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X12 824 Application Advice (X186A1)
—
Delimiters
- ~ Segment
- * Element
- > Component
- ^ Repetition
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
Original Transaction Identification Loop
SE
0900
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
0100
Heading > ST
Transaction Set Header
RequiredMax use 1
—
Example
BGN
0200
Heading > BGN
Beginning Segment
RequiredMax use 1
—
Example
1000A Submitter Name Loop
RequiredMax 1
Variants (all may be used)
Receiver Name LoopN1
0300
Heading > Submitter Name Loop > N1
Submitter Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 1
- D-U-N-S Number, Dun & Bradstreet
- 9
- D-U-N-S+4, D-U-N-S Number with Four Character Suffix
- 24
- Employer's Identification Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- 75
- State or Province Assigned Number
- EQ
- Insurance Company Assigned Identification Number
- FI
- Federal Taxpayer's Identification Number
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
REF
0700
Heading > Submitter Name Loop > REF
Submitter Secondary Indentifier
OptionalMax use 1
—
Usage notes
—
Example
PER
0800
Heading > Submitter Name Loop > PER
Submitter EDI Contact Information
OptionalMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-03) or Communication Number (PER-04) is present, then the other is required
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
Optional
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 LoopN1
0300
Heading > Receiver Name Loop > N1
Receiver Name
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 1
- D-U-N-S Number, Dun & Bradstreet
- 9
- D-U-N-S+4, D-U-N-S Number with Four Character Suffix
- 24
- Employer's Identification Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- 75
- State or Province Assigned Number
- EQ
- Insurance Company Assigned Identification Number
- FI
- Federal Taxpayer's Identification Number
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
1000B Receiver Name Loop end
Heading end
Detail
2000 Original Transaction Identification Loop
RequiredMax >1
OTI
0100
Detail > Original Transaction Identification Loop > OTI
Original Transaction Identification
RequiredMax use 1
—
Usage notes
—
Example
If Transaction Set Control Number (OTI-09) is present, then Functional Group Control Number (OTI-08) is required
Required
Identifier (ID)
—
Usage notes
—
- BA
- Batch Accept
- BC
- Batch Accept with Data Content Change
- BE
- Batch Accept with Error
- BP
- Batch Partial Accept/Reject
- BR
- Batch Reject
- IA
- Item Accept
- IC
- Item Accept with Data Content Change
- IE
- Item Accept with Error
- IP
- Item Partial Accept/Reject
- IR
- Item Reject
- TA
- Transaction Set Accept
- TC
- Transaction Set Accept with Data Content Change
- TE
- Transaction Set Accept with Error
- TP
- Transaction Set Partial Accept/Reject
- TR
- Transaction Set Reject
Required
Identifier (ID)
—
- BT
- Batch Number—
- IX
- Item Number—
- TN
- Transaction Reference Number—
Optional
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
Usage notes
—
Required
Identifier (ID)
—
- 112
- Property Damage Report
- 124
- Vehicle Damage
- 148
- Report of Injury, Illness or Incident
- 187
- Premium Audit Request and Return
- 266
- Mortgage or Property Record Change Notification
- 269
- Health Care Benefit Coordination Verification
- 270
- Eligibility, Coverage or Benefit Inquiry
- 271
- Eligibility, Coverage or Benefit Information
- 272
- Property and Casualty Loss Notification
- 274
- Healthcare Provider Information
- 275
- Patient Information
- 276
- Health Care Claim Status Request
- 277
- Health Care Information Status Notification
- 278
- Health Care Services Review Information
- 811
- Consolidated Service Invoice/Statement
