X12 837 Health Care Claim: Dental (X224A3)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.
For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HC
- Health Care Claim (837)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X224A3
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 837
- Health Care Claim
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time.
- 005010X224A3
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
- The second example denotes the case where the entire transaction set contains ENCOUNTERS.
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0019
- Information Source, Subscriber, Dependent
Code identifying purpose of transaction set
- BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status.
- 00
- Original
Original transmissions are transmissions which have never been sent to the receiver.
- 18
- Reissue
If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number.
- This field is limited to 30 characters.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
- This is the date that the original submitter created the claim file from their business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
- This is the time that the original submitter created the claim file from their business application system.
Code specifying the type of transaction
- 31
- Subrogation Demand
The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners.
***NOTE: ***At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. - CH
- Chargeable
Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH.
- RP
- Reporting
Use RP when the entire ST-SE envelope contains only capitated encounters.
Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes.
Submitter Name
To supply the full name of an individual or organizational entity
- The submitter is the entity responsible for the creation and formatting of this transaction.
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Established by trading partner agreement
Submitter EDI Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
- The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
- There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Receiver Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- 40
- Receiver
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Billing Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when the Billing Provider is also the Rendering Provider for at least one of the claims in this transaction.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Foreign Currency Information
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
- Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.
- It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code (Standard ISO) for country in whose currency the charges are specified
- The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid.
Billing Provider Name
To supply the full name of an individual or organizational entity
- Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
- Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
- The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
- The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration).
- When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Billing Provider Address
To specify the location of the named party
- The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
Billing Provider City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Billing Provider Tax Identification
To specify identifying information
- This is the tax identification number (TIN) of the entity to be paid for the submitted services.
Code qualifying the Reference Identification
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider UPIN/License Information
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
- There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Pay-to Address Name
To supply the full name of an individual or organizational entity
- Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
- The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
Pay-to Address - ADDRESS
To specify the location of the named party
Pay-To Address City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Pay-To Plan Name
To supply the full name of an individual or organizational entity
- Required when willing trading partners agree to use this implementation for their subrogation payment requests.
- This loop may only be used when BHT06 = 31.
Code identifying an organizational entity, a physical location, property or an individual
- PE
- Payee
PE is used to indicate the subrogated payee.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.
Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.
If a phase-in period is designated, PI must be sent unless:
- Both the sender and receiver agree to use the National Plan ID,
- The receiver has a National Plan ID, and
- The sender has the capability to send the National Plan ID.
If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Code identifying a party or other code
Pay-to Plan Address
To specify the location of the named party
Pay-To Plan City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Pay-to Plan Secondary Identification
To specify identifying information
- Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
This code is only allowed when the National Plan Identifier is reported in NM109 of this loop.
- FY
- Claim Office Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pay-To Plan Tax Identification Number
To specify identifying information
Code qualifying the Reference Identification
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
- 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
This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
- 18
- Self
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109.
Code identifying the type of insurance policy within a specific insurance program
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
Code identifying type of claim
- 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
Use code OF when submitting Medicare Part D claims.
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined
Use Code ZZ when Type of Insurance is not known.
Subscriber Name
To supply the full name of an individual or organizational entity
- In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.
When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Code identifying a party or other code
Subscriber Address
To specify the location of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Demographic Information
To supply demographic information
- Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Subscriber Secondary Identification
To specify identifying information
- Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Property and Casualty Claim Number
To specify identifying information
- Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
- This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
- This segment is not a HIPAA requirement as of this writing.
Code qualifying the Reference Identification
- Y4
- Agency Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Name
To supply the full name of an individual or organizational entity
- This is the destination payer.
- For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.
Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.
If a phase-in period is designated, PI must be sent unless:
- Both the sender and receiver agree to use the National Plan ID,
- The receiver has a National Plan ID, and
- The sender has the capability to send the National Plan ID.
If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Payer Address
To specify the location of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Payer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Payer Secondary Identification
To specify identifying information
- Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
This code is only allowed when the National Plan Identifier is reported in NM109 of this loop.
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
- FY
- Claim Office Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Billing Provider Secondary Identification
To specify identifying information
- Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Information
To specify basic data about the claim
- The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
- For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Identifier used to track a claim from creation by the health care provider through payment
- The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
- When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
- The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
Monetary amount
- CLM02 is the total amount of all submitted charges of service segments for this claim.
- The Total Claim Charge Amount must be greater than or equal to zero.
- The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- B
- Place of Service Codes for Professional or Dental Services
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
Code indicating a Yes or No condition or response
- CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
- N
- No
- Y
- Yes
Code indicating whether the provider accepts assignment
- Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
- A
- Assigned
Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. - C
- Not Assigned
Required when code `A' does not apply.
Code indicating a Yes or No condition or response
- CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- The Release of Information response is limited to the information carried in this claim.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
For this Implementation Guide, this also applies to dental billing data related to a claim.
Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.
Code identifying an accompanying cause of an illness, injury or an accident
- AA
- Auto Accident
- EM
- Employment
- OA
- Other Accident
Code identifying an accompanying cause of an illness, injury or an accident
Code (Standard State/Province) as defined by appropriate government agency
- C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
Code indicating the Special Program under which the services rendered to the patient were performed
- 01
- Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
- 02
- Physically Handicapped Children's Program
This code is used for Medicaid claims only.
- 03
- Special Federal Funding
This code is used for Medicaid claims only.
- 05
- Disability
This code is used for Medicaid claims only.
Code identifying reason for claim submission
- PB
- Predetermination of Dental Benefits
Code indicating the reason why a request was delayed
- 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
Date - Accident
To specify any or all of a date, a time, or a time period
- Required when CLM11-1 or CLM11-2 has a value of
AA' or
OA'.
OR
Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 439
- Accident
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Appliance Placement
To specify any or all of a date, a time, or a time period
- Required when reporting the date orthodontic appliances were placed. If not required by this implementation guide, do not send.
- Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Code specifying type of date or time, or both date and time
- 452
- Appliance Placement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Repricer Received Date
To specify any or all of a date, a time, or a time period
- Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 050
- Received
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Service Date
To specify any or all of a date, a time, or a time period
- Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. If not required by this implementation guide, do not send.
- Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Orthodontic Total Months of Treatment
To supply orthodontic information
Required when reporting the total months of orthodontic treatment. If not required by this implementation guide, do not send.
- Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
- When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
Numeric value of quantity
- DN101 is the estimated number of treatment months.
Numeric value of quantity
- DN102 is the number of treatment months remaining.
A free-form description to clarify the related data elements and their content
- DN104 is the appliance description.
- The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.
Tooth Status
To specify the status of individual teeth
- Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- DN201 is the tooth number.
- The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
Code specifying the status of the tooth
- E
- To Be Extracted
- M
- Missing
Code identifying a specific industry code list
- DN206 designates the code set used to identify the tooth in DN201.
- JP
- Universal National Tooth Designation System
Claim Supplemental Information
To identify the type or transmission or both of paperwork or supporting information
- Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.
Code indicating the title or contents of a document, report or supporting item
- B4
- Referral Form
- DA
- Dental Models
- DG
- Diagnostic Report
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- OZ
- Support Data for Claim
- P6
- Periodontal Charts
- RB
- Radiology Films
- RR
- Radiology Reports
Code defining timing, transmission method or format by which reports are to be sent
- AA
- Available on Request at Provider Site
This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.
- BM
- By Mail
- EL
- Electronically Only
Indicates that the attachment is being transmitted in a separate X12 functional group.
- EM
- FT
- File Transfer
Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- FX
- By Fax
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
- For the purpose of this implementation, the maximum field length is 50.
Contract Information
To specify basic data about the contract or contract line item
- The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
- Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Code identifying a contract type
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
Monetary amount
- CN102 is the contract amount.
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
- CN103 is the allowance or charge percent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CN104 is the contract code.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
Revision level of a particular format, program, technique or algorithm
- CN106 is an additional identifying number for the contract.
Patient Amount Paid
To indicate the total monetary amount
- Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
- Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
Predetermination Identification
To specify identifying information
- Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
- Reference numbers at this position apply to the entire claim.
Code qualifying the Reference Identification
- G3
- Predetermination of Benefits Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Authorization Exception Code
To specify identifying information
- Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 4N
- Special Payment Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Allowable values for this element are:
1 Immediate/Urgent Care
2 Services Rendered in a Retroactive Period
3 Emergency Care
4 Client has Temporary Medicaid
5 Request from County for Second Opinion to Determine
if Recipient Can Work
6 Request for Override Pending
7 Special Handling
Payer Claim Control Number
To specify identifying information
- Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- F8
- Original Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
AND
a referral is involved.
If not required by this implementation guide, do not send. - Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
- This segment must not be used to report the Predetermination of Benefits Identification Number.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Prior Authorization
To specify identifying information
- Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
- Required when an authorization number is assigned by the payer or UMO
AND
the services on this claim were preauthorized.
If not required by this implementation guide, do not send. - This segment must not be used to report the Predetermination of Benefits Identification Number.
- Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9A
- Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Adjusted Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9C
- Adjusted Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identifier For Transmission Intermediaries
To specify identifying information
- Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
- Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
Code qualifying the Reference Identification
- Number assigned by clearinghouse, van, etc.
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The value carried in this element is limited to a maximum of 20 positions.
File Information
To transmit a fixed-format record or matrix contents
- Required when ALL of the following conditions are met:
- A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement; - The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement - X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send. - At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. - Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
- X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Data in fixed format agreed upon by sender and receiver
Claim Note
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
If not required by this implementation guide, do not send. - The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Health Care Diagnosis Code
To supply information related to the delivery of health care
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
- Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
- TQ
- Systemized Nomenclature of Dentistry (SNODENT)
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- TQ
- Systemized Nomenclature of Dentistry (SNODENT)
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- See element HI02-1 for a list of valid values.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- See element HI02-1 for a list of valid values.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Claim Pricing/Repricing Information
To specify pricing or repricing information about a health care claim or line item
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code specifying pricing methodology at which the claim or line item has been priced or repriced
- Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Monetary amount
- HCP02 is the allowed amount.
Monetary amount
- HCP03 is the savings amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP04 is the repricing organization identification number.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Rate expressed in the standard monetary denomination for the currency specified
- HCP05 is the pricing rate associated with per diem or flat rate repricing.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP06 is the approved DRG code.
- HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code assigned by issuer to identify reason for rejection
- HCP13 is the rejection message returned from the third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Code specifying policy compliance
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Code specifying the exception reason for consideration of out-of-network health care services
- HCP15 is the exception reason generated by a third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
Referring Provider Name
To supply the full name of an individual or organizational entity
- Required when this claim involves a referral. If not required by this implementation guide, do not send.
- When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
- When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Use on the first iteration of this loop. Use if loop is used only once.
- P3
- Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Referring Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referring Provider Secondary Identification
To specify identifying information
- The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. If not required by this implementation guide, do not send.
- Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
- The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Facility Location Name
To supply the full name of an individual or organizational entity
- Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
If not required by this implementation guide, do not send. - When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
- When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
- The purpose of this loop is to identify specifically where the service was rendered.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Service Facility Location Address
To specify the location of the named party
- If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider provided these services in the role of the Assisting Surgeon.
If not required by this implementation guide, do not send. - Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- DD
- Assistant Surgeon
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Assistant Surgeon Specialty Information
To specify the identifying characteristics of a provider
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying the type of provider
- AS
- Assistant Surgeon
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Supervising Provider Name
To supply the full name of an individual or organizational entity
- Required when the rendering provider is supervised by a physician or dentist. If not required by this implementation guide, do not send.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Supervising Provider Secondary Identification
To specify identifying information
- Required when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop;
OR
Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider;
OR
Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
- Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
- All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
- 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
This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
- 01
- Spouse
- 18
- Self
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
Code identifying the type of insurance policy within a specific insurance program
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
Code identifying type of claim
- 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
Use code OF when submitting Medicare Part D claims.
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined
Use Code ZZ when Type of Insurance is not known.
Claim Level Adjustments
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
- Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
- Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
- Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Code identifying the general category of payment adjustment
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Coordination of Benefits (COB) Payer Paid Amount
To indicate the total monetary amount
- Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
If not required by this implementation guide, do not send.;
Monetary amount
- It is acceptable to show "0" as the amount paid.
- When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
Remaining Patient Liability
To indicate the total monetary amount
- Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
OR
Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
If not required by this implementation guide, do not send. - In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
- This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
Coordination of Benefits (COB) Total Non-Covered Amount
To indicate the total monetary amount
- Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
- When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Other Insurance Coverage Information
To specify information associated with other health insurance coverage
- All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Code indicating a Yes or No condition or response
- OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- This is a crosswalk from CLM08 when doing COB.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- The Release of Information response is limited to the information carried in this claim.
