prosthodontics
40: Oral Surgery
42: Home Health Care
44: Home Health Visits
45: Hospice
46: Respite Care
54: Long Term Care
56: Medically Related Transportation
61: In-vitro Fertilization
62: MRI/CAT Scan
63: Donor Procedures
64: Acupuncture
65: Newborn Care
66: Pathology
67: Smoking Cessation
68: Well Baby Care
69: Maternity
70: Transplants
71: Audiology Exam
72: Inhalation Therapy
73: Diagnostic Medical
74: Private Duty Nursing
75: Prosthetic Device
76: Dialysis
77: Otological Exam
78: Chemotherapy
79: Allergy Testing
80: Immunizations
82: Family Planning
83: Infertility
84: Abortion
85: AIDS
86: Emergency Services
87: Cancer
88: Pharmacy
93: Podiatry
A4: Psychiatric
A6: Psychotherapy
A9: Rehabilitation
AD: Occupational Therapy
AE: Physical Medicine
AF: Speech Therapy
AG: Skilled Nursing Care
AI: Substance Abuse
AJ: Alcoholism
AK: Drug Addiction
AL: Vision (Optometry)
AR: Experimental Drug Therapy
B1: Burn Care
BB: Partial Hospitalization (Psychiatric)
BC: Day Care (Psychiatric)
BD: Cognitive Therapy
BE: Massage Therapy
BF: Pulmonary Rehabilitation
BG: Cardiac Rehabilitation
BL: Cardiac
BN: Gastrointestinal
BP: Endocrine
BQ: Neurology
BS: Invasive Procedures
BY: Physician Visit - Office: Sick
BZ: Physician Visit - Office: Well
C1: Coronary Care
GY: Allergy
IC: Intensive Care
MH: Mental Health
NI: Neonatal Intensive Care
ON: Oncology
PT: Physical Therapy
PU: Pulmonary
RN: Renal
RT: Residential Psychiatric Treatment
TC: Transitional Care
TN: Transitional Nursery Care

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

Previous Review Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

127

Previous Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Service Date

OptionalMax use 1

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

472: Service

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Proposed or Actual Service Date

Required

String (AN)

Min 1Max 35

—

SV1

0810

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV1

Professional Service

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (SV1-03) or Service Unit Count (SV1-04) is present, then the other is required

SV1-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format
WK: Advanced Billing Concepts (ABC) Codes
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Procedure Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV1-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV1-03

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

F2: International Unit
—
MJ: Minutes
UN: Unit

SV1-04

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV1-07

C004

Composite Diagnosis Code Pointer

OptionalMax use 1

To identify one or more diagnosis code pointers

Usage notes

—

C004-01

1328

Diagnosis Code Pointer

Required

Numeric (N0)

Min 1Max 2

—

C004-02

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-03

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-04

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

SV1-11

1073

EPSDT Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

SV1-20

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

1: Skilled Nursing Facility (SNF)
2: Intermediate Care Facility (ICF)
3: Intermediate Care Facility - Mentally Retarded (ICF-MR)
4: Chronic Disease Hospital (CD)
5: Intermediate Care Facility (ICF) Level II
6: Special Skilled Nursing Facility (SNF)
7: Nursing Facility (NF)
8: Hospice

SV2

0820

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV2

Institutional Service Line

OptionalMax use 1

—

Usage notes

—

Example

At least one of Service Line Revenue Code (SV2-01) or Composite Medical Procedure Identifier (SV2-02) is required

If either Unit or Basis for Measurement Code (SV2-04) or Service Unit Count (SV2-05) is present, then the other is required

SV2-01

234

Service Line Revenue Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-02

C003

Composite Medical Procedure Identifier

OptionalMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

Usage notes

—

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format
WK: Advanced Billing Concepts (ABC) Codes
—
ZZ: Mutually Defined
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Procedure Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-03

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV2-04

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
F2: International Unit
—
UN: Unit

SV2-05

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV2-06

1371

Service Line Rate

Optional

Decimal number (R)

Min 1Max 10

—

SV2-09

1345

Nursing Home Residential Status Code

Optional

Identifier (ID)

—

1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
2: Newly Admitted
3: Newly Eligible
4: No Longer Eligible
5: Still a Resident
6: Temporary Absence - Hospital
7: Temporary Absence - Other
8: Transferred to Intermediate Care Facility - Level II (ICF II)

SV2-10

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

1: Skilled Nursing Facility (SNF)
2: Intermediate Care Facility (ICF)
3: Intermediate Care Facility - Mentally Retarded (ICF-MR)
4: Chronic Disease Hospital (CD)
5: Intermediate Care Facility (ICF) Level II
6: Special Skilled Nursing Facility (SNF)
7: Nursing Facility (NF)
8: Hospice

SV3

0830

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV3

Dental Service

OptionalMax use 1

—

Usage notes

—

Example

SV3-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

AD: American Dental Association Codes
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Procedure Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV3-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV3-04

C006

Oral Cavity Designation

OptionalMax use 1

To identify one or more areas of the oral cavity

Usage notes

—

C006-01

1361

Oral Cavity Designation Code

Required

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-02

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-03

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-04

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-05

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

SV3-05

1358

Prosthesis, Crown, or Inlay Code

Optional

Identifier (ID)

—

I: Initial Placement
R: Replacement

SV3-06

380

Service Unit Count

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SV3-07

352

Description

Optional

String (AN)

Min 1Max 80

—

TOO

0840

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TOO

Tooth Information

OptionalMax use 32

—

Usage notes

—

Example

TOO-01

1270

Code List Qualifier Code

Required

Identifier (ID)

—

JP: Universal National Tooth Designation System

TOO-02

1271

Tooth Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

TOO-03

C005

Tooth Surface

OptionalMax use 1

To identify one or more tooth surface codes

Usage notes

—

C005-01

1369

Tooth Surface Code

Required

Identifier (ID)

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-02

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

C005-03

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

C005-04

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

C005-05

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

HSD

0900

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

PWK

1550

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > PWK

Additional Service Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
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
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
P7: Periodontal Reports
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
QC: Cause and Corrective Action Report
QR: Quality Report
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

756

Report Transmission Code

Required

Identifier (ID)

—

AA: Available on Request at Provider Site
—
BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

MSG

1600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010F Service Provider Name Loop

OptionalMax 10

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > NM1

Service Provider Name

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

1T: Physician, Clinic or Group Practice
72: Operating Physician
73: Other Physician
77: Service Location
DD: Assistant Surgeon
DK: Ordering Physician
DQ: Supervising Physician
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Service Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Service Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Service Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Service Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Service Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Service Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Service Provider Supplemental Identification

OptionalMax use 8

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Service Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

2000

Service Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Service Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Service Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Service Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Service 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

Service Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Service Provider State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Service Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Service Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

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

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

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

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Service Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

PRV

2400

Service Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AS: Assistant Surgeon
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

2010F Service Provider Name Loop end

2000F Service Level Loop end

2000E Patient Event Level Loop end

2000D Dependent Level Loop end

2000E Patient Event Level Loop

OptionalMax 1

Variants (all may be used)

Dependent Level Loop

0100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

EV: Event

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.

