X12 278 Health Care Services Review Information - Acknowledgment (X216)

X12 Release 5010

Delimiters

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

ISA Interchange Control Header

Required · Max use 1

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

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

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

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

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

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

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

Codes

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

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

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

Codes

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

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

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

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

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

• ^: Repetition Separator

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

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

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

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

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

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

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

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

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

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

• HI: Health Care Services Review Information (278)

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

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

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

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

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

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

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

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

005010X216

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

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 4 Max 9

ST-03 · 1705 · Implementation Guide Version Name · Required · String (AN)

005010X216

0200 Heading > BHT

BHT Beginning of Hierarchical Transaction

Required · Max use 1

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)

• 44: Rejection
• 53: Completion

BHT-03 · 127 · Submitter Transaction Identifier · Required · String (AN) · Min 1 Max 50

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

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

Detail

2000A Information Source Level Loop Required Max 1

0100 Detail > Information Source Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

• 20: Information Source

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

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

0300 Detail > Information Source Level Loop > AAA

AAA Notification Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 04: Authorized Quantity Exceeded
• 41: Authorization/Access Restrictions
• 42: Unable to Respond at Current Time
• 79: Invalid Participant Identification

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• P: Please Resubmit Original Transaction
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

2010A Information Source Name Loop Required Max 2

1700 Detail > Information Source Level Loop > Information Source Name Loop > NM1

NM1 Information Source Name

Required · Max use 1

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

• 1P: Provider
• 2B: Third-Party Administrator
• FA: Facility
• PR: Payer
• X3: Utilization Management Organization

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

• 1: Person
• 2: Non-Person Entity

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

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

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

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

NM1-08 · 66 · 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
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

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

1800 Detail > Information Source Level Loop > Information Source Name Loop > REF

REF Information Source Supplemental Identification

Optional · Max use 9

REF-01 · 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

REF-02 · 127 · Information Source Supplemental Identifier · Required · String (AN) · Min 1 Max 50

2300 Detail > Information Source Level Loop > Information Source Name Loop > AAA

AAA Information Source Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 35: Out of Network
• 41: Authorization/Access Restrictions
• 43: Invalid/Missing Provider Identification
• 44: Invalid/Missing Provider Name
• 45: Invalid/Missing Provider Specialty
• 46: Invalid/Missing Provider Phone Number
• 47: Invalid/Missing Provider State
• 49: Provider is Not Primary Care Physician
• 50: Provider Ineligible for Inquiries
• 51: Provider Not on File
• 79: Invalid Participant Identification
• 97: Invalid or Missing Provider Address

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• R: Resubmission Allowed

2400 Detail > Information Source Level Loop > Information Source Name Loop > PRV

PRV Information Source Provider Information

Optional · Max use 1

PRV-01 · 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

PRV-02 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Taxonomy Code · Required · String (AN) · Min 1 Max 50

2000B Information Receiver Level Loop Optional Max 1

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

HL Hierarchical Level

Required · Max use 1

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

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

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

• 21: Information Receiver

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

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

2010B Information Receiver Name Loop Required Max 1

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

NM1 Information Receiver Name

Required · Max use 1

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

• 1P: Provider
• 2B: Third-Party Administrator
• FA: Facility
• PR: Payer
• X3: Utilization Management Organization

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

• 1: Person
• 2: Non-Person Entity

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

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

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

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

NM1-08 · 66 · 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
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

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

2200 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > PER

PER Information Receiver Contact Information

Optional · Max use 1

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

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

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

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IC: Information Contact

PER-02 · 93 · Information Receiver Contact Name · Optional · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone

PER-04 · 364 · Information Receiver Contact Communication Number · Optional · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-06 · 364 · Information Receiver Contact Communication Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-08 · 364 · Information Receiver Contact Communication Number · Optional · String (AN) · Min 1 Max 256

2300 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > AAA

AAA Information Receiver Notification Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 04: Authorized Quantity Exceeded
• 41: Authorization/Access Restrictions
• 42: Unable to Respond at Current Time
• 79: Invalid Participant Identification
• 80: No Response received - Transaction Terminated
• T4: Payer Name or Identifier Missing

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• N: Resubmission Not Allowed
• P: Please Resubmit Original Transaction
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

