X12 277 Claim Acknowledgment (X214)

Beginning of Hierarchical Transaction

Functional Group Header

Transaction Set Header

Information Source Level Loop

detail

Information Source Name Loop

NM1

0500

Information Source Name

Transmission Receipt Control Identifier Loop

Transmission Receipt Control Identifier

Information Source Receipt Date

Information Source Process Date

Information Receiver Level Loop

Information Receiver Name Loop

NM1

0500

Information Receiver Name

Information Receiver Application Trace Identifier Loop

Information Receiver Application Trace Identifier

Information Receiver Status Information

Total Accepted Quantity

Total Rejected Quantity

Total Accepted Amount

Total Rejected Amount

Billing Provider of Service Level Loop

Optional

Billing Provider Name Loop

NM1

0500

Billing Provider Name

Provider of Service Information Trace Identifier Loop

Provider of Service Information Trace Identifier

Billing Provider Status Information

Provider Secondary Identifier

Total Accepted Quantity

Total Rejected Quantity

Total Accepted Amount

Total Rejected Amount

Claim Status Tracking Number Loop

Claim Status Tracking Number

Claim Level Status Information

Payer Claim Control Number

Claim Identifier For Transmission Intermediaries

Institutional Bill Type Identification

Claim Level Service Date

Service Line Information Loop

SVC

1800

Service Line Information

Service Line Level Status Information

Service Line Item Identification

Pharmacy Prescription Number

Transaction Set Trailer

Functional Group Trailer

Interchange Control Trailer

IEA

ISA

Interchange Control Header

RequiredMax use 1

—

Example

ISA-01

I01

Authorization Information Qualifier

Required

Identifier (ID)

—

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

ISA-02

I02

Authorization Information

Required

String (AN)

Min 10Max 10

—

ISA-03

I03

Security Information Qualifier

Required

Identifier (ID)

—

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

ISA-04

I04

Security Information

Required

String (AN)

Min 10Max 10

—

ISA-05

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 2

—

Codes

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

ISA-06

I06

Interchange Sender ID

Required

String (AN)

Min 15Max 15

—

ISA-07

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 2

—

Codes

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

ISA-08

I07

Interchange Receiver ID

Required

String (AN)

Min 15Max 15

—

ISA-09

I08

Interchange Date

Required

Date (DT)

YYMMDD format

—

ISA-10

I09

Interchange Time

Required

Time (TM)

HHMM format

—

ISA-11

I65

Repetition Separator

Required

String (AN)

Min 1Max 1

—

^: Repetition Separator

ISA-12

I11

Interchange Control Version Number

Required

Identifier (ID)

—

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

ISA-13

I12

Interchange Control Number

Required

Numeric (N0)

Min 9Max 9

—

ISA-14

I13

Acknowledgment Requested

Required

Identifier (ID)

Min 1Max 1

—

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

ISA-15

I14

Interchange Usage Indicator

Required

Identifier (ID)

Min 1Max 1

—

I: Information
P: Production Data
T: Test Data

ISA-16

I15

Component Element Separator

Required

String (AN)

Min 1Max 1

—

>: Component Element Separator

Functional Group Header

RequiredMax use 1

—

Example

GS-01

479

Functional Identifier Code

Required

Identifier (ID)

—

HN: Health Care Information Status Notification (277)

GS-02

142

Application Sender's Code

Required

String (AN)

Min 2Max 15

—

GS-03

124

Application Receiver's Code

Required

String (AN)

Min 2Max 15

—

GS-04

373

Date

Required

Date (DT)

CCYYMMDD format

—

GS-05

337

Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

GS-06

Group Control Number

Required

Numeric (N0)

Min 1Max 9

—

GS-07

455

Responsible Agency Code

Required

Identifier (ID)

Min 1Max 2

—

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

GS-08

480

Version / Release / Industry Identifier Code

Required

String (AN)