TRN

0200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > TRN

Patient Event Tracking Number

OptionalMax use 2

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

127

Patient Event Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

0400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > UM

Health Care Services Review Information

RequiredMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

AR: Admission Review
—
HS: Health Services Review
—
IN: Individual
—
SC: Specialty Care Review
—

1322

Certification Type Code

Required

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
I: Initial
N: Reconsideration
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

1: Medical Care
2: Surgical
3: Consultation
4: Diagnostic X-Ray
5: Diagnostic Lab
6: Radiation Therapy
7: Anesthesia
8: Surgical Assistance
11: Used Durable Medical Equipment
12: Durable Medical Equipment Purchase
14: Renal Supplies in the Home
15: Alternate Method Dialysis
16: Chronic Renal Disease (CRD) Equipment
17: Pre-Admission Testing
18: Durable Medical Equipment Rental
20: Second Surgical Opinion
21: Third Surgical Opinion
23: Diagnostic Dental
24: Periodontics
25: Restorative
—
26: Endodontics
27: Maxillofacial Prosthetics
28: Adjunctive Dental Services
33: Chiropractic
35: Dental Care
36: Dental Crowns
37: Dental Accident
38: Orthodontics
39: Prosthodontics
40: Oral Surgery
42: Home Health Care
44: Home Health Visits
45: Hospice
46: Respite Care
54: Long Term Care
56: Medically Related Transportation
61: In-vitro Fertilization
62: MRI/CAT Scan
63: Donor Procedures
64: Acupuncture
65: Newborn Care
66: Pathology
67: Smoking Cessation
68: Well Baby Care
69: Maternity
70: Transplants
71: Audiology Exam
72: Inhalation Therapy
73: Diagnostic Medical
74: Private Duty Nursing
75: Prosthetic Device
76: Dialysis
77: Otological Exam
78: Chemotherapy
79: Allergy Testing
80: Immunizations
82: Family Planning
83: Infertility
84: Abortion
85: AIDS
86: Emergency Services
87: Cancer
88: Pharmacy
93: Podiatry
A4: Psychiatric
A6: Psychotherapy
A9: Rehabilitation
AD: Occupational Therapy
AE: Physical Medicine
AF: Speech Therapy
AG: Skilled Nursing Care
AI: Substance Abuse
AJ: Alcoholism
AK: Drug Addiction
AL: Vision (Optometry)
AR: Experimental Drug Therapy
B1: Burn Care
BB: Partial Hospitalization (Psychiatric)
BC: Day Care (Psychiatric)
BD: Cognitive Therapy
BE: Massage Therapy
BF: Pulmonary Rehabilitation
BG: Cardiac Rehabilitation
BL: Cardiac
BN: Gastrointestinal
BP: Endocrine
BQ: Neurology
BS: Invasive Procedures
BY: Physician Visit - Office: Sick
BZ: Physician Visit - Office: Well
C1: Coronary Care
CQ: Case Management
GY: Allergy
IC: Intensive Care
MH: Mental Health
NI: Neonatal Intensive Care
ON: Oncology
PT: Physical Therapy
PU: Pulmonary
RN: Renal
RT: Residential Psychiatric Treatment
TC: Transitional Care
TN: Transitional Nursery Care

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

UM-05

C024

Related Causes Information

OptionalMax use 1

To identify one or more related causes and associated state or country information

Usage notes

—

C024-01

1362

Related Causes Code

Required

Identifier (ID)

—

Usage notes

—

AA: Auto Accident
AP: Another Party Responsible
EM: Employment

C024-02

1362

Related Causes Code

Optional

Identifier (ID)

—

AP: Another Party Responsible
EM: Employment

C024-03

1362

Related Causes Code

Optional

Identifier (ID)

—

AP: Another Party Responsible

C024-04

156

State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

C024-05

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

UM-06

1338

Level of Service Code

Optional

Identifier (ID)

—

03: Emergency
E: Elective
U: Urgent

UM-07

1213

Current Health Condition Code

Optional

Identifier (ID)

—

1: Acute
2: Stable
3: Chronic
4: Systemic
5: Localized
6: Mild Disease
7: Normal, Healthy
8: Severe Systemic disease
9: Severe Systemic Disease that is a Constant Threat to Life
E: Excellent
F: Fair
G: Good
P: Poor

UM-08

923

Prognosis Code

Optional

Identifier (ID)

—

1: Poor
2: Guarded
3: Fair
4: Good
5: Very Good
6: Excellent
7: Less than 6 Months to Live
8: Terminal

UM-09

1363

Release of Information Code

Optional

Identifier (ID)

—

Usage notes

—

M: The Provider has Limited or Restricted Ability to Release Data Related to a Claim
—
Y: Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

UM-10

1514

Delay Reason Code

Optional

Identifier (ID)

—

1: Proof of Eligibility Unknown or Unavailable
2: Litigation
3: Authorization Delays
4: Delay in Certifying Provider
7: Third Party Processing Delay
8: Delay in Eligibility Determination
10: Administration Delay in the Prior Approval Process
11: Other
15: Natural Disaster
16: Lack of Information
17: No response to initial request

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > REF

Previous Review Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date

127

Previous Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Accident Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

439: Accident

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date

1251

Accident Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Last Menstrual Period Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

484: Last Menstrual Period

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date DTPDischarge Date

1251

Last Menstrual Period Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Estimated Date of Birth

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

ABC: Estimated Date of Birth

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPEvent Date DTPAdmission Date DTPDischarge Date