- 820
- Payment Order/Remittance Advice
- 834
- Benefit Enrollment and Maintenance
- 835
- Health Care Claim Payment/Advice
- 837
- Health Care Claim—
- 841
- Specifications/Technical Information
REF
0200
Detail > Original Transaction Identification Loop > REF
Reference Information
OptionalMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 0B
- State License Number
- 0F
- Subscriber Number
- 0M
- Mortgage Identification Number
- 1A
- Blue Cross Provider Number
- 1B
- Blue Shield Provider Number
- 1C
- Medicare Provider Number
- 1D
- Medicaid Provider Number
- 1E
- Dentist License Number
- 1F
- Anesthesia License Number
- 1G
- Provider UPIN Number
- 1H
- CHAMPUS Identification Number
- 1J
- Facility ID Number
- 1K
- Payor's Claim Number
- 1L
- Group or Policy Number
- 1S
- Ambulatory Patient Group (APG) Number
- 1W
- Member Identification Number
- 2F
- Consolidated Invoice Number
- 2I
- Tracking Number
- 2U
- Payer Identification Number
- 3H
- Case Number
- 3J
- Office Number
- 4A
- Personal Identification Number (PIN)
- 4N
- Special Payment Reference Number
- 5G
- Complaint
- 5H
- Incident
- 06
- System Number
- 6N
- Claimant Number
- 6P
- Group Number
- 6R
- Provider Control Number
- 7I
- Subscriber Authorization Number
- 7K
- List of Materials
- 8U
- Bank Assigned Security Identifier
- 8X
- Transaction Category or Type
- 9A
- Repriced Claim Reference Number
- 9B
- Repriced Line Item Reference Number
- 9C
- Adjusted Repriced Claim Reference Number
- 9D
- Adjusted Repriced Line Item Reference Number
- 9K
- Servicer
- 9N
- Investor
- 9R
- Job Order Number
- 11
- Account Number
- 14
- Master Account Number
- 17
- Client Reporting Category
- 18
- Plan Number
- 23
- Client Number
- 28
- Employee Identification Number
- 33
- Lender Case Number
- 38
- Master Policy Number
- 49
- Family Unit Number
- 60
- Account Suffix Code
- 72
- Schedule Reference Number
- 87
- Functional Category
- 89
- Assembly Number
- 94
- File Identification Number
- A9
- Health Insurance Account Number
- AAL
- Agent Number
- AB
- Acceptable Source Purchaser ID
- ADB
- Master Property Number
- AZ
- Health Insurance Policy Number
- B3
- Preferred Provider Organization Number
- B7
- Life Insurance Policy Number
- BA
- Retirement Plan Policy Number
- BB
- Authorization Number
- BLT
- Billing Type
- BQ
- Health Maintenance Organization Code Number
- BR
- Broker or Sales Office Number
- BT
- Batch Number
- CE
- Class of Contract Code
- CK
- Check Number
- CRN
- Casualty Report Number
- CT
- Contract Number
- D3
- National Council for Prescription Drug Programs Pharmacy Number
- D8
- Loss Report Number
- D9
- Claim Number
- DD
- Document Identification Code
- DX
- Department/Agency Number
- E5
- Claimant's Claim Number
- E9
- Attachment Code
- EA
- Medical Record Identification Number
- EI
- Employer's Identification Number
- EJ
- Patient Account Number
- EL
- Electronic device pin number
- EM
- Electronic Payment Reference Number
- EO
- Submitter Identification Number
- EV
- Receiver Identification Number
- EW
- Mammography Certification Number
- F2
- Version Code - Local
- F4
- Facility Certification Number
- F5
- Medicare Version Code
- F6
- Health Insurance Claim (HIC) Number
- F8
- Original Reference Number
- FH
- Clinic Number
- FI
- File Identifier
- FJ
- Line Item Control Number
- FY
- Claim Office Number
- G1
- Prior Authorization Number
- G2
- Provider Commercial Number
- G3
- Predetermination of Benefits Identification Number
- G4
- Peer Review Organization (PRO) Approval Number
- G5
- Provider Site Number
- HI
- Health Industry Number (HIN)
- HJ
- Identity Card Number
- HPI
- Centers for Medicare and Medicaid Services National Provider Identifier
- IF