—

005010X214

Heading

0100

Heading > ST

Transaction Set Header

RequiredMax use 1

—

Example

ST-01

143

Transaction Set Identifier Code

Required

Identifier (ID)

—

277: Health Care Information Status Notification

ST-02

329

Transaction Set Control Number

Required

Numeric (N)

Min 4Max 9

—

Usage notes

—

ST-03

1705

Version, Release, or Industry Identifier

Required

String (AN)

—

Usage notes

—

005010X214

BHT

0200

Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

—

Example

BHT-01

1005

Hierarchical Structure Code

Required

Identifier (ID)

—

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

BHT-02

353

Transaction Set Purpose Code

Required

Identifier (ID)

—

08: Status

BHT-03

127

Reference Identification

Required

String (AN)

Min 1Max 50

—

Usage notes

—

BHT-04

373

Transaction Set Creation Date

Required

Date (DT)

CCYYMMDD format

—

BHT-05

337

Transaction Set Creation Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

BHT-06

640

Transaction Type Code

Required

Identifier (ID)

—

TH: Receipt Acknowledgment Advice

Heading end

Detail

2000A Information Source Level Loop

RequiredMax 1

0100

Detail > Information Source Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

20: Information Source

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2100A Information Source Name Loop

RequiredMax 1

NM1

0500

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

Information Source Name

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

AY: Clearinghouse
—
PR: Payer

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Information Source Name

Required

String (AN)

Min 1Max 60

—

Identification Code Qualifier

Required

Identifier (ID)

—

46: Electronic Transmitter Identification Number (ETIN)
—
FI: Federal Taxpayer's Identification Number
PI: Payor Identification
XV: Centers for Medicare and Medicaid Services PlanID

Information Source Identifier

Required

String (AN)

Min 2Max 80

—

2100A Information Source Name Loop end

2200A Transmission Receipt Control Identifier Loop

RequiredMax 1

TRN

0900

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

Transmission Receipt Control Identifier

RequiredMax use 1

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

DTPInformation Source Process Date

127

Information Source Application Trace Identifier

Required

String (AN)

Min 1Max 50

—

Usage notes

—

DTP

1200

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

Information Source Receipt Date

RequiredMax use 1

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

050: Received

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTPInformation Source Receipt Date

1251

Information Source Receipt Date

Required

String (AN)

Min 1Max 35

—

Usage notes

—

DTP

1200

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

Information Source Process Date

RequiredMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

009: Process

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Information Source Process Date

Required

String (AN)

Min 1Max 35

—

2200A Transmission Receipt Control Identifier Loop end

2000B Information Receiver Level Loop

RequiredMax 1

0100

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

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

HL-02

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

21: Information Receiver

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2100B Information Receiver Name Loop

RequiredMax 1

NM1

0500

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

Information Receiver Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

41: Submitter

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Information Receiver Last or Organization Name

Required

String (AN)

Min 1Max 60

—

NM1-04

1036

Information Receiver First Name

Optional

String (AN)

Min 1Max 35

—

NM1-05

1037

Information Receiver Middle Name

Optional

String (AN)

Min 1Max 25

—

Identification Code Qualifier

Required

Identifier (ID)

—

46: Electronic Transmitter Identification Number (ETIN)

Information Receiver Primary Identifier

Required

String (AN)

Min 2Max 80

—

2100B Information Receiver Name Loop end

2200B Information Receiver Application Trace Identifier Loop

RequiredMax 1

TRN

0900

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

Information Receiver Application Trace Identifier

RequiredMax use 1

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

2: Referenced Transaction Trace Numbers

127

Claim Transaction Batch Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

STC

1000

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

Information Receiver Status Information

RequiredMax use >1

—

Usage notes

—

Example

C043

Health Care Claim Status

RequiredMax use 1

Used to convey status of the entire claim or a specific service line

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

—

36: Employer
40: Receiver
41: Submitter
AY: Clearinghouse
PR: Payer

STC-02

373

Status Information Effective Date

Required

Date (DT)