- This is a crosswalk from CLM09 when doing COB.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
Outpatient Adjudication Information
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
Required when returned in the remittance advice. If not required by this implementation guide, do not send.
- Required when outpatient adjudication information is reported in the remittance advice
OR
Required when it is necessary to report remark codes.
If not required by this implementation guide, do not send.
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
- MOA01 is the reimbursement rate.
Monetary amount
- MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA03 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA04 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA05 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA06 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA07 is the Claim Payment Remark Code. See Code Source 411.
Monetary amount
- MOA09 is the professional component amount billed but not payable.
Other Subscriber Name
To supply the full name of an individual or organizational entity
- If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
- If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.
When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Code identifying a party or other code
Other Subscriber Address
To specify the location of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Other Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Other Subscriber Secondary Identification
To specify identifying information
- Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Name
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.
Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.
If a phase-in period is designated, PI must be sent unless:
- Both the sender and receiver agree to use the National Plan ID,
- The receiver has a National Plan ID, and
- The sender has the capability to send the National Plan ID.
If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Code identifying a party or other code
- When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
Other Payer Address
To specify the location of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Other Payer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Claim Check or Remittance Date
To specify any or all of a date, a time, or a time period
- Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Other Payer Secondary Identifier
To specify identifying information
- Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
- FY
- Claim Office Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Prior Authorization Number
To specify identifying information
- This segment must not be used to report the Predetermination of Benefits Identification Number.
- Required when the payer identified in this loop has assigned a prior authorization number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Referral Number
To specify identifying information
- Required when the payer identified in this loop has assigned a referral number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Claim Adjustment Indicator
To specify identifying information
- Required when the claim is being sent in the payer-to-payer COB model,
AND
the destination payer is secondary to the payer identified in this Loop ID-2330B,
AND
the payer identified in this Loop ID-2330B has re-adjudicated the claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- T4
- Signal Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The only valid value for this element is `Y'.
Other Payer Predetermination Identification
To specify identifying information
- Required when the payer identified in this loop has assigned a predetermination identification number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G3
- Predetermination of Benefits Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Claim Control Number
To specify identifying information
- Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
OR
Required when the Other Payer's Claim Control Number is available.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- F8
- Original Reference Number
This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Referring Provider
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Use on the first iteration of this loop. Use if loop is used only once.
- P3
- Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Other Payer Referring Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Rendering Provider
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send.
Other Payer Rendering Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Supervising Provider
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Other Payer Supervising Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Billing Provider
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Other Payer Billing Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Service Facility Location
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Other Payer Service Facility Location Secondary Identification
To specify identifying information
Code qualifying the Reference Identification
- 0B
- State License Number
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Assistant Surgeon
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Other Payer Assistant Surgeon Secondary Identifier
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Number
To reference a line number in a transaction set
- The LX functions as a line counter.
- The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
- LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Number assigned for differentiation within a transaction set
Dental Service
To specify the service line item detail for dental work
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
CDT = Current Dental Terminology
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Monetary amount
- SV302 is the submitted service line item amount.
- This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
- Zero "0" is an acceptable value for this element.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
- SV303 is the place of service code representing the location where the dental treatment was rendered.
- See CODE SOURCE 237: Place of Service Codes for Professional Claims
Required when the nomenclature associated with the procedure reported in SV301-2 refers to quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure description. Report individual tooth numbers in one or more TOO segments.
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code specifying the placement status for the dental work
- I
- Initial Placement
- R
- Replacement
When SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is Required.
Numeric value of quantity
- SV306 is the number of procedures.
- Number of procedures
Required when the service relates to that specific diagnosis and is needed to substantiate the medical treatment. If not required by this implementation guide, do not send.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
Tooth Information
To identify a tooth by number and, if applicable, one or more tooth surfaces
- Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
- Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.
Code identifying a specific industry code list
- JP
- Universal National Tooth Designation System
Code indicating a code from a specific industry code list
- See Appendix A for code source 135: American Dental Association Codes.
- This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304.
Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.
Code identifying the area of the tooth that was treated
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1.
Code identifying the area of the tooth that was treated
Code identifying the area of the tooth that was treated
Code identifying the area of the tooth that was treated
Date - Service Date
To specify any or all of a date, a time, or a time period
- Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
- Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
- Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Prior Placement
To specify any or all of a date, a time, or a time period
- Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 139
- Estimated
Required when the exact Prior Placement Date is not known.
- 441
- Prior Placement
Required when the exact Prior Placement Date is known.
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Appliance Placement
To specify any or all of a date, a time, or a time period
- Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;
Code specifying type of date or time, or both date and time
- 452
- Appliance Placement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Replacement
To specify any or all of a date, a time, or a time period
- Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 446
- Replacement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Treatment Start
To specify any or all of a date, a time, or a time period
- Required when reporting initial impression or preparation for a crown or denture.
OR
Required when reporting initial endodontic treatment.
OR
Required when reporting the implant fixture placement.
If not required by this implementation guide, do not send. - When the Treatment Start Date is used, the Date of Service must not be used.
Code specifying type of date or time, or both date and time
- 196
- Start
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Treatment Completion
To specify any or all of a date, a time, or a time period
- Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
- When the Treatment Completion Date is used, the Date of Service must not be used.
Code specifying type of date or time, or both date and time
- 198
- Completion
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Contract Information
To specify basic data about the contract or contract line item
- The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
- Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Code identifying a contract type
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
Monetary amount
- CN102 is the contract amount.
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
- CN103 is the allowance or charge percent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CN104 is the contract code.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
Revision level of a particular format, program, technique or algorithm
- CN106 is an additional identifying number for the contract.
Service Predetermination Identification
To specify identifying information
- Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
- Reference numbers at this position apply to the current line item only.
- When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
Code qualifying the Reference Identification
- G3
- Predetermination of Benefits Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Predetermination Identification reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Prior Authorization
To specify identifying information
- This segment must not be used to report the Predetermination of Benefits Identification Number.
- Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300).
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Line Item Control Number
To specify identifying information
- Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
- The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
- Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
Code qualifying the Reference Identification
- 6R
- Provider Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The maximum number of characters to be supported for this field is
30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is
30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9A
- Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Adjusted Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9C
- Adjusted Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300).
