X12 278 Health Care Services Review Information - Acknowledgment (X216)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.
Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.
- ~ 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
- HI
- Health Care Services Review Information (278)
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
- 005010X216
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
- This segment indicates the start of a health care services review notification acknowledgment response transaction set with all the supporting information. This transaction set is the electronic equivalent of a phone, fax, or paper-based receipt acknowledgment.
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).
- 278
- Health Care Services Review Information
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 Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research. Use the corresponding value in SE02 for this transaction set.
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 (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X216
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
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0007
- Information Source, Information Receiver, Subscriber, Dependent, Event, Services
Code identifying purpose of transaction set
- 44
- Rejection
Use to indicate that this transaction acknowledges a notification that was rejected due to data errors or non-availability of the receiving system.
- 53
- Completion
Use to indicate that this is an acknowledgment of successful receipt of a notification.
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.
- Return the transaction identifier entered in BHT03 on the 278 notification.
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.
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.
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.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Notification Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Use this code to indicate that the notification transaction has been rejected as identified by the code in AAA03.
Code assigned by issuer to identify reason for rejection
- 04
- Authorized Quantity Exceeded
Use this code to indicate that the functional group exceeds the maximum number of transactions as specified by agreement between the application sender GS02 and application receiver GS03.
- 41
- Authorization/Access Restrictions
Use this code to indicate that the application sender (GS02) and application receiver (GS03) do not have a trading partner agreement for the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02. The 278 transaction set has three different implementations. The transaction set purpose, as identified in BHT02, specifies the implementation.
- 42
- Unable to Respond at Current Time
Use this code to indicate that the entity responsible for forwarding the request to the information receiver (Loop 2010B) is unable to process the transaction at the current time. This indicates a problem in the system forwarding the notification transaction and not in the information receiver's system.
- 79
- Invalid Participant Identification
Use this code to indicate that the identifier used in GS02 or GS03 is invalid or unknown.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- P
- Please Resubmit Original Transaction
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
Information Source Name
To supply the full name of an individual or organizational entity
- This NM1 loop identifies the notification sender. In most cases, the sender is the same entity as the information source. The information source is the entity that determined the outcome of a health services review or the owner of the information.
If the sender is not the same entity as the information source, use the first NM1 loop to identify the information sender and the second NM1 loop to identify the information source.
- The second NM1 loop is required when the sender is not the same entity as the information source. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
- 2B
- Third-Party Administrator
- FA
- Facility
- PR
- Payer
- X3
- Utilization Management Organization
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)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- PI
- Payor Identification
Use until the National PlanID is mandated if the information source is a payer.
- XV
- Centers for Medicare and Medicaid Services PlanID
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Information Source Supplemental Identification
To specify identifying information
- Required when valued on the notification and used by the receiver to identify the information source or sender. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1G
- Provider UPIN Number
- 1J
- Facility ID Number
- EI
- Employer's Identification Number
Not used if NM108 = 24.
- G5
- Provider Site Number
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- SY
- Social Security Number
The social security number may not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use if the sender or information source is a provider to indicate the identifier assigned to the provider by the receiver identified in Loop 2000B.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Information Source Validation
To specify the validity of the request and indicate follow-up action authorized
- Use this segment to convey rejection information regarding the entity;that initiated a notification or information copy transaction.
- Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 35
- Out of Network
- 41
- Authorization/Access Restrictions
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 47
- Invalid/Missing Provider State
- 49
- Provider is Not Primary Care Physician
- 50
- Provider Ineligible for Inquiries
Use if the provider is not authorized for notifications.
- 51
- Provider Not on File
- 79
- Invalid Participant Identification
Use for invalid/missing information source supplemental identifier.
- 97
- Invalid or Missing Provider Address
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- R
- Resubmission Allowed
Information Source Provider Information
To specify the identifying characteristics of a provider
- Required when used by the information receiver to identify the information source. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AD
- Admitting
- AS
- Assistant Surgeon
- AT
- Attending
- CO
- Consulting
- CV
- Covering
- OP
- Operating
- OR
- Ordering
- OT
- Other Physician
- PC
- Primary Care Physician
- PE
- Performing
- RF
- Referring
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
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.