2000C Subscriber Level Loop Optional Max 1

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

HL Hierarchical Level

Required · Max use 1

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

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

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

• 22: Subscriber

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

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

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > TRN

TRN Subscriber Trace Number

Optional · Max use 3

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

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

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > AAA

AAA Subscriber Notification Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 56: Inappropriate Date

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > REF

REF Notification Receipt Number

Optional · Max use 1

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

• BAF: Receipt Number

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

2010C Subscriber Name Loop Required Max 1

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

NM1 Subscriber Name

Required · Max use 1

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

• IL: Insured or Subscriber

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

• 1: Person

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

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

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

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

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

• MI: Member Identification Number
• ZZ: Mutually Defined

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

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

REF Subscriber Supplemental Identification

Optional · Max use 9

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

• 1L: Group or Policy Number
• 6P: Group 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

REF-02 · 127 · Subscriber Supplemental Identifier · Required · String (AN) · Min 1 Max 50

2300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > AAA

AAA Subscriber Notification Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 58: Invalid/Missing Date-of-Birth
• 64: Invalid/Missing Patient ID
• 65: Invalid/Missing Patient Name
• 66: Invalid/Missing Patient Gender Code
• 67: Patient Not Found
• 68: Duplicate Patient ID Number
• 71: Patient Birth Date Does Not Match That for the Patient on the Database
• 72: Invalid/Missing Subscriber/Insured ID
• 73: Invalid/Missing Subscriber/Insured Name
• 74: Invalid/Missing Subscriber/Insured Gender Code
• 75: Subscriber/Insured Not Found
• 76: Duplicate Subscriber/Insured ID Number
• 77: Subscriber Found, Patient Not Found
• 78: Subscriber/Insured Not in Group/Plan Identified
• 79: Invalid Participant Identification
• 95: Patient Not Eligible

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

2500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

DMG Subscriber Demographic Information

Optional · Max use 1

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

• D8: Date Expressed in Format CCYYMMDD

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

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

• F: Female
• M: Male
• U: Unknown

2600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

INS Subscriber Relationship

Optional · Max use 1

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)

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

2000D Dependent Level Loop Optional Max 1

Variants (all may be used)

Patient Event Level Loop

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

HL Hierarchical Level

Required · Max use 1

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

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

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

• 23: Dependent

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

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

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > TRN

TRN Dependent Trace Number

Optional · Max use 3

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

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

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > AAA

AAA Dependent Notification Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 56: Inappropriate Date

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > REF

REF Notification Receipt Number

Optional · Max use 1

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

• BAF: Receipt Number

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

2010D Dependent Name Loop Required Max 1

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

NM1 Dependent Name

Required · Max use 1

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

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

• QC: Patient

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

• 1: Person

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

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

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

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

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

• MI: Member Identification Number
• ZZ: Mutually Defined

NM1-09 · 67 · Dependent Primary Identifier · Optional · String (AN) · Min 2 Max 80

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

REF Dependent Supplemental Identification

Optional · Max use 3

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

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

REF-02 · 127 · Dependent Supplemental Identifier · Required · String (AN) · Min 1 Max 50

2300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > AAA

AAA Dependent Notification Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 58: Invalid/Missing Date-of-Birth
• 64: Invalid/Missing Patient ID
• 65: Invalid/Missing Patient Name
• 66: Invalid/Missing Patient Gender Code
• 67: Patient Not Found
• 68: Duplicate Patient ID Number
• 71: Patient Birth Date Does Not Match That for the Patient on the Database
• 77: Subscriber Found, Patient Not Found
• 95: Patient Not Eligible

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

2500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

DMG Dependent Demographic Information

Optional · Max use 1

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

• D8: Date Expressed in Format CCYYMMDD

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

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

• F: Female
• M: Male
• U: Unknown

2600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

INS Dependent Relationship

Optional · Max use 1

INS-01 · 1073 · Insured Indicator · Required · Identifier (ID)