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Referral Number reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Sales Tax Amount
To indicate the total monetary amount
- Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
- When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV302) for this service line must include the amount reported in the Sales Tax Amount.
File Information
To transmit a fixed-format record or matrix contents
- Required when ALL of the following conditions are met:
- A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement; - The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement - X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send. - At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. - Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
- X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Data in fixed format agreed upon by sender and receiver
Line Pricing/Repricing Information
To specify pricing or repricing information about a health care claim or line item
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code specifying pricing methodology at which the claim or line item has been priced or repriced
- Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Monetary amount
- HCP02 is the allowed amount.
Monetary amount
- HCP03 is the savings amount.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP04 is the repricing organization identification number.
Rate expressed in the standard monetary denomination for the currency specified
- HCP05 is the pricing rate associated with per diem or flat rate repricing.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- AD
- American Dental Association Codes
Identifying number for a product or service
- HCP10 is the approved procedure code.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- UN
- Unit
Numeric value of quantity
- HCP12 is the approved service units or inpatient days.
- Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Code assigned by issuer to identify reason for rejection
- HCP13 is the rejection message returned from the third party organization.
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Code specifying policy compliance
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Code specifying the exception reason for consideration of out-of-network health care services
- HCP15 is the exception reason generated by a third party organization.
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present
OR
Required when each of the following conditions apply: - the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA)
- this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider
- the Assistant Surgeon loop (Loop ID-2420C) is not used.
If not required by this implementation guide, do not send. - Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Assistant Surgeon Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D.
If not required by this implementation guide, do not send.;
Code identifying an organizational entity, a physical location, property or an individual
- DD
- Assistant Surgeon
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Assistant Surgeon Specialty Information
To specify the identifying characteristics of a provider
- Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;
Code identifying the type of provider
- AS
- Assistant Surgeon
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
- When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Supervising Provider Name
To supply the full name of an individual or organizational entity
- Required when the rendering provider is supervised by a physician or dentist and the supervising physician or dentist is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Supervising Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
- When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Service Facility Location Name
To supply the full name of an individual or organizational entity
- When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
- Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Service Facility Location Address
To specify the location of the named party
- If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Line Adjudication Information
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
- Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
- To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Code identifying a party or other code
- SVD01 is the payer identification code.
- This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
Monetary amount
- SVD02 is the amount paid for this service line.
- Zero "0" is an acceptable value for this element.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- This is the first procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- This is the second procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- This is the third procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- This is the fourth procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Numeric value of quantity
- SVD05 is the paid units of service.
- This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Number assigned for differentiation within a transaction set
- SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
Line Adjustment
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Code identifying the general category of payment adjustment
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Line Check or Remittance Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Remaining Patient Liability
To indicate the total monetary amount
- Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
- In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
- This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Patient Information
To supply patient information
Code indicating the relationship between two individuals or entities
- 01
- Spouse
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Patient Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Patient Address
To specify the location of the named party
Patient City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Patient Demographic Information
To supply demographic information
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Property and Casualty Claim Number
To specify identifying information
- Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.
- This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;
- This segment is not a HIPAA requirement as of this writing.
Code qualifying the Reference Identification
- Y4
- Agency Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Property and Casualty Patient Identifier
To specify identifying information
- Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1W
- Member Identification Number
This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim.
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Information
To specify basic data about the claim
- The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
- For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details.
Identifier used to track a claim from creation by the health care provider through payment
- The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim.
- When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies.
- The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system.
Monetary amount
- CLM02 is the total amount of all submitted charges of service segments for this claim.
- The Total Claim Charge Amount must be greater than or equal to zero.
- The total claim charge amount must balance to the sum of all service line charge amounts reported in the Dental Service (SV3) segments for this claim.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- B
- Place of Service Codes for Professional or Dental Services
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
Code indicating a Yes or No condition or response
- CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
- N
- No
- Y
- Yes
Code indicating whether the provider accepts assignment
- Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08.
- A
- Assigned
Required when the provider accepts assignment and/or has a participation agreement with the destination payer.
OR
Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. - C
- Not Assigned
Required when code `A' does not apply.
Code indicating a Yes or No condition or response
- CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- The Release of Information response is limited to the information carried in this claim.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
For this Implementation Guide, this also applies to dental billing data related to a claim.
Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send.
Code identifying an accompanying cause of an illness, injury or an accident
- AA
- Auto Accident
- EM
- Employment
- OA
- Other Accident
Code identifying an accompanying cause of an illness, injury or an accident
Code (Standard State/Province) as defined by appropriate government agency
- C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
Code indicating the Special Program under which the services rendered to the patient were performed
- 01
- Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP)
- 02
- Physically Handicapped Children's Program
This code is used for Medicaid claims only.
- 03
- Special Federal Funding
This code is used for Medicaid claims only.
- 05
- Disability
This code is used for Medicaid claims only.
Code identifying reason for claim submission
- PB
- Predetermination of Dental Benefits
Code indicating the reason why a request was delayed
- 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
Date - Accident
To specify any or all of a date, a time, or a time period
- Required when CLM11-1 or CLM11-2 has a value of
AA' or
OA'.
OR
Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.
If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 439
- Accident
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Appliance Placement
To specify any or all of a date, a time, or a time period
- Required when reporting the date orthodontic appliances were placed. If not required by this implementation guide, do not send.
- Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Code specifying type of date or time, or both date and time
- 452
- Appliance Placement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Repricer Received Date
To specify any or all of a date, a time, or a time period
- Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 050
- Received
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Service Date
To specify any or all of a date, a time, or a time period
- Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. If not required by this implementation guide, do not send.
- Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Orthodontic Total Months of Treatment
To supply orthodontic information
Required when reporting the total months of orthodontic treatment. If not required by this implementation guide, do not send.
- Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
- When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
Numeric value of quantity
- DN101 is the estimated number of treatment months.
Numeric value of quantity
- DN102 is the number of treatment months remaining.
A free-form description to clarify the related data elements and their content
- DN104 is the appliance description.
- The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted.
Tooth Status
To specify the status of individual teeth
- Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- DN201 is the tooth number.
- The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
Code specifying the status of the tooth
- E
- To Be Extracted
- M
- Missing
Code identifying a specific industry code list
- DN206 designates the code set used to identify the tooth in DN201.
- JP
- Universal National Tooth Designation System
Claim Supplemental Information
To identify the type or transmission or both of paperwork or supporting information
- Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment.
