Stedi maintains this guide based on public documentation from X12 HIPAA. Contact X12 HIPAA for official EDI specifications. To report any errors in this guide, please contact us.
X12 837 Post-adjudicated Claims Data Reporting: Dental (X300A1)
—
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- ^ Repetition
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
detail
Billing Provider Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PRV
0030
Billing Provider Specialty Information
Max use 1
Optional
CUR
0100
Foreign Currency Information
Max use 1
Optional
Billing Provider Name Loop
NM1
0150
Billing Provider Name
Max use 1
Required
N3
0250
Billing Provider Address
Max use 1
Required
N4
0300
Billing Provider City, State, ZIP Code
Max use 1
Required
REF
0350
Billing Provider Tax Identification
Max use 1
Required
REF
0350
Billing Provider License Information
Max use 2
Optional
REF
0350
Billing Provider Secondary Identification
Max use 1
Optional
Subscriber Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
SBR
0050
Subscriber Information
Max use 1
Required
Subscriber Name Loop
NM1
0150
Subscriber Name
Max use 1
Required
N3
0250
Subscriber Address
Max use 1
Required
N4
0300
Subscriber City, State, ZIP Code
Max use 1
Required
DMG
0320
Subscriber Demographic Information
Max use 1
Required
REF
0350
Subscriber Social Security Number
Max use 1
Optional
REF
0350
Property and Casualty Claim Number
Max use 1
Optional
Patient Hierarchical Level Loop
HL
0010
Hierarchical Level
Max use 1
Required
PAT
0070
Patient Information
Max use 1
Required
Claim Information Loop
CLM
1300
Claim Information
Max use 1
Required
DTP
1350
Date - Accident
Max use 1
Optional
DTP
1350
Date - Appliance Placement
Max use 1
Optional
DTP
1350
Date - Service Date
Max use 1
Optional
DN1
1450
Orthodontic Total Months of Treatment
Max use 1
Optional
DN2
1500
Tooth Status
Max use 35
Optional
CN1
1600
Contract Information
Max use 1
Optional
AMT
1750
Patient Amount Paid
Max use 1
Optional
REF
1800
Referral Number
Max use 1
Optional
REF
1800
Prior Authorization
Max use 1
Optional
REF
1800
Claim Identifier For Transmission Intermediaries
Max use 1
Optional
K3
1850
File Information
Max use 10
Optional
HI
2310
Health Care Diagnosis Code
Max use 1
Optional
Other Subscriber Information Loop
SBR
2900
Other Subscriber Information
Max use 1
Required
CAS
2950
Claim Level Adjustments
Max use 5
Optional
AMT
3000
Coordination of Benefits (COB) Payer Paid Amount
Max use 1
Required
AMT
3000
Remaining Patient Liability
Max use 1
Optional
MOA
3200
Outpatient Adjudication Information
Max use 1
Optional
Other Payer Name Loop
NM1
3250
Other Payer Name
Max use 1
Required
DTP
3500
Claim Check or Remittance Date
Max use 1
Required
REF
3550
Other Payer Secondary Identifier
Max use 3
Optional
REF
3550
Other Payer Claim Adjustment Indicator
Max use 1
Optional
REF
3550
Other Payer Claim Control Number
Max use 1
Optional
REF
3550
Other Payer Adjusted Claim Control Number
Max use 1
Optional
Service Line Number Loop
LX
3650
Service Line Number
Max use 1
Required
SV3
3800
Dental Service
Max use 1
Required
TOO
3820
Tooth Information
Max use 32
Optional
DTP
4550
Date - Service Date
Max use 1
Optional
DTP
4550
Date - Prior Placement
Max use 1
Optional
DTP
4550
Date - Appliance Placement
Max use 1
Optional
DTP
4550
Date - Replacement
Max use 1
Optional
DTP
4550
Date - Treatment Start
Max use 1
Optional
DTP
4550
Date - Treatment Completion
Max use 1
Optional
CN1
4650
Contract Information
Max use 1
Optional
REF
4700
Prior Authorization
Max use 5
Optional
REF
4700
Referral Number
Max use 5
Optional
K3
4800
File Information
Max use 10
Optional
SE
5550
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA
Interchange Control Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Required
Identifier (ID)
—
- 00
- No Security Information Present (No Meaningful Information in I04)
Required
Identifier (ID)
—
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
Required
Identifier (ID)
Min 1Max 1
—
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Required
Identifier (ID)
Min 1Max 1
—
- I
- Information
- P
- Production Data
- T
- Test Data
GS
Functional Group Header
RequiredMax use 1
—
Example
Required
Identifier (ID)
Min 1Max 2
—
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Heading
ST
0050
Heading > ST
Transaction Set Header
RequiredMax use 1
—
Example
BHT
0100
Heading > BHT
Beginning of Hierarchical Transaction
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 0019
- Information Source, Subscriber, Dependent
1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name LoopNM1
0200
Heading > Submitter Name Loop > NM1
Submitter Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)—
PER
0450
Heading > Submitter Name Loop > PER
Submitter EDI Contact Information
RequiredMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
Required
Identifier (ID)
—
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Optional
Identifier (ID)
—
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
1000A Submitter Name Loop end
1000B Receiver Name Loop
RequiredMax 1
Variants (all may be used)
Submitter Name LoopNM1
0200
Heading > Receiver Name Loop > NM1
Receiver Name
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
- 46
- Electronic Transmitter Identification Number (ETIN)