• N: No

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 01: Spouse
• 04: Grandfather or Grandmother
• 05: Grandson or Granddaughter
• 07: Nephew or Niece
• 09: Adopted Child
• 10: Foster Child
• 15: Ward
• 17: Stepson or Stepdaughter
• 19: Child
• 20: Employee
• 21: Unknown
• 22: Handicapped Dependent
• 23: Sponsored Dependent
• 24: Dependent of a Minor Dependent
• 29: Significant Other
• 32: Mother
• 33: Father
• 34: Other Adult
• 39: Organ Donor
• 40: Cadaver Donor
• 41: Injured Plaintiff
• 43: Child Where Insured Has No Financial Responsibility
• 53: Life Partner
• G8: Other Relationship

INS-17 · 1470 · Birth Sequence Number · Optional · Numeric (N0) · Min 1 Max 9

2000E Patient Event Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• EV: Event

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

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

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > TRN

TRN Patient Event Tracking Number

Optional · Max use 3

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

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

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > AAA

AAA Patient Event Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Optional · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 52: Service Dates Not Within Provider Plan Enrollment
• 56: Inappropriate Date
• 57: Invalid/Missing Date(s) of Service
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 84: Certification Not Required for this Service
• 90: Requested Information Not Received
• AF: Invalid/Missing Diagnosis Code(s)
• AH: Invalid/Missing Onset of Current Condition or Illness Date
• AI: Invalid/Missing Accident Date
• AJ: Invalid/Missing Last Menstrual Period Date
• AK: Invalid/Missing Expected Date of Birth
• AM: Invalid/Missing Admission Date
• AN: Invalid/Missing Discharge Date
• T5: Certification Information Missing

AAA-04 · 889 · Follow-up Action Code · Optional · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > UM

UM Health Care Services Review Information

Required · Max use 1

UM-01 · 1525 · Request Category Code · Required · Identifier (ID)

• AR: Admission Review
• HS: Health Services Review
• SC: Specialty Care Review

UM-02 · 1322 · Certification Type Code · Required · Identifier (ID)

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

UM-03 · 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
• 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

UM-04 · C023 · Health Care Service Location Information · Optional Max 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

C023-01 · 1331 · Facility Type Code · Required · String (AN) · Min 1 Max 2

C023-02 · 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-06 · 1338 · Level of Service Code · Optional · Identifier (ID)

• 03: Emergency
• E: Elective
• U: Urgent

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HCR

HCR Health Care Services Review

Optional · Max use 1

HCR-01 · 306 · Action Code · Required · Identifier (ID)

• A1: Certified in total
• A2: Certified - partial
• A3: Not Certified
• A4: Pended
• A6: Modified
• C: Cancelled
• CT: Contact Payer
• NA: No Action Required

HCR-02 · 127 · Review Identification Number · Optional · String (AN) · Min 1 Max 50

HCR-03 · 1271 · Review Decision Reason Code · Optional · String (AN) · Max use 5 · Min 1 Max 30

HCR-04 · 1073 · Second Surgical Opinion Indicator · Optional · Identifier (ID)

• N: No
• Y: Yes

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

REF Administrative Reference Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Authorization Number

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

• NT: Administrator's Reference Number

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

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > REF

REF Previous Review Authorization Number

Optional · Max use 1

Variants (all may be used)

REFAdministrative Reference Number

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

• BB: Authorization Number

REF-02 · 127 · Previous Review Authorization Number · Required · String (AN) · Min 1 Max 50

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Event Date

Optional · Max use 1

Variants (all may be used)

DTPAdmission DateDTPDischarge DateDTPCertification Issue DateDTPCertification Expiration DateDTPCertification Effective Date

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

• AAH: Event

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

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

DTP-03 · 1251 · Proposed or Actual Event Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Admission Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPDischarge DateDTPCertification Issue DateDTPCertification Expiration DateDTPCertification Effective Date

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

• 435: Admission

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

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

DTP-03 · 1251 · Proposed or Actual Admission Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Discharge Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPCertification Issue DateDTPCertification Expiration DateDTPCertification Effective Date

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

• 096: Discharge

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Proposed or Actual Discharge Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Certification Issue Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPDischarge DateDTPCertification Expiration DateDTPCertification Effective Date

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

• 102: Issue

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Issue Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Certification Expiration Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPDischarge DateDTPCertification Issue DateDTPCertification Effective Date

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

• 036: Expiration

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Expiration Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > DTP