1251

Estimated Birth Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Onset of Current Symptoms or Illness Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

431: Onset of Current Symptoms or Illness

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPAdmission Date DTPDischarge Date

1251

Onset Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Event Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

AAH: Event

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPDischarge Date

1251

Proposed or Actual Event Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Admission Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

435: Admission

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

DTPAccident Date DTPLast Menstrual Period Date DTPEstimated Date of Birth DTPOnset of Current Symptoms or Illness Date DTPEvent Date DTPAdmission Date

1251

Proposed or Actual Admission Date

Required

String (AN)

Min 1Max 35

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

Discharge Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

096: Discharge

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Proposed or Actual Discharge Date

Required

String (AN)

Min 1Max 35

—

0800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > HI

Patient Diagnosis

OptionalMax use 1

—

Usage notes

—

Example

HI-01

C022

Health Care Code Information

RequiredMax use 1

To send health care codes and their associated dates, amounts and quantities

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
ABJ: International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ: International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
BK: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-02

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
ABJ: International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
BJ: International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-03

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-04

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-05

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-06

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-07

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-08

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-09

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-10

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-11

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HI-12

C022

Health Care Code Information

OptionalMax use 1

To send health care codes and their associated dates, amounts and quantities

Usage notes

—

If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required

1270

Diagnosis Type Code

Required

Identifier (ID)

—

ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
DR: Diagnosis Related Group (DRG)
PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

1271

Diagnosis Code

Required

String (AN)

Min 1Max 30

—

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Diagnosis Date

Optional

String (AN)

Min 1Max 35

—

HSD

0900

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CRC

Ambulance Certification Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

07: Ambulance Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

01: Patient was admitted to a hospital
02: Patient was bed confined before the ambulance service
03: Patient was bed confined after the ambulance service
04: Patient was moved by stretcher
05: Patient was unconscious or in shock
5A: Treatment is rendered related to the terminal illness
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
9D: Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
60: Transportation Was To the Nearest Facility

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CRC

Chiropractic Certification Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

08: Chiropractic Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
12: Patient is confined to a bed or chair
14: Ambulation is Impaired and Walking Aid is Used for Mobility
24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
25: Item has been prescribed as part of a planned regimen of treatment in patient home
27: Patient or a care-giver has been instructed in use of equipment
30: Without the equipment, the patient would require surgery

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CRC

Durable Medical Equipment Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

09: Durable Medical Equipment Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

01: Patient was admitted to a hospital
02: Patient was bed confined before the ambulance service
03: Patient was bed confined after the ambulance service
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
9D: Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
9H: Patient Requires Intensive IV Therapy
9J: Patient Requires Protective Isolation
9K: Patient Requires Frequent Monitoring
10: Patient is ambulatory
11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
12: Patient is confined to a bed or chair
13: Patient is Confined to a Room or an Area Without Bathroom Facilities
14: Ambulation is Impaired and Walking Aid is Used for Mobility
15: Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
17: Patient's Ability to Breathe is Severely Impaired
18: Patient condition requires frequent and/or immediate changes in body positions
19: Patient can operate controls
20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
21: Patient owns equipment
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
25: Item has been prescribed as part of a planned regimen of treatment in patient home
26: Patient is highly susceptible to decubitus ulcers
27: Patient or a care-giver has been instructed in use of equipment
29: A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds
30: Without the equipment, the patient would require surgery
31: Patient has had a total knee replacement
32: Patient has intractable lymphedema of the extremities
33: Patient is in a nursing home
35: This Feeding is the Only Form of Nutritional Intake for This Patient
37: Oxygen delivery equipment is stationary
38: Certification signed by the physician is on file at the supplier's office
40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
42: Patient Requires Leg Elevation for Edema or Body Alignment
43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
44: Patient Requires Reclining Function of a Wheelchair
45: Patient is Unable to Operate a Wheelchair Manually
46: Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
58: Durable Medical Equipment (DME) Purchased New
59: Durable Medical Equipment (DME) Is Under Warranty
60: Transportation Was To the Nearest Facility
IH: Independent at Home
LB: Legally Blind
SL: Speech Limitations

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CRC

Oxygen Therapy Certification Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

11: Oxygen Therapy Certification

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

5A: Treatment is rendered related to the terminal illness
06: Patient was transported in an emergency situation
9J: Patient Requires Protective Isolation
9K: Patient Requires Frequent Monitoring
16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
17: Patient's Ability to Breathe is Severely Impaired
25: Item has been prescribed as part of a planned regimen of treatment in patient home
33: Patient is in a nursing home
37: Oxygen delivery equipment is stationary
39: Patient Has Mobilizing Respiratory Tract Secretions
DY: Dyspnea with Minimal Exertion

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CRC

Functional Limitations Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

75: Functional Limitations

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

02: Patient was bed confined before the ambulance service
03: Patient was bed confined after the ambulance service
04: Patient was moved by stretcher
05: Patient was unconscious or in shock
5A: Treatment is rendered related to the terminal illness
06: Patient was transported in an emergency situation
9E: Sudden Onset of Disorientation
9F: Sudden Onset of Severe, Incapacitating Pain
9H: Patient Requires Intensive IV Therapy
11: Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
12: Patient is confined to a bed or chair
14: Ambulation is Impaired and Walking Aid is Used for Mobility
15: Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
16: Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
17: Patient's Ability to Breathe is Severely Impaired
18: Patient condition requires frequent and/or immediate changes in body positions
19: Patient can operate controls
20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
21: Patient owns equipment
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
24: Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
25: Item has been prescribed as part of a planned regimen of treatment in patient home
26: Patient is highly susceptible to decubitus ulcers
27: Patient or a care-giver has been instructed in use of equipment
28: Patient has poor diabetic control
30: Without the equipment, the patient would require surgery
31: Patient has had a total knee replacement
32: Patient has intractable lymphedema of the extremities
35: This Feeding is the Only Form of Nutritional Intake for This Patient
37: Oxygen delivery equipment is stationary
39: Patient Has Mobilizing Respiratory Tract Secretions
40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
41: Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
42: Patient Requires Leg Elevation for Edema or Body Alignment
43: Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
44: Patient Requires Reclining Function of a Wheelchair
45: Patient is Unable to Operate a Wheelchair Manually
46: Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
68: Severe
69: Moderate
AA: Amputation
AL: Ambulation Limitations
BL: Bowel Limitations, Bladder Limitations, or both (Incontinence)
BPD: Beneficiary is Partially Dependent
BTD: Beneficiary is Totally Dependent
CA: Cane Required
CB: Complete Bedrest
CNJ: Cumulative Injury
CO: Contracture
DY: Dyspnea with Minimal Exertion
EL: Endurance Limitations
EP: Exercises Prescribed
HL: Hearing Limitations
LB: Legally Blind
LE: Lethargic
OL: Other Limitation
PA: Paralysis
PW: Partial Weight Bearing
SL: Speech Limitations
TNJ: Traumatic Injury
WA: Walker Required
WR: Wheelchair Required