- 21
- Information Receiver
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.
Information Receiver Name
To supply the full name of an individual or organizational entity
- This NM1 loop identifies the notification receiver.
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
- 2B
- Third-Party Administrator
- FA
- Facility
- PR
- Payer
- X3
- Utilization Management Organization
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)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- PI
- Payor Identification
Use until the National PlanID is mandated if the information receiver is a payer.
- XV
- Centers for Medicare and Medicaid Services PlanID
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Information Receiver 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 should 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 (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
- Required when the information source must direct requests for follow-up to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.
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
When used, the value following this code is the extension for the preceding communications contact number.
- 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
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Information Receiver Notification Validation
To specify the validity of the request and indicate follow-up action authorized
- Use this AAA segment to report the reasons why the information receiver cannot receive the notification at a system or application level based on the information source identified in Loop 2010A.
- Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 04
- Authorized Quantity Exceeded
Use this code to indicate that the transaction exceeds the maximum number of patient events for this information receiver. This implementation guide limits each transaction to a single patient event.
- 41
- Authorization/Access Restrictions
Use this reason code to indicate that the sender, as identified in ISA06 or GS02 is not authorized to send the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02 to the information receiver identified in Loop 2010B. The 278 transaction set has three different implementations. The transaction set purpose as identified in BHT02 specifies the implementation.
- 42
- Unable to Respond at Current Time
Use this code to indicate that the information receiver identified in Loop 2010B is unable to process the transaction at the current time. This indicates that there is a problem within the receiver's system.
- 79
- Invalid Participant Identification
Use this code to indicate that the code used in Loop 2010B of the notification to identify the information receiver is invalid.
- 80
- No Response received - Transaction Terminated
Use this code to indicate that the trading partner/application system responsible for sending the notification to the information receiver has not received a response in the expected timeframe and therefore has terminated the notification.
- T4
- Payer Name or Identifier Missing
Use this code to indicate that either the name or identifier for the information receiver identified in Loop 2010B is missing.
Code identifying follow-up actions allowed
- N
- Resubmission Not Allowed
- P
- Please Resubmit Original Transaction
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
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 Trace Number
To uniquely identify a transaction to an application
- Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.
- If the 278 notification transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:
If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
- If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number.
- Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information receiver).
- 2
- Referenced Transaction Trace Numbers
The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction. If TRN01 is "1", use this information to identify the information receiver organization that assigned this trace number.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Subscriber Notification Validation
To specify the validity of the request and indicate follow-up action authorized
- Use this AAA segment to identify the reasons why the notification could not be received based on the contents of the HI Subscriber Diagnosis segment or the DTP date segments in Loop 2000C of the notification.
- Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use for missing diagnosis codes and dates.
- 33
- Input Errors
Use for invalid diagnosis codes and dates.
- 56
- Inappropriate Date
Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Notification Receipt Number
To specify identifying information
- Required when the information receiver returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BAF
- Receipt Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Subscriber Name
To supply the full name of an individual or organizational entity
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
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.
- ZZ
- Mutually Defined
The value "ZZ", when used in this data element, shall be defined as "HIPAA Individual Identifier" once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.
Code identifying a party or other code
Subscriber Supplemental Identification
To specify identifying information
- Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
- Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1L
- Group or Policy Number
Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).
- 6P
- Group Number
- EJ
- Patient Account Number
The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.
- F6
- Health Insurance Claim (HIC) Number
Use the NM1 (Subscriber Name) segment if the subscriber's HIC number is the primary identifier for his or her coverage. Use this code only in a REF segment when the payer has a different member number, and there also is a need to pass the dependent's HIC number. This might occur in a Medicare HMO situation.
- HJ
- Identity Card Number
Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.
- IG
- Insurance Policy Number
- N6
- Plan Network Identification Number
- NQ
- Medicaid Recipient Identification Number
- SY
- Social Security Number
Use this code only if the Social Security Number is not the primary;identifier for the subscriber. The social security number may not be;used for Medicare.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Subscriber Notification Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. Use to indicate that there is not enough data to identify the subscriber.