DTP Certification Effective Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPDischarge DateDTPCertification Issue DateDTPCertification Expiration Date

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

• 007: Effective

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

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

DTP-03 · 1251 · Certification Effective Date · Required · String (AN) · Min 1 Max 35

0800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > HI

HI Patient Diagnosis

Optional · Max use 1

HI-01 · C022 · Health Care Code Information · Required Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-02 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-03 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-04 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-05 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-06 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-07 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-08 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-09 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-10 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-11 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-12 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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)
• LOI: Logical Observation Identifier Names and Codes (LOINC<190>) Codes
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

2010E Patient Event Provider Name Loop Optional Max 12

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

NM1 Patient Event Provider Name

Required · Max use 1

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

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

• 1T: Physician, Clinic or Group Practice
• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• AAJ: Admitting Services
• DD: Assistant Surgeon
• DK: Ordering Physician
• DN: Referring Provider
• FA: Facility
• P3: Primary Care Provider
• QB: Purchase Service Provider
• SJ: Service Provider

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

• 1: Person
• 2: Non-Person Entity

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

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

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

NM1-06 · 1038 · Patient Event Provider Name Prefix · Optional · String (AN) · Min 1 Max 10

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

NM1-08 · 66 · 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

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

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

REF Patient Event Provider Supplemental Identification

Optional · Max use 7

REF-01 · 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

REF-02 · 127 · Patient Event Provider Supplemental Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · License Number State Code · Optional · String (AN) · Min 1 Max 80

2300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > AAA

AAA Patient Event Provider Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Optional · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 35: Out of Network
• 41: Authorization/Access Restrictions
• 43: Invalid/Missing Provider Identification
• 44: Invalid/Missing Provider Name
• 47: Invalid/Missing Provider State
• 49: Provider is Not Primary Care Physician
• 51: Provider Not on File
• 52: Service Dates Not Within Provider Plan Enrollment
• 79: Invalid Participant Identification

AAA-04 · 889 · Follow-up Action Code · Optional · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

2400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

PRV Patient Event Provider Information

Optional · Max use 1

PRV-01 · 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

PRV-02 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Taxonomy Code · Required · String (AN) · Min 1 Max 50

2000F Service Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• SS: Services

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

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

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TRN

TRN Service Trace Number

Optional · Max use 3

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

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

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > AAA

AAA Service Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 52: Service Dates Not Within Provider Plan Enrollment
• 57: Invalid/Missing Date(s) of Service
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 84: Certification Not Required for this Service
• 90: Requested Information Not Received
• AG: Invalid/Missing Procedure Code(s)
• T5: Certification Information Missing

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > UM

UM Health Care Services Review Information

Optional · Max use 1

UM-01 · 1525 · Request Category Code · Required · Identifier (ID)

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

UM-02 · 1322 · Certification Type Code · Optional · Identifier (ID)

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

UM-03 · 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
• 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

UM-04 · C023 · Health Care Service Location Information · Optional Max 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

C023-01 · 1331 · Facility Type Code · Required · String (AN) · Min 1 Max 2

C023-02 · 1332 · Facility Code Qualifier · Required · Identifier (ID)

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

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > HCR

HCR Health Care Services Review

Optional · Max use 1

HCR-01 · 306 · Action Code · Required · Identifier (ID)

• A1: Certified in total
• A3: Not Certified
• A4: Pended
• A6: Modified
• C: Cancelled
• CT: Contact Payer
• NA: No Action Required

HCR-02 · 127 · Review Identification Number · Optional · String (AN) · Min 1 Max 50

HCR-03 · 1271 · Review Decision Reason Code · Optional · String (AN) · Max use 5 · Min 1 Max 30

HCR-04 · 1073 · Yes No Condition or Response Code · Optional · Identifier (ID) · Min 1 Max 1

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

REF Previous Review Authorization Number

Optional · Max use 1

Variants (all may be used)

REFAdministrative Reference Number

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

• BB: Authorization Number

REF-02 · 127 · Previous Review Authorization Number · Required · String (AN) · Min 1 Max 50

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > REF

REF Administrative Reference Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Authorization Number

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

• NT: Administrator's Reference Number

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

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Certification Effective Date

Optional · Max use 1

Variants (all may be used)