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCChiropractic Certification Information CRCDurable Medical Equipment Information CRCOxygen Therapy Certification Information CRCFunctional Limitations Information CRCMental Status Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CRC

Activities Permitted Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

76: Activities Permitted

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

10: Patient is ambulatory
13: Patient is Confined to a Room or an Area Without Bathroom Facilities
19: Patient can operate controls
21: Patient owns equipment
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
27: Patient or a care-giver has been instructed in use of equipment
31: Patient has had a total knee replacement
40: Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
BR: Bedrest BRP (Bathroom Privileges)
CA: Cane Required
CB: Complete Bedrest
CR: Crutches Required
EL: Endurance Limitations
EP: Exercises Prescribed
IH: Independent at Home
NR: No Restrictions
PA: Paralysis
PW: Partial Weight Bearing
TR: Transfer to Bed, or Chair, or Both
UT: Up as Tolerated
WA: Walker Required
WR: Wheelchair Required

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRCAmbulance Certification Information CRCChiropractic Certification Information CRCDurable Medical Equipment Information CRCOxygen Therapy Certification Information CRCFunctional Limitations Information CRCActivities Permitted Information

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CRC

1000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CRC

Mental Status Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

1136

Code Category

Required

Identifier (ID)

—

77: Mental Status

1073

Certification Condition Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

1321

Condition Code

Required

Identifier (ID)

—

01: Patient was admitted to a hospital
05: Patient was unconscious or in shock
5A: Treatment is rendered related to the terminal illness
07: Patient had to be physically restrained
9E: Sudden Onset of Disorientation
9F: Sudden Onset of Severe, Incapacitating Pain
9J: Patient Requires Protective Isolation
9K: Patient Requires Frequent Monitoring
13: Patient is Confined to a Room or an Area Without Bathroom Facilities
20: Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
22: Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
23: Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
26: Patient is highly susceptible to decubitus ulcers
33: Patient is in a nursing home
34: Patient is conscious
68: Severe
69: Moderate
AG: Agitated
BPD: Beneficiary is Partially Dependent
BTD: Beneficiary is Totally Dependent
CB: Complete Bedrest
CM: Comatose
DI: Disoriented
DP: Depressed
FO: Forgetful
HO: Hostile
LE: Lethargic
MC: Other Mental Condition
OT: Oriented
UN: Uncooperative

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1321

Condition Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

CL1

1100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CL1

Institutional Claim Code

OptionalMax use 1

—

Usage notes

—

Example

CL1-01

1315

Admission Type Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-02

1314

Admission Source Code

Optional

Identifier (ID)

Min 1Max 1

—

CL1-03

1352

Patient Status Code

Optional

Identifier (ID)

Min 1Max 2

—

CL1-04

1345

Nursing Home Residential Status Code

Optional

Identifier (ID)

—

1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
2: Newly Admitted
3: Newly Eligible
4: No Longer Eligible
5: Still a Resident
6: Temporary Absence - Hospital
7: Temporary Absence - Other
8: Transferred to Intermediate Care Facility - Level II (ICF II)
9: Other

CR1

1200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR1

Ambulance Transport Information

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required

If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required

CR1-01

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

KG: Kilogram
LB: Pound

CR1-02

Patient Weight

Optional

Decimal number (R)

Min 1Max 10

—

CR1-03

1316

Ambulance Transport Code

Required

Identifier (ID)

—

I: Initial Trip
R: Return Trip
T: Transfer Trip
X: Round Trip

CR1-04

1317

Ambulance Transport Reason Code

Optional

Identifier (ID)

—

A: Patient was transported to nearest facility for care of symptoms, complaints, or both
B: Patient was transported for the benefit of a preferred physician
C: Patient was transported for the nearness of family members
D: Patient was transported for the care of a specialist or for availability of specialized equipment
E: Patient Transferred to Rehabilitation Facility
F: Patient Transferred to Residential Facility

CR1-05

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DH: Miles
DK: Kilometers

CR1-06

380

Transport Distance

Optional

Decimal number (R)

Min 1Max 15

—

CR1-09

352

Round Trip Purpose Description

Optional

String (AN)

Min 1Max 80

—

CR1-10

352

Stretcher Purpose Description

Optional

String (AN)

Min 1Max 80

—

CR2

1300

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR2

Spinal Manipulation Service Information

OptionalMax use 1

—

Usage notes

—

Example

If either Treatment Series Number (CR2-01) or Treatment Count (CR2-02) is present, then the other is required

If Subluxation Level Code (CR2-04) is present, then Subluxation Level Code (CR2-03) is required

CR2-01

609

Treatment Series Number

Optional

Numeric (N0)

Min 1Max 9

—

CR2-02

380

Treatment Count

Optional

Decimal number (R)

Min 1Max 15

—

CR2-03

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR2-04

1367

Subluxation Level Code

Optional

Identifier (ID)

—

C1: Cervical 1
C2: Cervical 2
C3: Cervical 3
C4: Cervical 4
C5: Cervical 5
C6: Cervical 6
C7: Cervical 7
CO: Coccyx
IL: Ilium
L1: Lumbar 1
L2: Lumbar 2
L3: Lumbar 3
L4: Lumbar 4
L5: Lumbar 5
OC: Occiput
SA: Sacrum
T1: Thoracic 1
T10: Thoracic 10
T11: Thoracic 11
T12: Thoracic 12
T2: Thoracic 2
T3: Thoracic 3
T4: Thoracic 4
T5: Thoracic 5
T6: Thoracic 6
T7: Thoracic 7
T8: Thoracic 8
T9: Thoracic 9

CR2-08

1342

Patient Condition Code

Required

Identifier (ID)