1000B Receiver Name Loop end
Heading end
Detail
2000A Billing Provider Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
PRV
0030
Detail > Billing Provider Hierarchical Level Loop > PRV
Billing Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
CUR
0100
Detail > Billing Provider Hierarchical Level Loop > CUR
Foreign Currency Information
OptionalMax use 1
—
Usage notes
—
Example
2010AA Billing Provider Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1
Billing Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
Usage notes
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3
Billing Provider Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4
Billing Provider City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider Tax Identification
RequiredMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider License InformationREFBilling Provider Secondary IdentificationREF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider License Information
OptionalMax use 2
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Tax IdentificationREFBilling Provider Secondary IdentificationREF
0350
Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF
Billing Provider Secondary Identification
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFBilling Provider Tax IdentificationREFBilling Provider License Information2010AA Billing Provider Name Loop end
2000B Subscriber Hierarchical Level Loop
RequiredMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
SBR
0050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR
Subscriber Information
RequiredMax use 1
—
Example
2010BA Subscriber Name Loop
RequiredMax 1
Variants (all may be used)
Data Receiver LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1
Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3
Subscriber Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4
Subscriber City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG
Subscriber Demographic Information
RequiredMax use 1
—
Usage notes
—
Example
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF
Subscriber Social Security Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim NumberREF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF
Property and Casualty Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFSubscriber Social Security Number2010BA Subscriber Name Loop end
2010BB Data Receiver Loop
RequiredMax 1
Variants (all may be used)
Subscriber Name LoopNM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Data Receiver Loop > NM1
Data Receiver
RequiredMax use 1
—
Example
2010BB Data Receiver Loop end
2000C Patient Hierarchical Level Loop
OptionalMax >1
HL
0010
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > HL
Hierarchical Level
RequiredMax use 1
—
Example
Optional
Identifier (ID)
—
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
PAT
0070
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT
Patient Information
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 01
- Spouse
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
2010CA Patient Name Loop
RequiredMax 1
NM1
0150
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1
Patient Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Patient Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
0250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N3
Patient Address
RequiredMax use 1
—
Usage notes
—
Example
N4
0300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N4
Patient City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
DMG
0320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG
Patient Demographic Information
RequiredMax use 1
—
Usage notes
—
Example
REF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF
Patient Social Security Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFProperty and Casualty Claim NumberREF
0350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF
Property and Casualty Claim Number
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFPatient Social Security Number2010CA Patient Name Loop end
2300 Claim Information Loop
RequiredMax 100
CLM
1300
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CLM
Claim Information
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax 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
Optional
Identifier (ID)
—
Usage notes
—
- A
- Assigned
- C
- Not Assigned
Optional
Identifier (ID)
—
Usage notes
—
- N
- No
- W
- Not Applicable—
- Y
- Yes
Optional
Identifier (ID)
—
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
OptionalMax use 1
To identify one or more related causes and associated state or country information
Usage notes
—
Optional
Identifier (ID)
—
- 01
- Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
- 02
- Physically Handicapped Children's Program
- 03
- Special Federal Funding
- 05
- Disability
Optional
Identifier (ID)
—
- 1
- Proof of Eligibility Unknown or Unavailable
- 2
- Litigation
- 3
- Authorization Delays
- 4
- Delay in Certifying Provider
- 5
- Delay in Supplying Billing Forms
- 6
- Delay in Delivery of Custom-made Appliances
- 7
- Third Party Processing Delay
- 8
- Delay in Eligibility Determination
- 9
- Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
- 10
- Administration Delay in the Prior Approval Process
- 11
- Other
- 15