- Issue Number
- IG
- Insurance Policy Number
- IJ
- Standard Industry Classification (SIC) Code
- IP
- Inspection Report Number
- IX
- Item Number
- JD
- User Identification
- KW
- Certification
- LC
- Lease Number
- LD
- Loan Number
- LU
- Location Number
- LX
- Qualified Products List
- LZ
- Lender Account Number
- ME
- Message Address or ID
- N5
- Provider Plan Network Identification Number
- N6
- Plan Network Identification Number
- N7
- Facility Network Identification Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
- NQ
- Medicaid Recipient Identification Number
- OZ
- Product Number
- P4
- Project Code
- PG
- Product Group
- PM
- Part Number
- POL
- Policy Number
- PQ
- Payee Identification
- Q4
- Prior Identifier Number
- Q5
- Property Control Number
- Unit Number
- RB
- Rate code number
- S3
- Specification Number
- ST
- Store Number
- SY
- Social Security Number
- T4
- Signal Code
- T7
- Affected Subsystem Code
- TJ
- Federal Taxpayer's Identification Number
- TN
- Transaction Reference Number
- TT
- Terminal Code
- TX
- Tax Exempt Number
- U3
- Unique Supplier Identification Number (USIN)
- UA
- Mortgage Number
- VD
- Volume Number
- VE
- Vendor Abbreviation Code
- VP
- Vendor Product Number
- VR
- Vendor ID Number
- VT
- Motor Vehicle ID Number
- WU
- Vessel
- X1
- Provider Claim Number
- X4
- Clinical Laboratory Improvement Amendment Number
- X5
- State Industrial Accident Provider Number
- Y4
- Agency Claim Number
- Z8
- Federal Housing Administration Case Number
- Z9
- Veterans Affairs Case Number
- ZH
- Carrier Assigned Reference Number
- ZS
- Software Application Number
- ZZ
- Mutually Defined
DTM
0300
Detail > Original Transaction Identification Loop > DTM
Date/Time Reference
OptionalMax use 2
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 003
- Invoice
- 007
- Effective
- 009
- Process
- 011
- Shipped
- 017
- Estimated Delivery
- 035
- Delivered
- 036
- Expiration
- 050
- Received
- 089
- Inquiry
- 090
- Report Start
- 091
- Report End
- 096
- Discharge
- 097
- Transaction Creation
- 102
- Issue
- 119
- Test Performed
- 142
- Loss
- 150
- Service Period Start
- 151
- Service Period End
- 186
- Invoice Period Start
- 187
- Invoice Period End
- 193
- Period Start
- 194
- Period End
- 198
- Completion
- 227
- Lease Term Start
- 228
- Lease Term End
- 232
- Claim Statement Period Start
- 233
- Claim Statement Period End
- 242
- Actual Start
- 245
- Estimated Completion
- 285
- Employment or Hire
- 286
- Retirement
- 296
- Initial Disability Period Return To Work
- 297
- Initial Disability Period Last Day Worked
- 300
- Enrollment Signature Date
- 301
- Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event
- 303
- Maintenance Effective
- 304
- Latest Visit or Consultation
- 307
- Eligibility
- 310
- Date of Closing
- 313
- Cycle
- 330
- Referral Date
- 336
- Employment Begin
- 337
- Employment End
- 338
- Medicare Begin
- 339
- Medicare End
- 340
- Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
- 341
- Consolidated Omnibus Budget Reconciliation Act (COBRA) End
- 344
- Coordination of Benefits Begin
- 345
- Coordination of Benefits End
- 348
- Benefit Begin
- 349
- Benefit End
- 350
- Education Begin
- 351
- Education End
- 356
- Eligibility Begin
- 357
- Eligibility End
- 360
- Initial Disability Period Start
- 361
- Initial Disability Period End
- 370
- Actual Departure Date
- 372
- Actual Arrival Date
- 383
- Adjusted Hire
- 388
- Payment Commencement
- 393
- Plan Participation Suspension
- 394
- Rehire
- 405
- Production
- 431
- Onset of Current Symptoms or Illness
- 434
- Statement
- 435
- Admission
- 438
- Onset of Similar Symptoms or Illness
- 439
- Accident
- 441
- Prior Placement
- 446
- Replacement
- 452
- Appliance Placement