- 58
- Invalid/Missing Date-of-Birth
- 64
- Invalid/Missing Patient ID
- 65
- Invalid/Missing Patient Name
- 66
- Invalid/Missing Patient Gender Code
- 67
- Patient Not Found
- 68
- Duplicate Patient ID Number
- 71
- Patient Birth Date Does Not Match That for the Patient on the Database
- 72
- Invalid/Missing Subscriber/Insured ID
- 73
- Invalid/Missing Subscriber/Insured Name
- 74
- Invalid/Missing Subscriber/Insured Gender Code
- 75
- Subscriber/Insured Not Found
- 76
- Duplicate Subscriber/Insured ID Number
- 77
- Subscriber Found, Patient Not Found
- 78
- Subscriber/Insured Not in Group/Plan Identified
- 79
- Invalid Participant Identification
Use for invalid/missing subscriber supplemental identifier.
- 95
- Patient Not Eligible
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Subscriber Demographic Information
To supply demographic information
- Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify 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 Relationship
To provide benefit information on insured entities
- Required when the subscriber's role in the military is used by the information receiver to identify the subscriber. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- Y
- Yes
Code indicating the relationship between two individuals or entities
- 18
- Self
Code showing the general employment status of an employee/claimant
- Use to qualify the patient's relationship to the military.
- AO
- Active Military - Overseas
- AU
- Active Military - USA
- DI
- Deceased
- PV
- Previous
- RU
- Retired Military - USA
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.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Dependent Trace Number
To uniquely identify a transaction to an application
- Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.
- If the 278 notification transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:
If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment.
If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 notification in the 278 acknowledgment response transaction.
- Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
- If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information receiver).
- 2
- Referenced Transaction Trace Numbers
The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction. If TRN01 is "1", use this information to identify the information receiver organization that assigned this trace number.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Dependent Notification Validation
To specify the validity of the request and indicate follow-up action authorized
- Use this AAA segment to identify the reasons why the notification could not be processed based on the contents of the HI Dependent Diagnosis Segment or the DTP date segments in Loop 2000D of the notification.
- Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use for missing diagnosis codes and dates.
- 33
- Input Errors
Use for invalid diagnosis codes and dates.
- 56
- Inappropriate Date
Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Notification Receipt Number
To specify identifying information
- Required when the information receiver returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BAF
- Receipt Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Dependent Name
To supply the full name of an individual or organizational entity
- This segment conveys the name of the dependent who is the patient.
- NM108 and NM109 are situational on the acknowledgment but Not Used on the notification. This enables the information receiver (UMO for example) to return a unique member ID for the dependent that was not known to the information source at the time of the review. Normally, if the dependent has a unique member ID, Loop 2000D is not used.
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
Code designating the system/method of code structure used for Identification Code (67)
- MI
- Member Identification Number
Use this code for the payer-assigned identifier for the dependent, even if the payer calls its number a policy number, recipient number, HIC number, or some other synonym.
- ZZ
- Mutually Defined
The value "ZZ", when used in this data element, shall be defined as "HIPAA Individual Identifier" once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.
Code identifying a party or other code
Dependent Supplemental Identification
To specify identifying information
- Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EJ
- Patient Account Number
The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.
- SY
- Social Security Number
The social security number may not be used for Medicare.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Dependent Notification Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use this code to indicate missing dependent relationship information.
- 33
- Input Errors
Use this code to indicate invalid dependent relationship information.
- 58
- Invalid/Missing Date-of-Birth
- 64
- Invalid/Missing Patient ID
- 65
- Invalid/Missing Patient Name
- 66
- Invalid/Missing Patient Gender Code
- 67
- Patient Not Found
- 68
- Duplicate Patient ID Number
- 71
- Patient Birth Date Does Not Match That for the Patient on the Database
- 77
- Subscriber Found, Patient Not Found
- 95
- Patient Not Eligible
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Dependent Demographic Information
To supply demographic information
- Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify the patient. 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
Dependent Relationship
To provide benefit information on insured entities
- Required when valued on the notification and used by the information receiver to identify the patient. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- N
- No
Code indicating the relationship between two individuals or entities
- 01
- Spouse
- 04
- Grandfather or Grandmother
- 05
- Grandson or Granddaughter
- 07
- Nephew or Niece
- 09
- Adopted Child
- 10
- Foster Child
- 15
- Ward
- 17
- Stepson or Stepdaughter
- 19
- Child
- 20
- Employee
- 21
- Unknown
- 22
- Handicapped Dependent
- 23
- Sponsored Dependent
- 24
- Dependent of a Minor Dependent
- 29
- Significant Other
- 32
- Mother
- 33
- Father
- 34
- Other Adult
- 39
- Organ Donor
- 40
- Cadaver Donor
- 41
- Injured Plaintiff
- 43
- Child Where Insured Has No Financial Responsibility
- 53
- Life Partner
- G8
- Other Relationship
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
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.