DTPService DateDTPCertification Issue DateDTPCertification Expiration Date

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

• 007: Effective

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

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

DTP-03 · 1251 · Certification Effective Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Service Date

Optional · Max use 1

Variants (all may be used)

DTPCertification Effective DateDTPCertification Issue DateDTPCertification Expiration Date

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

• 472: Service

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

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

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

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Certification Issue Date

Optional · Max use 1

Variants (all may be used)

DTPCertification Effective DateDTPService DateDTPCertification Expiration Date

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

• 102: Issue

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Issue Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Certification Expiration Date

Optional · Max use 1

Variants (all may be used)

DTPCertification Effective DateDTPService DateDTPCertification Issue Date

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

• 036: Expiration

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Expiration Date · Required · String (AN) · Min 1 Max 35

0810 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV1

SV1 Professional Service

Optional · Max use 1

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 · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers

C003-01 · 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

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

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

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

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

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

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

SV1-02 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 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 1 Max 15

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

0820 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV2

SV2 Institutional Service Line

Optional · Max use 1

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 1 Max 48

SV2-02 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers · Usage notes

C003-01 · 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
• ZZ: Mutually Defined

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

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

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

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

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

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

SV2-03 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 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 1 Max 15

SV2-06 · 1371 · Service Line Rate · Optional · Decimal number (R) · Min 1 Max 10

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

0830 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > SV3

SV3 Dental Service

Optional · Max use 1

SV3-01 · C003 · Composite Medical Procedure Identifier · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers

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

• AD: American Dental Association Codes

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

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

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

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

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

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

SV3-02 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 15

SV3-04 · C006 · Oral Cavity Designation · Optional Max 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 1 Max 3

C006-02 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

C006-03 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

C006-04 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

C006-05 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

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 1 Max 15

0840 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > TOO

TOO Tooth Information

Optional · Max use 32

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 1 Max 30

TOO-03 · C005 · Tooth Surface · Optional Max 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 1 Max 2

C005-03 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

C005-04 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

C005-05 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

2010F Service Provider Name Loop Optional Max 10

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > NM1

NM1 Service Provider Name

Required · Max use 1

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

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

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

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

• 1: Person
• 2: Non-Person Entity

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

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

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

NM1-06 · 1038 · Service Provider Name Prefix · Optional · String (AN) · Min 1 Max 10

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

NM1-08 · 66 · 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

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

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > REF

REF Service Provider Supplemental Identification

Optional · Max use 8

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

• 0B: State License Number
• 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

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

REF-03 · 352 · License Number State Code · Optional · String (AN) · Min 1 Max 80

2300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > AAA

AAA Service Provider Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Optional · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 35: Out of Network
• 41: Authorization/Access Restrictions
• 43: Invalid/Missing Provider Identification
• 44: Invalid/Missing Provider Name
• 45: Invalid/Missing Provider Specialty
• 46: Invalid/Missing Provider Phone Number
• 47: Invalid/Missing Provider State
• 49: Provider is Not Primary Care Physician
• 51: Provider Not on File
• 52: Service Dates Not Within Provider Plan Enrollment
• 79: Invalid Participant Identification
• 97: Invalid or Missing Provider Address

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

2400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PRV

PRV Service Provider Information

Optional · Max use 1

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

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

PRV-02 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Taxonomy Code · Required · String (AN) · Min 1 Max 50

2000E Patient Event Level Loop Optional Max >1

Variants (all may be used)

Dependent Level Loop

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• EV: Event

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

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

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > TRN

TRN Patient Event Tracking Number

Optional · Max use 3

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

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

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > AAA

AAA Patient Event Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Optional · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 52: Service Dates Not Within Provider Plan Enrollment
• 56: Inappropriate Date
• 57: Invalid/Missing Date(s) of Service
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 84: Certification Not Required for this Service
• 90: Requested Information Not Received
• AF: Invalid/Missing Diagnosis Code(s)
• AH: Invalid/Missing Onset of Current Condition or Illness Date
• AI: Invalid/Missing Accident Date
• AJ: Invalid/Missing Last Menstrual Period Date
• AK: Invalid/Missing Expected Date of Birth
• AM: Invalid/Missing Admission Date
• AN: Invalid/Missing Discharge Date
• T5: Certification Information Missing