- 453
- Acute Manifestation of a Chronic Condition
- 454
- Initial Treatment
- 455
- Last X-Ray
- 456
- Surgery
- 461
- Last Certification
- 463
- Begin Therapy
- 471
- Prescription
- 472
- Service
- 473
- Medicaid Begin
- 474
- Medicaid End
- 480
- Arterial Blood Gas Test
- 481
- Oxygen Saturation Test
- 484
- Last Menstrual Period
- 485
- Injury Begin
- 486
- Injury End
- 517
- Inspected
- 523
- Date of Claim
- 539
- Policy Effective
- 540
- Policy Expiration
- 543
- Last Premium Paid Date
- 547
- Date of Loan
- 573
- Date Claim Paid
- 582
- Report Period
- 607
- Certification Revision
- 666
- Date Paid
- 738
- Most Recent Hemoglobin or Hematocrit or Both
- 739
- Most Recent Serum Creatine
- 809
- Posted
- 866
- Examination
- 881
- Request
- 938
- Order
- 999
- Document Date
- ABC
- Estimated Date of Birth
- INC
- Incident
- ZZZ
- Mutually Defined
AMT
0500
Detail > Original Transaction Identification Loop > AMT
Monetary Amount Information
OptionalMax use 3
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 1
- Line Item Total
- 2
- Batch Total
- 3V
- Mortgage
- 3Y
- Non-operational Fixed Assets
- 4Y
- Damages
- 5
- Total Invoice Amount
- 8V
- Services
- 8Y
- Share Premium Capital
- A8
- Noncovered Charges - Actual
- AA
- Allocated
- AAE
- Approved Amount
- AU
- Coverage Amount
- B1
- Benefit Amount
- B6
- Allowed - Actual
- B7
- Deductible - Estimated
- B9
- Co-insurance - Actual
- BM
- Adjustments
- BR
- Adjusted Insured Loss Amount
- C1
- Co-Payment Amount
- C5
- Claim Amount Due - Estimated
- CE
- Summary Amount
- CI
- Funds Held for Insured
- D
- Payor Amount Paid
- D2
- Deductible Amount
- D8
- Discount Amount
- DX
- Deductible Waived
- DY
- Per Day Limit
- F2
- Patient Responsibility - Actual
- F3
- Patient Responsibility - Estimated
- F4
- Postage Claimed
- F5
- Patient Amount Paid
- F7
- Sales Tax
- GT
- Goods and Services Tax
- GW
- Total Charge
- I
- Interest
- KF
- Net Paid Amount
- KH
- Deduction Amount
- M8
- Markup Amount
- MA
- Maximum Amount
- N1
- Net Worth
- N8
- Miscellaneous Taxes
- NE
- Net Billed
- NL
- Negative Ledger Balance
- P3
- Premium Amount
- PG
- Payoff
- PN
- Prior Gross Invoice Total
- R
- Spend Down
- RP
- Repair
- SM
- Supplemental
- T
- Tax
- T2
- Total Claim Before Taxes
- T3
- Total Submitted Charges
- TP
- Total payment amount
- TT
- Total Transaction Amount
- YT
- Denied
- YU
- In Process—
- YY
- Returned—
- ZK
- Federal Medicare or Medicaid Payment Mandate - Category 1
- ZL
- Federal Medicare or Medicaid Payment Mandate - Category 2
- ZM
- Federal Medicare or Medicaid Payment Mandate - Category 3
- ZN
- Federal Medicare or Medicaid Payment Mandate - Category 4
- ZO
- Federal Medicare or Medicaid Payment Mandate - Category 5
- ZZ
- Mutually Defined
QTY
0600
Detail > Original Transaction Identification Loop > QTY
Quantity Information
OptionalMax use 3
—
Usage notes
—
Example
Required
Identifier (ID)
—
- 01
- Discrete Quantity
- 1N
- Scrap allowed
- 02
- Cumulative Quantity
- 2W
- Segments
- 2Y
- Functional Groups
- 2Z
- Transaction Sets
- 3S
- Total Debits
- 3T
- Total Credits
- 41
- Number of Batches
- 42
- Number of Checks
- 46
- Total transactions
- 90
- Acknowledged Quantity—
- AA
- Unacknowledged Quantity—
- BF
- Age Modifying Units
- CA
- Covered - Actual
- CD
- Co-insured - Actual
- EC
- Use of Extracorporeal Circulation
- EM
- Emergency Modifying Units
- HF
- Invoices
- HM
- Use of Hypothermia
- HO
- Use of Hypotension
- HP
- Use of Hyperbaric Pressurization
- HS
- Hours
- LA
- Life-time Reserve - Actual
- LE
- Life-time Reserve - Estimated
- NA
- Number of Non-covered Days
- NE
- Non-Covered - Estimated
- NP
- Number of Members
- NR
- Not Replaced Blood Units
- OU
- Outlier Days
- P3