CCYYMMDD format

—

306

Action Code

Required

Identifier (ID)

—

Usage notes

—

U: Reject
—
WQ: Accept
—

STC-04

782

Total Submitted Charges for Unit Work

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

QTYTotal Rejected Quantity

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

QTY

1210

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

Total Accepted Quantity

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

673

Quantity Qualifier

Required

Identifier (ID)

—

90: Acknowledged Quantity

QTYTotal Accepted Quantity

380

Total Accepted Quantity

Required

Decimal number (R)

Min 1Max 15

—

QTY

1210

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

Total Rejected Quantity

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

673

Quantity Qualifier

Required

Identifier (ID)

—

AA: Unacknowledged Quantity

380

Total Rejected Quantity

Required

Decimal number (R)

Min 1Max 15

—

AMT

1220

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

Total Accepted Amount

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

AMTTotal Rejected Amount

522

Amount Qualifier Code

Required

Identifier (ID)

—

YU: In Process

782

Total Accepted Amount

Required

Decimal number (R)

Min 1Max 15

—

AMT

1220

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

Total Rejected Amount

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

AMTTotal Accepted Amount

522

Amount Qualifier Code

Required

Identifier (ID)

—

YY: Returned

782

Total Rejected Amount

Required

Decimal number (R)

Min 1Max 15

—

2200B Information Receiver Application Trace Identifier Loop end

2000C Billing Provider of Service Level Loop

OptionalMax >1

0100

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

HL-02

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

19: Provider of Service

736

Hierarchical Child Code

Optional

Identifier (ID)

—

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

2100C Billing Provider Name Loop

RequiredMax 1

NM1

0500

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Billing Provider Name Loop > NM1

Billing Provider Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

85: Billing Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Provider Last or Organization Name

Required

String (AN)

Min 1Max 60

—

NM1-04

1036

Provider First Name

Optional

String (AN)

Min 1Max 35

—

NM1-05

1037

Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

NM1-07

1039

Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

FI: Federal Taxpayer's Identification Number
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

Billing Provider Identifier

Required

String (AN)

Min 2Max 80

—

2100C Billing Provider Name Loop end

2200C Provider of Service Information Trace Identifier Loop

OptionalMax 1

TRN

0900

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Provider of Service Information Trace Identifier Loop > TRN

Provider of Service Information Trace Identifier

RequiredMax use 1

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

1: Current Transaction Trace Numbers

127

Provider of Service Information Trace Identifier

Required

String (AN)

Min 1Max 50

—

STC

1000

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Provider of Service Information Trace Identifier Loop > STC

Billing Provider Status Information

OptionalMax use >1

—

Usage notes

—

Example

C043

Health Care Claim Status

RequiredMax use 1

Used to convey status of the entire claim or a specific service line

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

—

36: Employer
40: Receiver
41: Submitter
77: Service Location
82: Rendering Provider
85: Billing Provider
87: Pay-to Provider
AY: Clearinghouse
PR: Payer

306

Action Code

Required

Identifier (ID)

—

Usage notes

—

U: Reject
—
WQ: Accept

STC-04

782

Total Submitted Charges for Unit Work

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

REF

1100

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Provider of Service Information Trace Identifier Loop > REF

Provider Secondary Identifier

OptionalMax use 3

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0B: State License Number
1G: Provider UPIN Number
G2: Provider Commercial Number
LU: Location Number
SY: Social Security Number
TJ: Federal Taxpayer's Identification Number

QTYTotal Rejected Quantity

127

Billing Provider Additional Identifier

Required

String (AN)

Min 1Max 50

—

QTY

1210

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Provider of Service Information Trace Identifier Loop > QTY

Total Accepted Quantity

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

673

Quantity Qualifier

Required

Identifier (ID)

—

QA: Quantity Approved

QTYTotal Accepted Quantity

380

Total Accepted Quantity

Required

Decimal number (R)