—

A: Acute Condition
C: Chronic Condition
D: Non-acute
E: Non-Life Threatening
F: Routine
G: Symptomatic
M: Acute Manifestation of a Chronic Condition

CR2-09

1073

Complication Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

CR2-10

352

Patient Condition Description

Optional

String (AN)

Min 1Max 80

—

CR2-11

352

Patient Condition Description

Optional

String (AN)

Min 1Max 80

—

CR2-12

1073

X-ray Availability Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

CR5

1400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR5

Home Oxygen Therapy Information

OptionalMax use 1

—

Usage notes

—

Example

CR5-03

1348

Oxygen Equipment Type Code

Required

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-04

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR5-05

352

Equipment Reason Description

Optional

String (AN)

Min 1Max 80

—

CR5-06

380

Oxygen Flow Rate

Required

Decimal number (R)

Min 1Max 15

—

CR5-07

380

Daily Oxygen Use Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-08

380

Oxygen Use Period Hour Count

Optional

Decimal number (R)

Min 1Max 15

—

CR5-09

352

Respiratory Therapist Order Text

Optional

String (AN)

Min 1Max 80

—

CR5-10

380

Arterial Blood Gas Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CR5-11

380

Oxygen Saturation Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CR5-12

1349

Oxygen Test Condition Code

Optional

Identifier (ID)

—

E: Exercising
N: No special conditions for test
O: On oxygen
R: At rest on room air
S: Sleeping
W: Walking
X: Other

CR5-13

1350

Oxygen Test Findings Code

Optional

Identifier (ID)

—

1: Dependent edema suggesting congestive heart failure
2: "P" Pulmonale on Electrocardiogram (EKG)
3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-14

1350

Oxygen Test Findings Code

Optional

Identifier (ID)

—

1: Dependent edema suggesting congestive heart failure
2: "P" Pulmonale on Electrocardiogram (EKG)
3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-15

1350

Oxygen Test Findings Code

Optional

Identifier (ID)

—

1: Dependent edema suggesting congestive heart failure
2: "P" Pulmonale on Electrocardiogram (EKG)
3: Erythrocythemia with a hematocrit greater than 56 percent

CR5-16

380

Portable Oxygen System Flow Rate

Optional

Decimal number (R)

Min 1Max 15

—

CR5-17

1382

Oxygen Delivery System Code

Required

Identifier (ID)

—

A: Nasal Cannula
B: Oxygen Conserving Device
C: Oxygen Conserving Device with Oxygen Pulse System
D: Oxygen Conserving Device with Reservoir System
E: Transtracheal Catheter

CR5-18

1348

Oxygen Equipment Type Code

Optional

Identifier (ID)

—

A: Concentrator
B: Liquid Stationary
C: Gaseous Stationary
D: Liquid Portable
E: Gaseous Portable
O: Other

CR6

1500

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > CR6

Home Health Care Information

OptionalMax use 1

—

Usage notes

—

Example

If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required

If either Surgery Date (CR6-09), Product or Service ID Qualifier (CR6-10) or Surgical Procedure Code (CR6-11) are present, then the others are required

If either Date Time Period Format Qualifier (CR6-15), Last Admission Period (CR6-16) or Patient Location Code (CR6-17) are present, then the others are required

CR6-01

923

Prognosis Code

Required

Identifier (ID)

—

1: Poor
2: Guarded
3: Fair
4: Good
5: Very Good
6: Excellent
7: Less than 6 Months to Live
8: Terminal

CR6-02

373

Home Health Start Date

Required

Date (DT)

CCYYMMDD format

—

CR6-03

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

CR6-04

1251

Home Health Certification Period

Optional

String (AN)

Min 1Max 35

—

CR6-07

1073

Medicare Coverage Indicator

Required

Identifier (ID)

—

W: Not Applicable

CR6-08

1322

Certification Type Code

Required

Identifier (ID)

—

Usage notes

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
6: Verification
—
I: Initial
R: Renewal
—
S: Revised
—

CR6-09

373

Surgery Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-10

235

Product or Service ID Qualifier

Optional

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure

CR6-11

1137

Surgical Procedure Code

Optional

String (AN)

Min 1Max 15

—

CR6-12

373

Physician Order Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-13

373

Last Visit Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-14

373

Physician Contact Date

Optional

Date (DT)

CCYYMMDD format

—

CR6-15

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

CR6-16

1251

Last Admission Period

Optional

String (AN)

Min 1Max 35

—

CR6-17

1384

Patient Location Code

Optional

Identifier (ID)

—

A: Acute Care Facility
B: Boarding Home
C: Hospice
D: Intermediate Care Facility
E: Long-term or Extended Care Facility
F: Not Specified
G: Nursing Home
H: Sub-acute Care Facility
L: Other Location
M: Rehabilitation Facility
O: Outpatient Facility
P: Private Home
R: Residential Treatment Facility
S: Skilled Nursing Home
T: Rest Home

PWK

1550

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > PWK

Additional Patient Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
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
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
—
P7: Periodontal Reports
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
QC: Cause and Corrective Action Report
QR: Quality Report
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

756

Report Transmission Code

Required

Identifier (ID)

—

AA: Available on Request at Provider Site
—
BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

MSG

1600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

Patient Event Transport Information Loop Patient Event Other UMO Name Loop

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010EA Patient Event Provider Name Loop

OptionalMax 14

Variants (all may be used)

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

Patient Event Provider Name

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

71: Attending Physician
72: Operating Physician
73: Other Physician
77: Service Location
AAJ: Admitting Services
DD: Assistant Surgeon
DK: Ordering Physician
DN: Referring Provider
—
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Patient Event Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Patient Event Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Patient Event Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Patient Event Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Patient Event Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Patient Event Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

Patient Event Provider Supplemental Information

OptionalMax use 7

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Patient Event Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

2000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N3

Patient Event Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Patient Event Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > N4

Patient Event Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Patient Event Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Patient Event Provider State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Patient Event Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PER

Patient Event Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

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

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

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

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Patient Event Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

Usage notes

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Patient Event Provider Contact Communications Number

Optional

String (AN)

Min 1Max 256

—

PRV

2400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

Patient Event Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AD: Admitting
—
AS: Assistant Surgeon
—
AT: Attending
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—
RF: Referring
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code