- Physical Status III
- P4
- Physical Status IV
- P5
- Physical Status V
- P6
- Number of Services or Procedures
- PS
- Prescription
- SG
- Swan-Ganz
- TO
- Total
- VS
- Visits
- ZK
- Federal Medicare or Medicaid Payment Mandate - Category 1
- ZL
- Federal Medicare or Medicaid Payment Mandate - Category 2
- ZM
- Federal Medicare or Medicaid Payment Mandate - Category 3
- ZN
- Federal Medicare or Medicaid Payment Mandate - Category 4
- ZO
- Federal Medicare or Medicaid Payment Mandate - Category 5
NM1
0650
Detail > Original Transaction Identification Loop > NM1
Individual or Organizational Name
OptionalMax use 6
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Identification Code (NM1-09) is present, then the other is required
Required
Identifier (ID)
—
- 1B
- Applicant
- 1E
- Health Maintenance Organization (HMO)
- 1H
- Kidney Dialysis Unit
- 1I
- Preferred Provider Organization (PPO)
- 1K
- Franchisor
- 1P
- Provider
- 1R
- University, College or School
- 1T
- Physician, Clinic or Group Practice
- 1X
- Laboratory
- 2B
- Third-Party Administrator
- 2D
- Miscellaneous Health Care Facility
- 2K
- Partnership
- 03
- Dependent
- 3D
- Obstetrics and Gynecology Facility
- 8W
- Payment Address
- 13
- Contracted Service Provider
- 30
- Service Supplier
- 31
- Postal Mailing Address
- 36
- Employer
- 40
- Receiver
- 41
- Submitter
- 47
- Estimator
- 69
- Repairing Outlet
- 70
- Prior Incorrect Insured
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- 74
- Corrected Insured
- 77
- Service Location
- 80
- Hospital
- 82
- Rendering Provider
- 85
- Billing Provider
- 87
- Pay-to Provider
- AAP
- Employee
- ACV
- Information Source
- AG
- Agent/Agency
- AI
- Airline
- AO
- Account Of
- BB
- Business Partner
- BE
- Beneficiary
- BR
- Broker
- BV
- Billing Service
- CC
- Claimant
- CX
- Claim Administrator
- DK
- Ordering Physician
- DN
- Referring Provider
- DQ
- Supervising Physician
- E1
- Person or Other Entity Legally Responsible for a Child
- EF
- Electronic Filer
- EI
- Executor of Estate
- ENR
- Enroller
- EXS
- Ex-spouse
- EY
- Employee Name
- FA
- Facility
- FW
- Forwarder
- GD
- Guardian
- GP
- Gateway Provider
- GW
- Group
- GY
- Treatment Facility
- H5
- Paying Agent
- HA
- Owner
- HK
- Subscriber
- IAE
- Member
- IL
- Insured or Subscriber
- IN
- Insurer
- IP
- Independent Adjuster
- J6
- Power of Attorney
- KU
- Receiver Site
- L5
- Contact
- LE
- Lessor
- LI
- Independent Lab
- LN
- Lender
- LS
- Lessee
- M8
- Educational Institution
- MH
- Mortgage Insurer
- NZ
- Primary Physician
- OD
- Doctor of Optometry
- OW
- Owner of Property or Unit
- P2
- Primary Insured or Subscriber
- P3
- Primary Care Provider
- P4
- Prior Insurance Carrier
- P5
- Plan Sponsor
- PE
- Payee
- PR
- Payer
- PRP
- Primary Payer
- PV
- Party performing certification
- QA
- Pharmacy
- QB
- Purchase Service Provider
- QC
- Patient
- QD
- Responsible Party
- QE
- Policyholder
- QH
- Physician
- QN
- Dentist
- QV
- Group Practice
- R6
- Requester
- RI
- Remit To
- S3
- Custodial Parent
- SEP
- Secondary Payer
- SJ
- Service Provider
- SU
- Supplier/Manufacturer
- TL
- Testing Laboratory
- TM
- Transmitter
- TT
- Transfer To
- TTP
- Tertiary Payer
- TV
- Third Party Administrator (TPA)
- UY
- Vehicle
- VN
- Vendor
- X3
- Utilization Management Organization
- Y2
- Managed Care Organization
- ZZ
- Mutually Defined
2100 Error or Informational Message Location Loop
OptionalMax >1
TED
0700
Detail > Original Transaction Identification Loop > Error or Informational Message Location Loop > TED
Error or Informational Message Location
RequiredMax use 1
—
Usage notes
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 024
- Other Unlisted Reason—
OptionalMax use 1