If not required by this implementation guide, do not send.
Code indicating the title or contents of a document, report or supporting item
- B4
- Referral Form
- DA
- Dental Models
- DG
- Diagnostic Report
- EB
- Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
- OZ
- Support Data for Claim
- P6
- Periodontal Charts
- RB
- Radiology Films
- RR
- Radiology Reports
Code defining timing, transmission method or format by which reports are to be sent
- AA
- Available on Request at Provider Site
This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.
- BM
- By Mail
- EL
- Electronically Only
Indicates that the attachment is being transmitted in a separate X12 functional group.
- EM
- FT
- File Transfer
Required when the actual attachment is maintained by an attachment warehouse or similar vendor.
- FX
- By Fax
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.
- For the purpose of this implementation, the maximum field length is 50.
Contract Information
To specify basic data about the contract or contract line item
- The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
- Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Code identifying a contract type
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
Monetary amount
- CN102 is the contract amount.
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
- CN103 is the allowance or charge percent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CN104 is the contract code.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
Revision level of a particular format, program, technique or algorithm
- CN106 is an additional identifying number for the contract.
Patient Amount Paid
To indicate the total monetary amount
- Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send.
- Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
Predetermination Identification
To specify identifying information
- Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
- Reference numbers at this position apply to the entire claim.
Code qualifying the Reference Identification
- G3
- Predetermination of Benefits Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Authorization Exception Code
To specify identifying information
- Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 4N
- Special Payment Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Allowable values for this element are:
1 Immediate/Urgent Care
2 Services Rendered in a Retroactive Period
3 Emergency Care
4 Client has Temporary Medicaid
5 Request from County for Second Opinion to Determine
if Recipient Can Work
6 Request for Override Pending
7 Special Handling
Payer Claim Control Number
To specify identifying information
- Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- F8
- Original Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)
AND
a referral is involved.
If not required by this implementation guide, do not send. - Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
- This segment must not be used to report the Predetermination of Benefits Identification Number.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Prior Authorization
To specify identifying information
- Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information.
- Required when an authorization number is assigned by the payer or UMO
AND
the services on this claim were preauthorized.
If not required by this implementation guide, do not send. - This segment must not be used to report the Predetermination of Benefits Identification Number.
- Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9A
- Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Adjusted Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9C
- Adjusted Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identifier For Transmission Intermediaries
To specify identifying information
- Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send.
- Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish.
Code qualifying the Reference Identification
- Number assigned by clearinghouse, van, etc.
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The value carried in this element is limited to a maximum of 20 positions.
File Information
To transmit a fixed-format record or matrix contents
- Required when ALL of the following conditions are met:
- A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement; - The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement - X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send. - At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. - Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
- X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Data in fixed format agreed upon by sender and receiver
Claim Note
To transmit information in a free-form format, if necessary, for comment or special instruction
- Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.
If not required by this implementation guide, do not send. - The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;
Health Care Diagnosis Code
To supply information related to the delivery of health care
- Do not transmit the decimal point for ICD codes. The decimal point is implied.
- Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
- TQ
- Systemized Nomenclature of Dentistry (SNODENT)
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- TQ
- Systemized Nomenclature of Dentistry (SNODENT)
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the SNODENT codes as an allowable code set under HIPAA,
OR
the Secretary of Health and Human Services grants an exception to use the code set as a pilot project.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- See element HI02-1 for a list of valid values.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- See element HI02-1 for a list of valid values.
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Claim Pricing/Repricing Information
To specify pricing or repricing information about a health care claim or line item
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code specifying pricing methodology at which the claim or line item has been priced or repriced
- Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Monetary amount
- HCP02 is the allowed amount.
Monetary amount
- HCP03 is the savings amount.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP04 is the repricing organization identification number.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Rate expressed in the standard monetary denomination for the currency specified
- HCP05 is the pricing rate associated with per diem or flat rate repricing.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP06 is the approved DRG code.
- HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code assigned by issuer to identify reason for rejection
- HCP13 is the rejection message returned from the third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Code specifying policy compliance
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Code specifying the exception reason for consideration of out-of-network health care services
- HCP15 is the exception reason generated by a third party organization.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
Referring Provider Name
To supply the full name of an individual or organizational entity
- Required when this claim involves a referral. If not required by this implementation guide, do not send.
- When reporting the provider who ordered services such as diagnostic and lab, use the 2310A loop at the claim level.
- When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Use on the first iteration of this loop. Use if loop is used only once.
- P3
- Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Referring Provider Specialty Information
To specify the identifying characteristics of a provider
- Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referring Provider Secondary Identification
To specify identifying information
- The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. If not required by this implementation guide, do not send.
- Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
- The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Facility Location Name
To supply the full name of an individual or organizational entity
- Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).
If not required by this implementation guide, do not send. - When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
- When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
- The purpose of this loop is to identify specifically where the service was rendered.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Service Facility Location Address
To specify the location of the named party
- If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider provided these services in the role of the Assisting Surgeon.
If not required by this implementation guide, do not send. - Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- DD
- Assistant Surgeon
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Suffix to individual name
- Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic.
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Assistant Surgeon Specialty Information
To specify the identifying characteristics of a provider
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying the type of provider
- AS
- Assistant Surgeon
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Supervising Provider Name
To supply the full name of an individual or organizational entity
- Required when the rendering provider is supervised by a physician or dentist. If not required by this implementation guide, do not send.
- Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Supervising Provider Secondary Identification
To specify identifying information
- Required when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop;
OR
Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider;
OR
Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Subscriber Information
To record information specific to the primary insured and the insurance carrier for that insured
- Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send.
- All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once.
- 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
This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer.
Code indicating the relationship between two individuals or entities
- SBR02 specifies the relationship to the person insured.
- 01
- Spouse
- 18
- Self
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 39
- Organ Donor
- 40
- Cadaver Donor
- 53
- Life Partner
- G8
- Other Relationship
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- SBR03 is policy or group number.
- This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
Code identifying the type of insurance policy within a specific insurance program
- 12
- Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13
- Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14
- Medicare Secondary, No-fault Insurance including Auto is Primary
- 15
- Medicare Secondary Worker's Compensation
- 16
- Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41
- Medicare Secondary Black Lung
- 42
- Medicare Secondary Veteran's Administration
- 43
- Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47
- Medicare Secondary, Other Liability Insurance is Primary
Code identifying type of claim
- 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
Use code OF when submitting Medicare Part D claims.