- Natural Disaster
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Accident
OptionalMax use 1
—
Usage notes
—
Example
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Appliance Placement
OptionalMax use 1
—
Usage notes
—
Example
DTP
1350
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP
Date - Service Date
OptionalMax use 1
—
Usage notes
—
Example
DN1
1450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DN1
Orthodontic Total Months of Treatment
OptionalMax use 1
—
Usage notes
—
Example
DN2
1500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DN2
Tooth Status
OptionalMax use 35
—
Usage notes
—
Example
CN1
1600
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1
Contract Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
AMT
1750
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > AMT
Patient Amount Paid
OptionalMax use 1
—
Usage notes
—
Example
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Referral Number
OptionalMax use 1
—
Usage notes
—
Example
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Prior Authorization
OptionalMax use 1
—
Usage notes
—
Example
REF
1800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF
Claim Identifier For Transmission Intermediaries
OptionalMax use 1
—
Usage notes
—
Example
K3
1850
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3
File Information
OptionalMax use 10
—
Usage notes
—
Example
HI
2310
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI
Health Care Diagnosis Code
OptionalMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
Required
Identifier (ID)
—
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
- TQ
- Systemized Nomenclature of Dentistry (SNODENT)—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
Required
Identifier (ID)
—
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- TQ
- Systemized Nomenclature of Dentistry (SNODENT)—
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes
—
2310A Referring Provider Name Loop
OptionalMax 2
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1
Referring Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > PRV
Referring Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF
Referring Provider Secondary Identification
OptionalMax use 2
—
Usage notes
—
Example
2310A Referring Provider Name Loop end
2310B Rendering Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1
Rendering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV
Rendering Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF
Rendering Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310B Rendering Provider Name Loop end
2310C Service Facility Location Name Loop
RequiredMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1
Service Facility Location Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
N3
2650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3
Service Facility Location Address
RequiredMax use 1
—
Usage notes
—
Example
N4
2700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4
Service Facility Location City, State, ZIP Code
RequiredMax use 1
—
Usage notes
—
Example
Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
Optional
Identifier (ID)
Min 3Max 15
—
Usage notes
—
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF
Service Facility Location Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310C Service Facility Location Name Loop end
2310D Assistant Surgeon Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > NM1
Assistant Surgeon Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
2550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > PRV
Assistant Surgeon Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Assistant Surgeon Name Loop > REF
Assistant Surgeon Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2310D Assistant Surgeon Name Loop end
2310E Supervising Provider Name Loop
OptionalMax 1
NM1
2500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1
Supervising Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
2710
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF
Supervising Provider Secondary Identification
OptionalMax use 4
—
Usage notes
—
Example
2310E Supervising Provider Name Loop end
2320 Other Subscriber Information Loop
RequiredMax 10
SBR
2900
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR
Other Subscriber Information
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- A
- Payer Responsibility Four
- B
- Payer Responsibility Five
- C
- Payer Responsibility Six
- D
- Payer Responsibility Seven
- E
- Payer Responsibility Eight
- F
- Payer Responsibility Nine
- G
- Payer Responsibility Ten
- H
- Payer Responsibility Eleven
- P
- Primary
- S
- Secondary
- T
- Tertiary
- U
- Unknown
Required
Identifier (ID)
—
- 01
- Spouse
- 18
- Self
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Required
Identifier (ID)
—
- 1
- Coordination of Benefits—
- 6
- No Coordination of Benefits—
Required
Identifier (ID)
—
- 11
- Other Non-Federal Programs
- 12
- Preferred Provider Organization (PPO)
- 13
- Point of Service (POS)
- 14
- Exclusive Provider Organization (EPO)
- 15
- Indemnity Insurance
- 16
- Health Maintenance Organization (HMO) Medicare Risk
- 17
- Dental Maintenance Organization
- AM
- Automobile Medical
- BL
- Blue Cross/Blue Shield
- CH
- Champus
- CI
- Commercial Insurance Co.