Code indicating the relative position of the simple data element or composite data structure in error within a segment, count beginning with 1 for the position immediately following the segment ID; additionally indicating the relative position of a repeating structure in error, count beginning with 1 for the position immediately following the preceding element separator; additionally indicating the relative position of a component of a composite data structure in error, count beginning with 1 for the position following the preceding element or repetition separator
Usage notes
—
CTX
0750
Detail > Original Transaction Identification Loop > Error or Informational Message Location Loop > CTX
Situational Context Location
OptionalMax use 10
—
Usage notes
—
Example
RequiredMax use 10
Holds information to identify a context
OptionalMax use 1
Code indicating the relative position of the simple data element or composite data structure in error within a segment, count beginning with 1 for the position immediately following the segment ID; additionally indicating the relative position of a repeating structure in error, count beginning with 1 for the position immediately following the preceding element separator; additionally indicating the relative position of a component of a composite data structure in error, count beginning with 1 for the position following the preceding element or repetition separator
Usage notes
—
OptionalMax use 1
To hold the reference number of a data element and optionally a component data element within a composite
Usage notes
—
RED
0820
Detail > Original Transaction Identification Loop > Error or Informational Message Location Loop > RED
Error or Informational Message
RequiredMax use 100
—
Example
Required
Identifier (ID)
—
Usage notes
—
- 94
- Code Assigned by the Organization that is the Ultimate Destination of the Transaction Set
Required
Identifier (ID)
—
- IBP
- Insurance Business Process Application Error Code—
2100 Error or Informational Message Location Loop end
2000 Original Transaction Identification Loop end
SE
0900
Detail > SE
Transaction Set Trailer
RequiredMax use 1
—
Example
Detail end
GE
Functional Group Trailer
RequiredMax use 1
—
Example
IEA
Interchange Control Trailer
RequiredMax use 1
—
Example
EDI Samples
Example 1: Positive Acknowledgment
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240221*1407*^*00501*000000001*0*T*>~
GS*AG*SENDERGS*RECEIVERGS*20240221*140702*000000001*X*005010X186A1~
ST*824*021390001*005010X186A1~
BGN*11*FFA.ABCDEF.123456*20020709*0932**123456789**WQ~
N1*41*ABC INSURANCE*46*111111111~
PER*IC*JOHN JOHNSON*TE*8005551212*EX*1439~
N1*40*SMITHCO*46*A1234~
OTI*TA*TN*NA***20020709*0902*2*0001*834*005010X220A1~
SE*7*021390001~
GE*1*000000001~
IEA*1*000000001~
GS*AG*SENDERGS*RECEIVERGS*20240221*140702*000000001*X*005010X186A1~
ST*824*021390001*005010X186A1~
BGN*11*FFA.ABCDEF.123456*20020709*0932**123456789**WQ~
N1*41*ABC INSURANCE*46*111111111~
PER*IC*JOHN JOHNSON*TE*8005551212*EX*1439~
N1*40*SMITHCO*46*A1234~
OTI*TA*TN*NA***20020709*0902*2*0001*834*005010X220A1~
SE*7*021390001~
GE*1*000000001~
IEA*1*000000001~
Example 2: Complete Transaction Set Reject Reporting
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240221*1407*^*00501*000000001*0*T*>~
GS*AG*SENDERGS*RECEIVERGS*20240221*140729*000000001*X*005010X186A1~
ST*824*021390002*005010X186A1~
BGN*11*FFA.ABCDEF.123456*20020709*0932**123456789**U~
N1*41*DEF INSURANCE*46*222222222~
PER*IC*TOM EVANS*TE*8005551212*EX*1439~
N1*40*JONESCO*46*B5678~
OTI*TR*TN*NA***20020709*0902*2*0001*124*005010~
TED*024**VEH*36*2~
RED*NA**94**IBP*E054~
SE*9*021390002~
GE*1*000000001~
IEA*1*000000001~
GS*AG*SENDERGS*RECEIVERGS*20240221*140729*000000001*X*005010X186A1~
ST*824*021390002*005010X186A1~