- TV
- Title V
- VA
- Veterans Affairs Plan
- WC
- Workers' Compensation Health Claim
- ZZ
- Mutually Defined
Use Code ZZ when Type of Insurance is not known.
Claim Level Adjustments
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send.
- Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged.
- Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment.
- Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Code identifying the general category of payment adjustment
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Coordination of Benefits (COB) Payer Paid Amount
To indicate the total monetary amount
- Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.
If not required by this implementation guide, do not send.;
Monetary amount
- It is acceptable to show "0" as the amount paid.
- When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid.
Remaining Patient Liability
To indicate the total monetary amount
- Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.
OR
Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.
If not required by this implementation guide, do not send. - In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
- This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer.
Coordination of Benefits (COB) Total Non-Covered Amount
To indicate the total monetary amount
- Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send.
- When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer.
Other Insurance Coverage Information
To specify information associated with other health insurance coverage
- All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
Code indicating a Yes or No condition or response
- OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider.
- This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider.
- This is a crosswalk from CLM08 when doing COB.
- N
- No
- W
- Not Applicable
Use code `W' when the patient refuses to assign benefits.
- Y
- Yes
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- The Release of Information response is limited to the information carried in this claim.
- This is a crosswalk from CLM09 when doing COB.
- I
- Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
Outpatient Adjudication Information
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
Required when returned in the remittance advice. If not required by this implementation guide, do not send.
- Required when outpatient adjudication information is reported in the remittance advice
OR
Required when it is necessary to report remark codes.
If not required by this implementation guide, do not send.
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
- MOA01 is the reimbursement rate.
Monetary amount
- MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA03 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA04 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA05 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA06 is the Claim Payment Remark Code. See Code Source 411.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- MOA07 is the Claim Payment Remark Code. See Code Source 411.
Monetary amount
- MOA09 is the professional component amount billed but not payable.
Other Subscriber Name
To supply the full name of an individual or organizational entity
- If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;
- If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A.
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead.
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.
When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Code identifying a party or other code
Other Subscriber Address
To specify the location of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Other Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the information is available. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Other Subscriber Secondary Identification
To specify identifying information
- Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- SY
- Social Security Number
The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Name
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent.
Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.
If a phase-in period is designated, PI must be sent unless:
- Both the sender and receiver agree to use the National Plan ID,
- The receiver has a National Plan ID, and
- The sender has the capability to send the National Plan ID.
If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U.
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Code identifying a party or other code
- When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.;
Other Payer Address
To specify the location of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Other Payer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Claim Check or Remittance Date
To specify any or all of a date, a time, or a time period
- Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.;
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Other Payer Secondary Identifier
To specify identifying information
- Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
- EI
- Employer's Identification Number
The Employer's Identification Number must be a string of exactly nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid.
- FY
- Claim Office Number
- NF
- National Association of Insurance Commissioners (NAIC) Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Prior Authorization Number
To specify identifying information
- This segment must not be used to report the Predetermination of Benefits Identification Number.
- Required when the payer identified in this loop has assigned a prior authorization number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Referral Number
To specify identifying information
- Required when the payer identified in this loop has assigned a referral number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Claim Adjustment Indicator
To specify identifying information
- Required when the claim is being sent in the payer-to-payer COB model,
AND
the destination payer is secondary to the payer identified in this Loop ID-2330B,
AND
the payer identified in this Loop ID-2330B has re-adjudicated the claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- T4
- Signal Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The only valid value for this element is `Y'.
Other Payer Predetermination Identification
To specify identifying information
- Required when the payer identified in this loop has assigned a predetermination identification number to this claim.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- G3
- Predetermination of Benefits Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Claim Control Number
To specify identifying information
- Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.
OR
Required when the Other Payer's Claim Control Number is available.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- F8
- Original Reference Number
This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Referring Provider
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- DN
- Referring Provider
Use on the first iteration of this loop. Use if loop is used only once.
- P3
- Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Other Payer Referring Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Rendering Provider
To supply the full name of an individual or organizational entity
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send.
Other Payer Rendering Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Supervising Provider
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Other Payer Supervising Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Billing Provider
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Other Payer Billing Provider Secondary Identification
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Service Facility Location
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Other Payer Service Facility Location Secondary Identification
To specify identifying information
Code qualifying the Reference Identification
- 0B
- State License Number
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Other Payer Assistant Surgeon
To supply the full name of an individual or organizational entity
- Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.
If not required by this implementation guide, do not send. - See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Other Payer Assistant Surgeon Secondary Identifier
To specify identifying information
- See Crosswalking COB Data Elements section for more information on handling COB in the 837.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Number
To reference a line number in a transaction set
- The LX functions as a line counter.
- The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim.
- LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling.
Number assigned for differentiation within a transaction set
Dental Service
To specify the service line item detail for dental work
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
CDT = Current Dental Terminology
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Monetary amount
- SV302 is the submitted service line item amount.
- This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments.
- Zero "0" is an acceptable value for this element.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
- SV303 is the place of service code representing the location where the dental treatment was rendered.
- See CODE SOURCE 237: Place of Service Codes for Professional Claims
Required when the nomenclature associated with the procedure reported in SV301-2 refers to quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure description. Report individual tooth numbers in one or more TOO segments.
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code Identifying the area of the oral cavity in which service is rendered
Code specifying the placement status for the dental work
- I
- Initial Placement
- R
- Replacement
When SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is Required.
Numeric value of quantity
- SV306 is the number of procedures.
- Number of procedures
Required when the service relates to that specific diagnosis and is needed to substantiate the medical treatment. If not required by this implementation guide, do not send.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
Tooth Information
To identify a tooth by number and, if applicable, one or more tooth surfaces
- Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
- Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.
Code identifying a specific industry code list
- JP
- Universal National Tooth Designation System
Code indicating a code from a specific industry code list
- See Appendix A for code source 135: American Dental Association Codes.
- This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304.
Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send.
Code identifying the area of the tooth that was treated
- B
- Buccal
- D
- Distal
- F
- Facial
- I
- Incisal
- L
- Lingual
- M
- Mesial
- O
- Occlusal
Code identifying the area of the tooth that was treated
- Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1.