- DS
- Disability
- FI
- Federal Employees Program
- HM
- Health Maintenance Organization
- LM
- Liability Medical
- MA
- Medicare Part A
- MB
- Medicare Part B
- MC
- Medicaid
- OF
- Other Federal Program—
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined—
CAS
2950
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS
Claim Level Adjustments
OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
Required
Identifier (ID)
—
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
AMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT
Coordination of Benefits (COB) Payer Paid Amount
RequiredMax use 1
—
Example
Variants (all may be used)
AMTRemaining Patient LiabilityAMT
3000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT
Remaining Patient Liability
OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
AMTCoordination of Benefits (COB) Payer Paid AmountMOA
3200
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA
Outpatient Adjudication Information
OptionalMax use 1
—
Usage notes
—
Example
2330A Other Subscriber Name Loop
RequiredMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1
Other Subscriber Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3
Other Subscriber Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4
Other Subscriber City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF
Other Subscriber Social Security Number
OptionalMax use 2
—
Usage notes
—
Example
2330A Other Subscriber Name Loop end
2330B Other Payer Name Loop
RequiredMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1
Other Payer Name
RequiredMax use 1
—
Example
Required
Identifier (ID)
—
Usage notes
—
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
DTP
3500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP
Claim Check or Remittance Date
RequiredMax use 1
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Secondary Identifier
OptionalMax use 3
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Claim Adjustment Indicator
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Claim Control Number
OptionalMax use 1
—
Usage notes
—
Example
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF
Other Payer Adjusted Claim Control Number
OptionalMax use 1
—
Usage notes
—
Example
2330B Other Payer Name Loop end
2330C Other Patient Name Loop
OptionalMax 1
NM1
3250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > NM1
Other Patient Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Other Insured Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- II
- Standard Unique Health Identifier for each Individual in the United States—
- MI
- Member Identification Number
N3
3320
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > N3
Other Patient Address
OptionalMax use 1
—
Usage notes
—
Example
N4
3400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > N4
Other Patient City, State, ZIP Code
OptionalMax use 1
—
Usage notes
—
Example
Only one of Other Patient State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
REF
3550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Patient Name Loop > REF
Other Patient Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2330C Other Patient Name Loop end
2320 Other Subscriber Information Loop end
2400 Service Line Number Loop
RequiredMax 50
LX
3650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX
Service Line Number
RequiredMax use 1
—
Usage notes
—
Example
SV3
3800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV3
Dental Service
RequiredMax use 1
—
Example
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Required
Identifier (ID)
—
- AD
- American Dental Association Codes—
OptionalMax use 1
To identify one or more areas of the oral cavity
Usage notes
—
Optional
Identifier (ID)
—
Usage notes
—
- I
- Initial Placement
- R
- Replacement—
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes
—
TOO
3820
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > TOO
Tooth Information
OptionalMax use 32
—
Usage notes
—
Example
Required
Identifier (ID)
—
- JP
- Universal National Tooth Designation System
OptionalMax use 1
To identify one or more tooth surface codes
Usage notes
—
Required
Identifier (ID)
—
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Service Date
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Prior Placement
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Appliance Placement
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Replacement
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Treatment Start
OptionalMax use 1
—
Usage notes
—
Example
DTP
4550
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP
Date - Treatment Completion
OptionalMax use 1
—
Usage notes
—
Example
CN1
4650
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CN1
Contract Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
REF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Prior Authorization
OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFReferral NumberREF
4700
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF
Referral Number
OptionalMax use 5
—
Usage notes
—
Example
Variants (all may be used)
REFPrior AuthorizationK3
4800
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > K3
File Information
OptionalMax use 10
—
Usage notes
—
Example
2420A Rendering Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1
Rendering Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > PRV
Rendering Provider Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF
Rendering Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2420A Rendering Provider Name Loop end
2420B Assistant Surgeon Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > NM1
Assistant Surgeon Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Assistant Surgeon Primary Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
PRV
5050
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > PRV
Assistant Surgeon Specialty Information
OptionalMax use 1
—
Usage notes
—
Example
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Assistant Surgeon Name Loop > REF
Assistant Surgeon Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2420B Assistant Surgeon Name Loop end
2420C Supervising Provider Name Loop
OptionalMax 1
NM1
5000
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > NM1
Supervising Provider Name
RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required
Optional
Identifier (ID)
—
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
5250
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Supervising Provider Name Loop > REF
Supervising Provider Secondary Identification
OptionalMax use 3
—
Usage notes
—
Example
2420C Supervising Provider Name Loop end
2430 Line Adjudication Information Loop
OptionalMax 15
SVD
5400
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD
Line Adjudication Information
RequiredMax use 1
—
Usage notes
—
Example
RequiredMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
- SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code.
Required
Identifier (ID)
—
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
CAS
5450
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS
Line Adjustment
OptionalMax use 5
—
Usage notes
—
Example
If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required
If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required
If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required
If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required
If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required
If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required
If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required
If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required
Required
Identifier (ID)
—
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
DTP
5500
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP
Line Check or Remittance Date
RequiredMax use 1
—
Example
AMT
5505
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT
Remaining Patient Liability
OptionalMax use 1
—
Usage notes
—
Example
2430 Line Adjudication Information Loop end
2400 Service Line Number Loop end
2300 Claim Information Loop end
2000C Patient Hierarchical Level Loop end
2000B Subscriber Hierarchical Level Loop end
2000A Billing Provider Hierarchical Level Loop end
SE
5550
Detail > SE
Transaction Set Trailer
RequiredMax use 1
—
Example
Detail end
GE
Functional Group Trailer
RequiredMax use 1
—
Example
Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.