Patient Event Provider Name Loop Patient Event Other UMO Name Loop

127

Provider Taxonomy Code

Required

String (AN)

Min 1Max 50

—

2010EA Patient Event Provider Name Loop end

2010EB Patient Event Transport Information Loop

OptionalMax 5

Variants (all may be used)

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > NM1

Patient Event Transport Information

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

45: Drop-off Location
FS: Final Scheduled Destination
ND: Next Destination
PW: Pickup Address
R3: Next Scheduled Destination

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Patient Event Transport Location Name

Optional

String (AN)

Min 1Max 60

—

2000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N3

Patient Event Transport Location Address

RequiredMax use 1

—

Example

166

Patient Event Transport Location Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Patient Event Transport Location Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Transport Information Loop > N4

Patient Event Transport Location City/State/ZIP Code

RequiredMax use 1

—

Usage notes

—

Example

Patient Event Transport Location City Name

Optional

String (AN)

Min 2Max 30

—

156

Patient Event Transport Location State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

Patient Event Provider Name Loop Patient Event Transport Information Loop

116

Patient Event Transport Location Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

2010EB Patient Event Transport Information Loop end

2010EC Patient Event Other UMO Name Loop

OptionalMax 3

Variants (all may be used)

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > NM1

Patient Event Other UMO Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

00: Alternate Insurer
—
CA: Carrier
—
GG: Intermediary
—

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Other UMO Name

Optional

String (AN)

Min 1Max 60

—

REF

1800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > REF

Other UMO Denial Reason

RequiredMax use 1

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

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

—

If either Reference Identification Qualifier (C040-03) or Other UMO Denial Reason (C040-04) is present, then the other is required

If either Reference Identification Qualifier (C040-05) or Reference Identification (C040-06) is present, then the other is required

C040-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-02

127

Other UMO Denial Reason

Required

String (AN)

Min 1Max 50

—

C040-03

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-04

127

Other UMO Denial Reason

Optional

String (AN)

Min 1Max 50

—

C040-05

128

Reference Identification Qualifier

Optional

Identifier (ID)

—

ZZ: Mutually Defined
—

C040-06

127

Reference Identification

Optional

String (AN)

Min 1Max 50

—

DTP

2700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Other UMO Name Loop > DTP

Other UMO Denial Date

RequiredMax use 1

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

598: Rejected

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Other UMO Denial Date

Required

String (AN)

Min 1Max 35

—

2010EC Patient Event Other UMO Name Loop end

2000F Service Level Loop

OptionalMax >1

0100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

SS: Services

736

Hierarchical Child Code

Optional

Identifier (ID)

—

0: No Subordinate HL Segment in This Hierarchical Structure.

TRN

0200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > TRN

Service Trace Number

OptionalMax use 2

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

127

Service Trace Number

Required

String (AN)

Min 1Max 50

—

509

Trace Assigning Entity Identifier

Required

String (AN)

Min 10Max 10

—

Usage notes

—

127

Trace Assigning Entity Additional Identifier

Optional

String (AN)

Min 1Max 50

—

0400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > UM

Health Care Services Review Information

OptionalMax use 1

—

Usage notes

—

Example

1525

Request Category Code

Required

Identifier (ID)

—

HS: Health Services Review
—
SC: Specialty Care Review
—

1322

Certification Type Code

Optional

Identifier (ID)

—

1: Appeal - Immediate
—
2: Appeal - Standard
—
3: Cancel
4: Extension
—
I: Initial
N: Reconsideration
R: Renewal
—
S: Revised
—

1365

Service Type Code

Optional

Identifier (ID)

—

Usage notes

—

1: Medical Care
2: Surgical
3: Consultation
4: Diagnostic X-Ray
5: Diagnostic Lab
6: Radiation Therapy
7: Anesthesia
8: Surgical Assistance
11: Used Durable Medical Equipment
12: Durable Medical Equipment Purchase
14: Renal Supplies in the Home
15: Alternate Method Dialysis
16: Chronic Renal Disease (CRD) Equipment
17: Pre-Admission Testing
18: Durable Medical Equipment Rental
20: Second Surgical Opinion
21: Third Surgical Opinion
23: Diagnostic Dental
24: Periodontics
25: Restorative
—
26: Endodontics
27: Maxillofacial Prosthetics
28: Adjunctive Dental Services
33: Chiropractic
35: Dental Care
36: Dental Crowns
37: Dental Accident
38: Orthodontics
39: Prosthodontics
40: Oral Surgery
42: Home Health Care
44: Home Health Visits
45: Hospice
46: Respite Care
54: Long Term Care
56: Medically Related Transportation
61: In-vitro Fertilization
62: MRI/CAT Scan
63: Donor Procedures
64: Acupuncture
65: Newborn Care
66: Pathology
67: Smoking Cessation
68: Well Baby Care
69: Maternity
70: Transplants
71: Audiology Exam
72: Inhalation Therapy
73: Diagnostic Medical
74: Private Duty Nursing
75: Prosthetic Device
76: Dialysis
77: Otological Exam
78: Chemotherapy
79: Allergy Testing
80: Immunizations
82: Family Planning
83: Infertility
84: Abortion
85: AIDS
86: Emergency Services
87: Cancer
88: Pharmacy
93: Podiatry
A4: Psychiatric
A6: Psychotherapy
A9: Rehabilitation
AD: Occupational Therapy
AE: Physical Medicine
AF: Speech Therapy
AG: Skilled Nursing Care
AI: Substance Abuse
AJ: Alcoholism
AK: Drug Addiction
AL: Vision (Optometry)
AR: Experimental Drug Therapy
B1: Burn Care
BB: Partial Hospitalization (Psychiatric)
BC: Day Care (Psychiatric)
BD: Cognitive Therapy
BE: Massage Therapy
BF: Pulmonary Rehabilitation
BG: Cardiac Rehabilitation
BL: Cardiac
BN: Gastrointestinal
BP: Endocrine
BQ: Neurology
BS: Invasive Procedures
BY: Physician Visit - Office: Sick
BZ: Physician Visit - Office: Well
C1: Coronary Care
GY: Allergy
IC: Intensive Care
MH: Mental Health
NI: Neonatal Intensive Care
ON: Oncology
PT: Physical Therapy
PU: Pulmonary
RN: Renal
RT: Residential Psychiatric Treatment
TC: Transitional Care
TN: Transitional Nursery Care