Code identifying the area of the tooth that was treated
Code identifying the area of the tooth that was treated
Code identifying the area of the tooth that was treated
Date - Service Date
To specify any or all of a date, a time, or a time period
- Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
- Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
- Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Prior Placement
To specify any or all of a date, a time, or a time period
- Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 139
- Estimated
Required when the exact Prior Placement Date is not known.
- 441
- Prior Placement
Required when the exact Prior Placement Date is known.
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Appliance Placement
To specify any or all of a date, a time, or a time period
- Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;
Code specifying type of date or time, or both date and time
- 452
- Appliance Placement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Replacement
To specify any or all of a date, a time, or a time period
- Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 446
- Replacement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Treatment Start
To specify any or all of a date, a time, or a time period
- Required when reporting initial impression or preparation for a crown or denture.
OR
Required when reporting initial endodontic treatment.
OR
Required when reporting the implant fixture placement.
If not required by this implementation guide, do not send. - When the Treatment Start Date is used, the Date of Service must not be used.
Code specifying type of date or time, or both date and time
- 196
- Start
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Date - Treatment Completion
To specify any or all of a date, a time, or a time period
- Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
- When the Treatment Completion Date is used, the Date of Service must not be used.
Code specifying type of date or time, or both date and time
- 198
- Completion
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Contract Information
To specify basic data about the contract or contract line item
- The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only.
- Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send.
Code identifying a contract type
- 02
- Per Diem
- 03
- Variable Per Diem
- 04
- Flat
- 05
- Capitated
- 06
- Percent
- 09
- Other
Monetary amount
- CN102 is the contract amount.
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
- CN103 is the allowance or charge percent.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CN104 is the contract code.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date
Revision level of a particular format, program, technique or algorithm
- CN106 is an additional identifying number for the contract.
Service Predetermination Identification
To specify identifying information
- Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
- Reference numbers at this position apply to the current line item only.
- When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
Code qualifying the Reference Identification
- G3
- Predetermination of Benefits Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Predetermination Identification reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Prior Authorization
To specify identifying information
- This segment must not be used to report the Predetermination of Benefits Identification Number.
- Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300).
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number.
Code qualifying the Reference Identification
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Line Item Control Number
To specify identifying information
- Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send.
- The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred.
- Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line.
Code qualifying the Reference Identification
- 6R
- Provider Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The maximum number of characters to be supported for this field is
30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is
30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system.
Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9A
- Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Adjusted Repriced Claim Number
To specify identifying information
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
Code qualifying the Reference Identification
- 9C
- Adjusted Repriced Claim Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Referral Number
To specify identifying information
- Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300).
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number.
Code qualifying the Reference Identification
- 9F
- Referral Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Referral Number reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Sales Tax Amount
To indicate the total monetary amount
- Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send.
- When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV302) for this service line must include the amount reported in the Sales Tax Amount.
File Information
To transmit a fixed-format record or matrix contents
- Required when ALL of the following conditions are met:
- A regulatory agency concludes it must use the K3 to meet an emergency
legislative requirement; - The administering regulatory agency or other state organization has
completed each one of the following steps:
contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not
an existing method within the implementation guide to meet this
requirement - X12N determines that there is no method to meet the requirement.
If not required by this implementation guide, do not send. - At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.
Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. - Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment.
- X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s).
Data in fixed format agreed upon by sender and receiver
Line Pricing/Repricing Information
To specify pricing or repricing information about a health care claim or line item
- Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send.
- This information is specific to the destination payer reported in Loop ID-2010BB.
- For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
Code specifying pricing methodology at which the claim or line item has been priced or repriced
- Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry.
- 00
- Zero Pricing (Not Covered Under Contract)
- 01
- Priced as Billed at 100%
- 02
- Priced at the Standard Fee Schedule
- 03
- Priced at a Contractual Percentage
- 04
- Bundled Pricing
- 05
- Peer Review Pricing
- 06
- Per Diem Pricing
- 07
- Flat Rate Pricing
- 08
- Combination Pricing
- 09
- Maternity Pricing
- 10
- Other Pricing
- 11
- Lower of Cost
- 12
- Ratio of Cost
- 13
- Cost Reimbursed
- 14
- Adjustment Pricing
Monetary amount
- HCP02 is the allowed amount.
Monetary amount
- HCP03 is the savings amount.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCP04 is the repricing organization identification number.
Rate expressed in the standard monetary denomination for the currency specified
- HCP05 is the pricing rate associated with per diem or flat rate repricing.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- AD
- American Dental Association Codes
Identifying number for a product or service
- HCP10 is the approved procedure code.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- UN
- Unit
Numeric value of quantity
- HCP12 is the approved service units or inpatient days.
- Note: When a decimal is needed to report units, include it in this element, for example, "15.6".
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Code assigned by issuer to identify reason for rejection
- HCP13 is the rejection message returned from the third party organization.
- T1
- Cannot Identify Provider as TPO (Third Party Organization) Participant
- T2
- Cannot Identify Payer as TPO (Third Party Organization) Participant
- T3
- Cannot Identify Insured as TPO (Third Party Organization) Participant
- T4
- Payer Name or Identifier Missing
- T5
- Certification Information Missing
- T6
- Claim does not contain enough information for re-pricing
Code specifying policy compliance
- 1
- Procedure Followed (Compliance)
- 2
- Not Followed - Call Not Made (Non-Compliance Call Not Made)
- 3
- Not Medically Necessary (Non-Compliance Non-Medically Necessary)
- 4
- Not Followed Other (Non-Compliance Other)
- 5
- Emergency Admit to Non-Network Hospital
Code specifying the exception reason for consideration of out-of-network health care services
- HCP15 is the exception reason generated by a third party organization.
- 1
- Non-Network Professional Provider in Network Hospital
- 2
- Emergency Care
- 3
- Services or Specialist not in Network
- 4
- Out-of-Service Area
- 5
- State Mandates
- 6
- Other
Rendering Provider Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present
OR
Required when each of the following conditions apply: - the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA)
- this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider
- the Assistant Surgeon loop (Loop ID-2420C) is not used.
If not required by this implementation guide, do not send. - Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Rendering Provider Specialty Information
To specify the identifying characteristics of a provider
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Rendering Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Assistant Surgeon Name
To supply the full name of an individual or organizational entity
- Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D.