AAA-04 · 889 · Follow-up Action Code · Optional · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > UM

UM Health Care Services Review Information

Required · Max use 1

UM-01 · 1525 · Request Category Code · Required · Identifier (ID)

• AR: Admission Review
• HS: Health Services Review
• SC: Specialty Care Review

UM-02 · 1322 · Certification Type Code · Required · Identifier (ID)

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

UM-03 · 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
• 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

UM-04 · C023 · Health Care Service Location Information · Optional Max 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

C023-01 · 1331 · Facility Type Code · Required · String (AN) · Min 1 Max 2

C023-02 · 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-06 · 1338 · Level of Service Code · Optional · Identifier (ID)

• 03: Emergency
• E: Elective
• U: Urgent

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > HCR

HCR Health Care Services Review

Optional · Max use 1

HCR-01 · 306 · Action Code · Required · Identifier (ID)

• A1: Certified in total
• A2: Certified - partial
• A3: Not Certified
• A4: Pended
• A6: Modified
• C: Cancelled
• CT: Contact Payer
• NA: No Action Required

HCR-02 · 127 · Review Identification Number · Optional · String (AN) · Min 1 Max 50

HCR-03 · 1271 · Review Decision Reason Code · Optional · String (AN) · Max use 5 · Min 1 Max 30

HCR-04 · 1073 · Second Surgical Opinion Indicator · Optional · Identifier (ID)

• N: No
• Y: Yes

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > REF

REF Administrative Reference Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Authorization Number

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

• NT: Administrator's Reference Number

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

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > REF

REF Previous Review Authorization Number

Optional · Max use 1

Variants (all may be used)

REFAdministrative Reference Number

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

• BB: Authorization Number

REF-02 · 127 · Previous Review Authorization Number · Required · String (AN) · Min 1 Max 50

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

DTP Event Date

Optional · Max use 1

Variants (all may be used)

DTPAdmission DateDTPDischarge DateDTPCertification Issue DateDTPCertification Expiration DateDTPCertification Effective Date

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

• AAH: Event

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

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

DTP-03 · 1251 · Proposed or Actual Event Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

DTP Admission Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPDischarge DateDTPCertification Issue DateDTPCertification Expiration DateDTPCertification Effective Date

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

• 435: Admission

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

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

DTP-03 · 1251 · Proposed or Actual Admission Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

DTP Discharge Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPCertification Issue DateDTPCertification Expiration DateDTPCertification Effective Date

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

• 096: Discharge

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Proposed or Actual Discharge Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

DTP Certification Issue Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPDischarge DateDTPCertification Expiration DateDTPCertification Effective Date

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

• 102: Issue

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Issue Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

DTP Certification Expiration Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPDischarge DateDTPCertification Issue DateDTPCertification Effective Date

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

• 036: Expiration

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Expiration Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > DTP

DTP Certification Effective Date

Optional · Max use 1

Variants (all may be used)

DTPEvent DateDTPAdmission DateDTPDischarge DateDTPCertification Issue DateDTPCertification Expiration Date

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

• 007: Effective

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

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

DTP-03 · 1251 · Certification Effective Date · Required · String (AN) · Min 1 Max 35

0800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > HI

HI Patient Diagnosis

Optional · Max use 1

HI-01 · C022 · Health Care Code Information · Required Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-02 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-03 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-04 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-05 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-06 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-07 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-08 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-09 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-10 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-11 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

HI-12 · C022 · Health Care Code Information · Optional Max 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

C022-01 · 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)
• LOI: Logical Observation Identifier Names and Codes (LOINC<190>) Codes
• PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

C022-03 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

C022-04 · 1251 · Diagnosis Date · Optional · String (AN) · Min 1 Max 35

2010E Patient Event Provider Name Loop Optional Max 12

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > NM1

NM1 Patient Event Provider Name

Required · Max use 1

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

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

• 1T: Physician, Clinic or Group Practice
• 71: Attending Physician
• 72: Operating Physician
• 73: Other Physician
• AAJ: Admitting Services
• DD: Assistant Surgeon
• DK: Ordering Physician
• DN: Referring Provider
• FA: Facility
• P3: Primary Care Provider
• QB: Purchase Service Provider
• SJ: Service Provider