C023

Health Care Service Location Information

OptionalMax use 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

Usage notes

—

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

1332

Facility Code Qualifier

Required

Identifier (ID)

—

A: Uniform Billing Claim Form Bill Type
B: Place of Service Codes for Professional or Dental Services

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > REF

Previous Review Authorization Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BB: Authorization Number

127

Previous Review Authorization Number

Required

String (AN)

Min 1Max 50

—

REF

0600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > REF

Previous Review Administrative Reference Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

NT: Administrator's Reference Number

127

Previous Administrative Reference Number

Required

String (AN)

Min 1Max 50

—

DTP

0700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

Service Date

OptionalMax use 1

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

472: Service

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Proposed or Actual Service Date

Required

String (AN)

Min 1Max 35

—

SV1

0810

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV1

Professional Service

OptionalMax use 1

—

Usage notes

—

Example

If either Unit or Basis for Measurement Code (SV1-03) or Service Unit Count (SV1-04) is present, then the other is required

SV1-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format
WK: Advanced Billing Concepts (ABC) Codes
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Procedure Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV1-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV1-03

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

F2: International Unit
—
MJ: Minutes
UN: Unit

SV1-04

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV1-07

C004

Composite Diagnosis Code Pointer

OptionalMax use 1

To identify one or more diagnosis code pointers

Usage notes

—

C004-01

1328

Diagnosis Code Pointer

Required

Numeric (N0)

Min 1Max 2

—

C004-02

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-03

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

C004-04

1328

Diagnosis Code Pointer

Optional

Numeric (N0)

Min 1Max 2

—

Usage notes

—

SV1-11

1073

EPSDT Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

SV1-20

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

1: Skilled Nursing Facility (SNF)
2: Intermediate Care Facility (ICF)
3: Intermediate Care Facility - Mentally Retarded (ICF-MR)
4: Chronic Disease Hospital (CD)
5: Intermediate Care Facility (ICF) Level II
6: Special Skilled Nursing Facility (SNF)
7: Nursing Facility (NF)
8: Hospice

SV2

0820

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV2

Institutional Service Line

OptionalMax use 1

—

Usage notes

—

Example

At least one of Service Line Revenue Code (SV2-01) or Composite Medical Procedure Identifier (SV2-02) is required

If either Unit or Basis for Measurement Code (SV2-04) or Service Unit Count (SV2-05) is present, then the other is required

SV2-01

234

Service Line Revenue Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-02

C003

Composite Medical Procedure Identifier

OptionalMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

Usage notes

—

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
—
ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
—
N4: National Drug Code in 5-4-2 Format
WK: Advanced Billing Concepts (ABC) Codes
—
ZZ: Mutually Defined
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Procedure Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV2-03

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV2-04

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
F2: International Unit
—
UN: Unit

SV2-05

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

SV2-06

1371

Service Line Rate

Optional

Decimal number (R)

Min 1Max 10

—

SV2-09

1345

Nursing Home Residential Status Code

Optional

Identifier (ID)

—

1: Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
2: Newly Admitted
3: Newly Eligible
4: No Longer Eligible
5: Still a Resident
6: Temporary Absence - Hospital
7: Temporary Absence - Other
8: Transferred to Intermediate Care Facility - Level II (ICF II)

SV2-10

1337

Nursing Home Level of Care

Optional

Identifier (ID)

—

1: Skilled Nursing Facility (SNF)
2: Intermediate Care Facility (ICF)
3: Intermediate Care Facility - Mentally Retarded (ICF-MR)
4: Chronic Disease Hospital (CD)
5: Intermediate Care Facility (ICF) Level II
6: Special Skilled Nursing Facility (SNF)
7: Nursing Facility (NF)
8: Hospice

SV3

0830

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV3

Dental Service

OptionalMax use 1

—

Usage notes

—

Example

SV3-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers

235

Product or Service ID Qualifier

Required

Identifier (ID)

—

AD: American Dental Association Codes
—

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

Usage notes

—

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

234

Procedure Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SV3-02

782

Service Line Amount

Optional

Decimal number (R)

Min 1Max 15

—

SV3-04

C006

Oral Cavity Designation

OptionalMax use 1

To identify one or more areas of the oral cavity

Usage notes

—

C006-01

1361

Oral Cavity Designation Code

Required

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-02

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-03

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-04

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

C006-05

1361

Oral Cavity Designation Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

SV3-05

1358

Prosthesis, Crown, or Inlay Code

Optional

Identifier (ID)

—

I: Initial Placement
R: Replacement

SV3-06

380

Service Unit Count

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SV3-07

352

Description

Optional

String (AN)

Min 1Max 80

—

TOO

0840

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > TOO

Tooth Information

OptionalMax use 32

—

Usage notes

—

Example

TOO-01

1270

Code List Qualifier Code

Required

Identifier (ID)

—

JP: Universal National Tooth Designation System

TOO-02

1271

Tooth Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

TOO-03

C005

Tooth Surface

OptionalMax use 1

To identify one or more tooth surface codes

Usage notes

—

C005-01

1369

Tooth Surface Code

Required

Identifier (ID)

—

B: Buccal
D: Distal
F: Facial
I: Incisal
L: Lingual
M: Mesial
O: Occlusal

C005-02

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

C005-03

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

C005-04

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

C005-05

1369

Tooth Surface Code

Optional

Identifier (ID)

Min 1Max 2

—

Usage notes

—

HSD

0900

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > HSD

Health Care Services Delivery

OptionalMax use 1

—

Usage notes

—

Example

If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

673

Quantity Qualifier

Optional

Identifier (ID)

—

DY: Days
FL: Units
HS: Hours
MN: Month
VS: Visits

380

Service Unit Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

355

Unit or Basis for Measurement Code

Optional

Identifier (ID)

—

DA: Days
MO: Months
WK: Week

1167

Sample Selection Modulus

Optional

Decimal number (R)

Min 1Max 6

—

615

Time Period Qualifier

Optional

Identifier (ID)

—

6: Hour
7: Day
21: Years
26: Episode
27: Visit
34: Month
35: Week

616

Period Count

Optional

Numeric (N0)

Min 1Max 3

—

678

Delivery Frequency Code

Optional

Identifier (ID)