BGN*11*FFA.ABCDEF.123456*20020709*0932**123456789**U~
N1*41*DEF INSURANCE*46*222222222~
PER*IC*TOM EVANS*TE*8005551212*EX*1439~
N1*40*JONESCO*46*B5678~
OTI*TR*TN*NA***20020709*0902*2*0001*124*005010~
TED*024**VEH*36*2~
RED*NA**94**IBP*E054~
SE*9*021390002~
GE*1*000000001~
IEA*1*000000001~
Example 3: Partial Transaction Set Reject Reporting
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240221*1409*^*00501*000000001*0*T*>~
GS*AG*SENDERGS*RECEIVERGS*20240221*140914*000000001*X*005010X186A1~
ST*824*0001*005010X186A1~
BGN*11*12345*20040831*150057**0123**RU~
N1*41*CONSOLIDATED INSURANCE CO*46*00000~
PER*IC*CUSTOMER SERVICE*TE*8005551212~
N1*40*PHIL GOOD, M.D.*46*TXX23~
OTI*TA*TN*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*F8*0123~
DTM*050*20040814~
AMT*GW*16970.33~
QTY*TO*5~
NM1*41*2*PHIL GOOD, M.D.*****46*TXX23~
TED*024~
RED*NA**94**IBP*W050~
OTI*BP*BT*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*1C*99983000~
AMT*2*16970.33~
QTY*46*5~
NM1*85*2*GOOD AND ASSOCIATES*****24*555667777~
OTI*IA*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*26462967~
AMT*GW*540~
NM1*QC*1*SMITH*TED****MI*000221111A~
OTI*IE*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*78945639837~
AMT*GW*1100.67~
NM1*QC*1*BROWN*ROBERT*W***MI*888553737~
TED*024**N4*32*3**10407~
RED*NA**94**IBP*E038~
OTI*IR*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*8437450584598~
AMT*GW*12642.16~
NM1*QC*1*JAMES*JIM*D***MI*011332211~
TED*024**N4*54*3**73076~
RED*NA**94**IBP*E038~
TED*024**REF*68~
CTX*2310A REFERRING PROVIDER*NM1*65*2310~
CTX*2010BB PAYER NAME*NM1*18*2010~
CTX*CLAIM FILING INDICATOR CODE - MB*SBR*13*2000*9~
RED*NA**94**IBP*E019~
OTI*IA*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*984576898~
AMT*GW*1900.5~
NM1*QC*1*MAE*SALLIE*M***MI*987654321~
OTI*IE*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*8767657645765~
AMT*GW*787~
NM1*QC*1*DOE*JANE****MI*777553333~
TED*024**N4*113*3**27387~
RED*NA**94**IBP*E038~
TED*024**N4*124*3**27378~
RED*NA**94**IBP*E038~
SE*52*0001~
GE*1*000000001~
IEA*1*000000001~
GS*AG*SENDERGS*RECEIVERGS*20240221*140914*000000001*X*005010X186A1~
ST*824*0001*005010X186A1~
BGN*11*12345*20040831*150057**0123**RU~
N1*41*CONSOLIDATED INSURANCE CO*46*00000~
PER*IC*CUSTOMER SERVICE*TE*8005551212~
N1*40*PHIL GOOD, M.D.*46*TXX23~
OTI*TA*TN*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*F8*0123~
DTM*050*20040814~
AMT*GW*16970.33~
QTY*TO*5~
NM1*41*2*PHIL GOOD, M.D.*****46*TXX23~
TED*024~
RED*NA**94**IBP*W050~
OTI*BP*BT*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*1C*99983000~
AMT*2*16970.33~
QTY*46*5~
NM1*85*2*GOOD AND ASSOCIATES*****24*555667777~
OTI*IA*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*26462967~
AMT*GW*540~
NM1*QC*1*SMITH*TED****MI*000221111A~
OTI*IE*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*78945639837~
AMT*GW*1100.67~
NM1*QC*1*BROWN*ROBERT*W***MI*888553737~
TED*024**N4*32*3**10407~
RED*NA**94**IBP*E038~
OTI*IR*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*8437450584598~
AMT*GW*12642.16~
NM1*QC*1*JAMES*JIM*D***MI*011332211~
TED*024**N4*54*3**73076~
RED*NA**94**IBP*E038~
TED*024**REF*68~
CTX*2310A REFERRING PROVIDER*NM1*65*2310~
CTX*2010BB PAYER NAME*NM1*18*2010~
CTX*CLAIM FILING INDICATOR CODE - MB*SBR*13*2000*9~
RED*NA**94**IBP*E019~
OTI*IA*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*984576898~
AMT*GW*1900.5~
NM1*QC*1*MAE*SALLIE*M***MI*987654321~
OTI*IE*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*8767657645765~
AMT*GW*787~
NM1*QC*1*DOE*JANE****MI*777553333~
TED*024**N4*113*3**27387~
RED*NA**94**IBP*E038~
TED*024**N4*124*3**27378~
RED*NA**94**IBP*E038~
SE*52*0001~
GE*1*000000001~
IEA*1*000000001~
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