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

• 1: Person
• 2: Non-Person Entity

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

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

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

NM1-06 · 1038 · Patient Event Provider Name Prefix · Optional · String (AN) · Min 1 Max 10

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

NM1-08 · 66 · 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

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

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > REF

REF Patient Event Provider Supplemental Identification

Optional · Max use 7

REF-01 · 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

REF-02 · 127 · Patient Event Provider Supplemental Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · License Number State Code · Optional · String (AN) · Min 1 Max 80

2300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > AAA

AAA Patient Event Provider Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Optional · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 35: Out of Network
• 41: Authorization/Access Restrictions
• 43: Invalid/Missing Provider Identification
• 44: Invalid/Missing Provider Name
• 47: Invalid/Missing Provider State
• 49: Provider is Not Primary Care Physician
• 51: Provider Not on File
• 52: Service Dates Not Within Provider Plan Enrollment
• 79: Invalid Participant Identification

AAA-04 · 889 · Follow-up Action Code · Optional · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

2400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Patient Event Provider Name Loop > PRV

PRV Patient Event Provider Information

Optional · Max use 1

PRV-01 · 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

PRV-02 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Taxonomy Code · Required · String (AN) · Min 1 Max 50

2000F Service Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > HL

HL Hierarchical Level

Required · Max use 1

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

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

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

• SS: Services

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

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

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > TRN

TRN Service Trace Number

Optional · Max use 3

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

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

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

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > AAA

AAA Service Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 52: Service Dates Not Within Provider Plan Enrollment
• 57: Invalid/Missing Date(s) of Service
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 84: Certification Not Required for this Service
• 90: Requested Information Not Received
• AG: Invalid/Missing Procedure Code(s)
• T5: Certification Information Missing

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > UM

UM Health Care Services Review Information

Optional · Max use 1

UM-01 · 1525 · Request Category Code · Required · Identifier (ID)

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

UM-02 · 1322 · Certification Type Code · Optional · Identifier (ID)

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

UM-03 · 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
• 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

UM-04 · C023 · Health Care Service Location Information · Optional Max 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

C023-01 · 1331 · Facility Type Code · Required · String (AN) · Min 1 Max 2

C023-02 · 1332 · Facility Code Qualifier · Required · Identifier (ID)

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

0500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > HCR

HCR Health Care Services Review

Optional · Max use 1

HCR-01 · 306 · Action Code · Required · Identifier (ID)

• A1: Certified in total
• A3: Not Certified
• A4: Pended
• A6: Modified
• C: Cancelled
• CT: Contact Payer
• NA: No Action Required

HCR-02 · 127 · Review Identification Number · Optional · String (AN) · Min 1 Max 50

HCR-03 · 1271 · Review Decision Reason Code · Optional · String (AN) · Max use 5 · Min 1 Max 30

HCR-04 · 1073 · Yes No Condition or Response Code · Optional · Identifier (ID) · Min 1 Max 1

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > REF

REF Previous Review Authorization Number

Optional · Max use 1

Variants (all may be used)

REFAdministrative Reference Number

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

• BB: Authorization Number

REF-02 · 127 · Previous Review Authorization Number · Required · String (AN) · Min 1 Max 50

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > REF

REF Administrative Reference Number

Optional · Max use 1

Variants (all may be used)

REFPrevious Review Authorization Number

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

• NT: Administrator's Reference Number

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

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Certification Effective Date

Optional · Max use 1

Variants (all may be used)

DTPService DateDTPCertification Issue DateDTPCertification Expiration Date

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

• 007: Effective

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

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

DTP-03 · 1251 · Certification Effective Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Service Date

Optional · Max use 1

Variants (all may be used)

DTPCertification Effective DateDTPCertification Issue DateDTPCertification Expiration Date

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

• 472: Service

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

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

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

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Certification Issue Date

Optional · Max use 1

Variants (all may be used)

DTPCertification Effective DateDTPService DateDTPCertification Expiration Date

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

• 102: Issue

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Issue Date · Required · String (AN) · Min 1 Max 35

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > DTP

DTP Certification Expiration Date

Optional · Max use 1

Variants (all may be used)