Min 1Max 15

—

QTY

1210

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Provider of Service Information Trace Identifier Loop > QTY

Total Rejected Quantity

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

673

Quantity Qualifier

Required

Identifier (ID)

—

QC: Quantity Disapproved

380

Total Rejected Quantity

Required

Decimal number (R)

Min 1Max 15

—

AMT

1220

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Provider of Service Information Trace Identifier Loop > AMT

Total Accepted Amount

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

AMTTotal Rejected Amount

522

Amount Qualifier Code

Required

Identifier (ID)

—

YU: In Process

782

Total Accepted Amount

Required

Decimal number (R)

Min 1Max 15

—

AMT

1220

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Provider of Service Information Trace Identifier Loop > AMT

Total Rejected Amount

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

AMTTotal Accepted Amount

522

Amount Qualifier Code

Required

Identifier (ID)

—

YY: Returned

782

Total Rejected Amount

Required

Decimal number (R)

Min 1Max 15

—

2200C Provider of Service Information Trace Identifier Loop end

2000D Patient Level Loop

OptionalMax >1

0100

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Patient Level Loop > HL

Hierarchical Level

RequiredMax use 1

—

Example

628

Hierarchical ID Number

Required

String (AN)

Min 1Max 12

—

HL-02

734

Hierarchical Parent ID Number

Required

String (AN)

Min 1Max 12

—

735

Hierarchical Level Code

Required

Identifier (ID)

—

PT: Patient

736

Hierarchical Child Code

Optional

Identifier (ID)

—

0: No Subordinate HL Segment in This Hierarchical Structure.

2100D Patient Name Loop

RequiredMax 1

NM1

0500

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Patient Level Loop > Patient Name Loop > NM1

Patient Name

RequiredMax use 1

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

QC: Patient

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Patient Last Name

Required

String (AN)

Min 1Max 60

—

NM1-04

1036

Patient First Name

Optional

String (AN)

Min 1Max 35

—

NM1-05

1037

Patient Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

NM1-07

1039

Patient Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

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

Patient Identification Number

Required

String (AN)

Min 2Max 80

—

Usage notes

—

2100D Patient Name Loop end

2200D Claim Status Tracking Number Loop

RequiredMax >1

TRN

0900

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > TRN

Claim Status Tracking Number

RequiredMax use 1

—

Usage notes

—

Example

481

Trace Type Code

Required

Identifier (ID)

—

2: Referenced Transaction Trace Numbers

127

Patient Control Number

Required

String (AN)

Min 1Max 50

—

STC

1000

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

Claim Level Status Information

RequiredMax use >1

—

Usage notes

—

Example

C043

Health Care Claim Status

RequiredMax use 1

Used to convey status of the entire claim or a specific service line

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

—

1P: Provider
1Z: Home Health Care
03: Dependent
40: Receiver
41: Submitter
71: Attending Physician
72: Operating Physician
73: Other Physician
77: Service Location
82: Rendering Provider
85: Billing Provider
87: Pay-to Provider
DK: Ordering Physician
DN: Referring Provider
DQ: Supervising Physician
FA: Facility
GB: Other Insured
HK: Subscriber
IL: Insured or Subscriber
LI: Independent Lab
MSC: Mammography Screening Center
PR: Payer
PRP: Primary Payer
QB: Purchase Service Provider
QC: Patient
QD: Responsible Party
SEP: Secondary Payer
TL: Testing Laboratory
TTP: Tertiary Payer
TU: Third Party Repricing Organization (TPO)

STC-02

373

Status Information Effective Date

Required

Date (DT)

CCYYMMDD format

—

306

Status Information Action Code

Required

Identifier (ID)

—

U: Reject
WQ: Accept

STC-04

782

Total Claim Charge Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

REFClaim Identifier For Transmission Intermediaries REFInstitutional Bill Type Identification

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

STC-12

933

Free Form Message Text

Optional

String (AN)

Min 1Max 264

—

Usage notes

—

REF

1100

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

Payer Claim Control Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1K: Payor's Claim Number