If not required by this implementation guide, do not send.;
Code identifying an organizational entity, a physical location, property or an individual
- DD
- Assistant Surgeon
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Assistant Surgeon Specialty Information
To specify the identifying characteristics of a provider
- Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;
Code identifying the type of provider
- AS
- Assistant Surgeon
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Assistant Surgeon Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When it is necessary to send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
- When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Supervising Provider Name
To supply the full name of an individual or organizational entity
- Required when the rendering provider is supervised by a physician or dentist and the supervising physician or dentist is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- DQ
- Supervising Physician
Use this code for the supervising dentist or physician.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Supervising Provider Secondary Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.
If not required by this implementation guide, do not send. - When this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
- When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Service Facility Location Name
To supply the full name of an individual or organizational entity
- When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
- Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 77
- Service Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Service Facility Location Address
To specify the location of the named party
- If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Service Facility Location City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided.
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Service Facility Location Secondary Identification
To specify identifying information
- When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier.
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1G
- Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
- G2
- Provider Commercial Number
This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc.
- LU
- Location Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the identifier reported in REF02 of this segment is for a non-destination payer.
Code qualifying the Reference Identification
- 2U
- Payer Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109.
Line Adjudication Information
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
- Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send.
- To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines.
Code identifying a party or other code
- SVD01 is the payer identification code.
- This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
Monetary amount
- SVD02 is the amount paid for this service line.
- Zero "0" is an acceptable value for this element.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- This is the first procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- This is the second procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- This is the third procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- This is the fourth procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the `Code on Dental Procedures and Nomenclature'.
A free-form description to clarify the related data elements and their content
- C003-07 is the description of the procedure identified in C003-02.
Numeric value of quantity
- SVD05 is the paid units of service.
- This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units.
- The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
Number assigned for differentiation within a transaction set
- SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled.
Line Adjustment
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send.
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Code identifying the general category of payment adjustment
- CO
- Contractual Obligations
- CR
- Correction and Reversals
- OA
- Other adjustments
- PI
- Payor Initiated Reductions
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS03 is the amount of adjustment.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS06 is the amount of the adjustment.
Numeric value of quantity
- CAS07 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS09 is the amount of the adjustment.
Numeric value of quantity
- CAS10 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS12 is the amount of the adjustment.
Numeric value of quantity
- CAS13 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS15 is the amount of the adjustment.
Numeric value of quantity
- CAS16 is the units of service being adjusted.
Code identifying the detailed reason the adjustment was made
Monetary amount
- CAS18 is the amount of the adjustment.
Numeric value of quantity
- CAS19 is the units of service being adjusted.
Line Check or Remittance Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 573
- Date Claim Paid
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Remaining Patient Liability
To indicate the total monetary amount
- Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send.
- In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430.
- This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
- This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1: Commercial Health Insurance
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*1234567890~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*150***11>B>1*Y*A*Y*I~
DTP*472*D8*20061029~
REF*D9*17312345600006351~
NM1*82*1*KILDARE*BEN****XX*9876543210~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D2150*100****1~
TOO*JP*12*M>O~
LX*2~
SV3*AD>D1110*50****1~
SE*31*3456~
Example 2a: Claim From Billing Provider to Payer A
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*4567890123~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*200***11>B>1*Y*A*Y*I~
DTP*472*D8*20061109~
REF*D9*111222333444~
NM1*82*1*KILDARE*BEN****XX*6789012345~
PRV*PE*PXC*1223P0221X~
LX*1~
SV3*AD>D3320*200****1~
TOO*JP*5~
SE*29*0002~
Example 2b: Claim from Billing Provider to Payer B
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*GREAT PRAIRIES HEALTH*****46*123456789~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*4567890123~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*S********CI~
NM1*IL*1*SMITH*JACK****MI*T55TY666~
NM1*PR*2*GREAT PRAIRIES HEALTH*****PI*123456789~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*200***11>B>1*Y*A*Y*I~
DTP*472*D8*20061109~
REF*D9*444333222111~
NM1*82*1*KILDARE*BEN****XX*6789012345~
PRV*PE*PXC*1223P0221X~
SBR*P*19*******CI~
CAS*PR*1*50*1~
AMT*D*150~
OI***Y***I~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
DTP*573*D8*20061122~
LX*1~
SV3*AD>D3320*200****1~
TOO*JP*5~
SE*38*0123~
Example 3: Predetermination of Benefits
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*ABC CLEARINGHOUSE*****46*ABC123~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
HL*1**20*1~
PRV*BI*PXC*1223G0001X~
NM1*85*1*JOHN*DOE****XX*2345678901~
N3*123 TOOTH DRIVE~
N4*MIAMI*FL*33411~
REF*EI*587654321~
HL*2*1*22*0~
SBR*P*18*******CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
CLM*SMITH878*750***11>B>1*Y*A*Y*I**********PB~
PWK*RB*BM***AC*SMITHJANE11122333~
REF*D9*123123123~
LX*1~
SV3*AD>D2750*750***I*1~
TOO*JP*13~
SE*25*0321~
Example 4: Orthodontic Treatment Plan
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*JOHN DOE*****46*940001~
PER*IC*SALLY*TE*7175555555~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
HL*1**20*1~
PRV*BI*PXC*1223G0001X~
NM1*85*1*JOHN*DOE****XX*2345678901~
N3*123 TOOTH DRIVE~
N4*MIAMI*FL*33411~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19911029*M~
CLM*SMITH788*4000***11>B>1*Y*A*Y*I~
DTP*452*D8*20061115~
DN1*36~
LX*1~
SV3*AD>D8080*4000****1~
SE*27*0322~
Example 5: Sales Tax
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*BLUE EXAMPLE*****PI*11111~
CLM*119033233*293.19***11>B>1*Y*C*Y*Y~
PWK*OZ*EL***AC*NEA123456798~
REF*D9*0001958960000001~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D7140*150~
TOO*JP*31~
REF*6R*01~
LX*2~
SV3*AD>D0140*130~
REF*6R*02~
LX*3~
SV3*AD>D9985*13.19~
REF*6R*03~
SE*34*0001~
Example 6: Multiple Tooth Numbers
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*ACME DENTAL PAYER*****PI*11111~
CLM*1191*900***11>B>1*Y*C*Y*Y~
PWK*OZ*EL***AC*NEA123456798~
REF*D9*0001958960000001~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D5214*900~
TOO*JP*31~
TOO*JP*30~
TOO*JP*21~
TOO*JP*19~
TOO*JP*18~
SE*31*0001~
Example 7: Quantity Greater Than 1
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
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