DTPCertification Effective DateDTPService DateDTPCertification Issue Date

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

• 036: Expiration

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Certification Expiration Date · Required · String (AN) · Min 1 Max 35

0810 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV1

SV1 Professional Service

Optional · Max use 1

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 · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers

C003-01 · 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

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

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

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

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

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

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

SV1-02 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 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 1 Max 15

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

0820 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV2

SV2 Institutional Service Line

Optional · Max use 1

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 1 Max 48

SV2-02 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers · Usage notes

C003-01 · 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
• ZZ: Mutually Defined

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

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

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

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

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

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

SV2-03 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 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 1 Max 15

SV2-06 · 1371 · Service Line Rate · Optional · Decimal number (R) · Min 1 Max 10

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

0830 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > SV3

SV3 Dental Service

Optional · Max use 1

SV3-01 · C003 · Composite Medical Procedure Identifier · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers

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

• AD: American Dental Association Codes

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

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

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

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

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

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

SV3-02 · 782 · Service Line Amount · Optional · Decimal number (R) · Min 1 Max 15

SV3-04 · C006 · Oral Cavity Designation · Optional Max 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 1 Max 3

C006-02 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

C006-03 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

C006-04 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

C006-05 · 1361 · Oral Cavity Designation Code · Optional · Identifier (ID) · Min 1 Max 3

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 1 Max 15

0840 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > TOO

TOO Tooth Information

Optional · Max use 32

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 1 Max 30

TOO-03 · C005 · Tooth Surface · Optional Max 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 1 Max 2

C005-03 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

C005-04 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

C005-05 · 1369 · Tooth Surface Code · Optional · Identifier (ID) · Min 1 Max 2

2010F Service Provider Name Loop Optional Max 10

1700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > NM1

NM1 Service Provider Name

Required · Max use 1

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

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

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

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

• 1: Person
• 2: Non-Person Entity

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

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

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

NM1-06 · 1038 · Service Provider Name Prefix · Optional · String (AN) · Min 1 Max 10

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

NM1-08 · 66 · 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

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

1800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > REF

REF Service Provider Supplemental Identification

Optional · Max use 8

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

• 0B: State License Number
• 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

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

REF-03 · 352 · License Number State Code · Optional · String (AN) · Min 1 Max 80

2300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > AAA

AAA Service Provider Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Optional · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 35: Out of Network
• 41: Authorization/Access Restrictions
• 43: Invalid/Missing Provider Identification
• 44: Invalid/Missing Provider Name
• 45: Invalid/Missing Provider Specialty
• 46: Invalid/Missing Provider Phone Number
• 47: Invalid/Missing Provider State
• 49: Provider is Not Primary Care Physician
• 51: Provider Not on File
• 52: Service Dates Not Within Provider Plan Enrollment
• 79: Invalid Participant Identification
• 97: Invalid or Missing Provider Address

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed

2400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Patient Event Level Loop > Service Level Loop > Service Provider Name Loop > PRV

PRV Service Provider Information

Optional · Max use 1

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

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

PRV-02 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Taxonomy Code · Required · String (AN) · Min 1 Max 50

2800 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

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

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

GE Functional Group Trailer

Required · Max use 1

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

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

IEA Interchange Control Trailer

Required · Max use 1

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

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

EDI Samples

Example 1: Acknowledgment

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240222*0119*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20240222*011952*000000001*X*005010X216~
ST*278*0034*005010X216~
BHT*0007*53*2004000345628*20050602*0420~
HL*1**20*1~
NM1*X3*2*MarylandCapital InsuranceCompany*****46*789312~
HL*2*1*21*1~
NM1*1P*2*St JosephHospital*****46*0000012121~
HL*3*2*22*1~
NM1*IL*1*Smith*Joe****MI*12345678901~
DMG*D8*19580322*M~
HL*4*3*EV*0~
TRN*2*040601002349A*9000012121~
UM*AR*I*2*21>B~
HCR*A1*A0405295498~
DTP*435*D8*20040530~
HI*BF>410.90~
NM1*SJ*2*St JosephHospital*****46*0000012121~
REF*1J*162354~
SE*18*0034~
GE*1*000000001~
IEA*1*000000001~