REFPayer Claim Control Number REFInstitutional Bill Type Identification

127

Payer Claim Control Number

Required

String (AN)

Min 1Max 50

—

REF

1100

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

Claim Identifier For Transmission Intermediaries

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

D9: Claim Number

REFPayer Claim Control Number REFClaim Identifier For Transmission Intermediaries

127

Clearinghouse Trace Number

Required

String (AN)

Min 1Max 50

—

REF

1100

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

Institutional Bill Type Identification

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

BLT: Billing Type
—

127

Bill Type Identifier

Required

String (AN)

Min 1Max 50

—

Usage notes

—

DTP

1200

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

Claim Level Service Date

RequiredMax use 1

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

472: Service

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Claim Service Period

Required

String (AN)

Min 1Max 35

—

2220D Service Line Information Loop

OptionalMax >1

SVC

1800

Detail > Information Source Level Loop > Information Receiver Level Loop > Billing Provider of Service Level Loop > Patient Level Loop > Claim Status Tracking Number Loop > Service Line Information Loop > SVC

Service Line Information

RequiredMax use 1

—

Usage notes

—

Example

SVC-01

C003

Composite Medical Procedure Identifier

RequiredMax use 1

To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

C003-01

235

Procedure Code

Required

Identifier (ID)

—

AD: American Dental Association Codes
ER: Jurisdiction Specific Procedure and Supply Codes
—
HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
NU: National Uniform Billing Committee (NUBC) UB92 Codes
—
WK: Advanced Billing Concepts (ABC) Codes

C003-02

234

Procedure Code

Required

String (AN)

Min 1Max 48

—

Usage notes

—

C003-03

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-04

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-05

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-06

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

SVC-02

782

Line Item Charge Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SVC-04

234

Revenue Code

Optional

String (AN)

Min 1Max 48

—

SVC-07

380

Original Units of Service Count

Optional

Decimal number (R)

Min 1Max 15

—

STC

1900

Service Line Level Status Information

RequiredMax use >1

—

Usage notes

—

Example

C043

Health Care Claim Status

RequiredMax use 1

Used to convey status of the entire claim or a specific service line

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

—

1P: Provider
1Z: Home Health Care
03: Dependent
40: Receiver
41: Submitter
71: Attending Physician
72: Operating Physician
73: Other Physician
77: Service Location
82: Rendering Provider
85: Billing Provider
87: Pay-to Provider
DK: Ordering Physician
DN: Referring Provider
DQ: Supervising Physician
FA: Facility
GB: Other Insured
HK: Subscriber
IL: Insured or Subscriber
LI: Independent Lab
MSC: Mammography Screening Center
PR: Payer
PRP: Primary Payer
QB: Purchase Service Provider
QC: Patient
QD: Responsible Party
SEP: Secondary Payer
TL: Testing Laboratory
TTP: Tertiary Payer
TU: Third Party Repricing Organization (TPO)

306

Action Code

Required

Identifier (ID)

—

U: Reject

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

C043

Health Care Claim Status

OptionalMax use 1

Used to convey status of the entire claim or a specific service line

Usage notes

—

1271

Health Care Claim Status Category Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

1271

Health Care Claim Status Code

Required

String (AN)

Min 1Max 30

—

Usage notes

—

REFPharmacy Prescription Number

Entity Identifier Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

STC-12

933

Free Form Message Text

Optional

String (AN)

Min 1Max 264

—

Usage notes

—

REF

2000

Service Line Item Identification

RequiredMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

FJ: Line Item Control Number

REFService Line Item Identification

127

Line Item Control Number

Required

String (AN)

Min 1Max 50

—

REF

2000

Pharmacy Prescription Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

XZ: Pharmacy Prescription Number

127

Pharmacy Prescription Number

Required

String (AN)

Min 1Max 50

—

DTP

2100

Service Line Date

OptionalMax use 1

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

472: Service

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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