—

1: 1st Week of the Month
2: 2nd Week of the Month
3: 3rd Week of the Month
4: 4th Week of the Month
5: 5th Week of the Month
6: 1st & 3rd Weeks of the Month
7: 2nd & 4th Weeks of the Month
8: 1st Working Day of Period
9: Last Working Day of Period
A: Monday through Friday
B: Monday through Saturday
C: Monday through Sunday
D: Monday
E: Tuesday
F: Wednesday
G: Thursday
H: Friday
J: Saturday
K: Sunday
L: Monday through Thursday
M: Immediately
N: As Directed
O: Daily Mon. through Fri.
P: 1/2 Mon. & 1/2 Thurs.
Q: 1/2 Tues. & 1/2 Thurs.
R: 1/2 Wed. & 1/2 Fri.
S: Once Anytime Mon. through Fri.
SA: Sunday, Monday, Thursday, Friday, Saturday
SB: Tuesday through Saturday
SC: Sunday, Wednesday, Thursday, Friday, Saturday
SD: Monday, Wednesday, Thursday, Friday, Saturday
SG: Tuesday through Friday
SL: Monday, Tuesday and Thursday
SP: Monday, Tuesday and Friday
SX: Wednesday and Thursday
SY: Monday, Wednesday and Thursday
SZ: Tuesday, Thursday and Friday
T: 1/2 Tue. & 1/2 Fri.
U: 1/2 Mon. & 1/2 Wed.
V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
W: Whenever Necessary
X: 1/2 By Wed., Bal. By Fri.
Y: None (Also Used to Cancel or Override a Previous Pattern)

679

Delivery Pattern Time Code

Optional

Identifier (ID)

—

A: 1st Shift (Normal Working Hours)
B: 2nd Shift
C: 3rd Shift
D: A.M.
E: P.M.
F: As Directed
G: Any Shift
Y: None (Also Used to Cancel or Override a Previous Pattern)

PWK

1550

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > PWK

Additional Service Information

OptionalMax use 10

—

Usage notes

—

Example

If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required

755

Attachment Report Type Code

Required

Identifier (ID)

—

03: Report Justifying Treatment Beyond Utilization Guidelines
04: Drugs Administered
05: Treatment Diagnosis
06: Initial Assessment
07: Functional Goals
—
08: Plan of Treatment
09: Progress Report
10: Continued Treatment
11: Chemical Analysis
13: Certified Test Report
15: Justification for Admission
21: Recovery Plan
48: Social Security Benefit Letter
55: Rental Agreement
—
59: Benefit Letter
77: Support Data for Verification
A3: Allergies/Sensitivities Document
A4: Autopsy Report
AM: Ambulance Certification
—
AS: Admission Summary
—
AT: Purchase Order Attachment
—
B2: Prescription
B3: Physician Order
BR: Benchmark Testing Results
BS: Baseline
BT: Blanket Test Results
CB: Chiropractic Justification
—
CK: Consent Form(s)
D2: Drug Profile Document
DA: Dental Models
DB: Durable Medical Equipment Prescription
DG: Diagnostic Report
DJ: Discharge Monitoring Report
DS: Discharge Summary
FM: Family Medical History Document
HC: Health Certificate
HR: Health Clinic Records
I5: Immunization Record
IR: State School Immunization Records
LA: Laboratory Results
M1: Medical Record Attachment
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
P4: Pathology Report
P5: Patient Medical History Document
P6: Periodontal Charts
P7: Periodontal Reports
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
QC: Cause and Corrective Action Report
QR: Quality Report
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

756

Report Transmission Code

Required

Identifier (ID)

—

AA: Available on Request at Provider Site
—
BM: By Mail
EL: Electronically Only
—
EM: E-Mail
FX: By Fax
VO: Voice
—

Identification Code Qualifier

Optional

Identifier (ID)

—

AC: Attachment Control Number

Attachment Control Number

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

352

Attachment Description

Optional

String (AN)

Min 1Max 80

—

MSG

1600

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > MSG

Message Text

OptionalMax use 1

—

Usage notes

—

Example

933

Free Form Message Text

Required

String (AN)

Min 1Max 264

—

2010F Service Provider Name Loop

OptionalMax 10

NM1

1700

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > NM1

Service Provider Name

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

1T: Physician, Clinic or Group Practice
72: Operating Physician
73: Other Physician
77: Service Location
DD: Assistant Surgeon
DK: Ordering Physician
DQ: Supervising Physician
FA: Facility
G3: Clinic
P3: Primary Care Provider
QB: Purchase Service Provider
QV: Group Practice
SJ: Service Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Service Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Service Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Service Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Service Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Service Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

24: Employer's Identification Number
34: Social Security Number
46: Electronic Transmitter Identification Number (ETIN)
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Service Provider Identifier

Optional

String (AN)

Min 2Max 80

—

REF

1800

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > REF

Service Provider Supplemental Identification

OptionalMax use 8

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
1J: Facility ID Number
EI: Employer's Identification Number
—
N5: Provider Plan Network Identification Number
N7: Facility Network Identification Number
SY: Social Security Number
—
ZH: Carrier Assigned Reference Number
—

127

Service Provider Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

352

License Number State Code

Optional

String (AN)

Min 1Max 80

—

Usage notes

—

2000

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > N3

Service Provider Address

OptionalMax use 1

—

Usage notes

—

Example

166

Service Provider Address Line

Required

String (AN)

Min 1Max 55

—

Usage notes

—

166

Service Provider Address Line

Optional

String (AN)

Min 1Max 55

—

2100

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > N4

Service Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

Only one of Service 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

Service Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Service Provider State or Province Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Service Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

2200

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PER

Service Provider Contact Information

OptionalMax use 1

—

Usage notes

—

Example

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

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

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

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

Service Provider Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
—
FX: Facsimile
TE: Telephone
UR: Uniform Resource Locator (URL)

364

Service Provider Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

PRV

2400

Detail > Utilization Management Organization (UMO) Level Loop > Requester Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PRV

Service Provider Information

OptionalMax use 1

—

Usage notes

—

Example

1221

Provider Code

Required

Identifier (ID)

—

AS: Assistant Surgeon
—
OP: Operating
—
OR: Ordering
—
OT: Other Physician
—
PC: Primary Care Physician
—
PE: Performing
—

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PXC: Health Care Provider Taxonomy Code