- EV
- Event
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.
Patient Event Tracking Number
To uniquely identify a transaction to an application
- Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the information source or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
- Any trace numbers provided at this level on the notification must be returned by the information sender at this level of the 278 notification.
- If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
- If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information source).
- 2
- Referenced Transaction Trace Numbers
The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the entity that assigned this trace number. If TRN01 is "1", use this value to identify the information source of this acknowledgment transaction that assigned the trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Patient Event Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level. If not required by this implementation guide do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
- Y
- Yes
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.
- 33
- Input Errors
Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid diagnosis codes and diagnosis dates.
- 52
- Service Dates Not Within Provider Plan Enrollment
Use for Event Date(s).
- 56
- Inappropriate Date
Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the notification is inconsistent with the patient condition or services requested.
- 57
- Invalid/Missing Date(s) of Service
Use for invalid/missing event date.
- 60
- Date of Birth Follows Date(s) of Service
Use for Date(s) of Event.
- 61
- Date of Death Precedes Date(s) of Service
Use for Date(s) of Event.
- 62
- Date of Service Not Within Allowable Inquiry Period
Use for Date of Event.
- 84
- Certification Not Required for this Service
- 90
- Requested Information Not Received
- AF
- Invalid/Missing Diagnosis Code(s)
- AH
- Invalid/Missing Onset of Current Condition or Illness Date
- AI
- Invalid/Missing Accident Date
- AJ
- Invalid/Missing Last Menstrual Period Date
- AK
- Invalid/Missing Expected Date of Birth
- AM
- Invalid/Missing Admission Date
- AN
- Invalid/Missing Discharge Date
- T5
- Certification Information Missing
Use to indicate missing previous certification number information.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Health Care Services Review Information
To specify health care services review information
- Required to identify the type of health care services review notification to which this acknowledgment pertains.
Code indicating a type of request
- AR
- Admission Review
Use this value to identify admission to a facility.
- HS
- Health Services Review
Use this value to identify services related to an episode of care.
- SC
- Specialty Care Review
Use this value to identify a referral to a specialty provider.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value to identify appeals of review decisions where the level of service required is emergency or urgent. If UM02 = 1 then UM06 must be valued.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service required is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Use this value to identify an extension request to a prior approved service.
- 5
- Notification
- 6
- Verification
- I
- Initial
- R
- Renewal
Use this value to identify the various services, such as physical therapy, spinal manipulation, and allergy treatment, that have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.
- S
- Revised
Use if the Information Source is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- 1
- Medical Care
- 2
- Surgical
- 3
- Consultation
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 6
- Radiation Therapy
- 7
- Anesthesia
- 8
- Surgical Assistance
- 11
- Used Durable Medical Equipment
- 12
- Durable Medical Equipment Purchase
- 14
- Renal Supplies in the Home
- 15
- Alternate Method Dialysis
- 16
- Chronic Renal Disease (CRD) Equipment
- 17
- Pre-Admission Testing
- 18
- Durable Medical Equipment Rental
- 20
- Second Surgical Opinion
- 21
- Third Surgical Opinion
- 23
- Diagnostic Dental
- 24
- Periodontics
- 25
- Restorative
Use for restorative dental.
- 26
- Endodontics
- 27
- Maxillofacial Prosthetics
- 28
- Adjunctive Dental Services
- 33
- Chiropractic
- 35
- Dental Care
- 36
- Dental Crowns
- 37
- Dental Accident
- 38
- Orthodontics
- 39
- Prosthodontics
- 40
- Oral Surgery
- 42
- Home Health Care
- 44
- Home Health Visits
- 45
- Hospice
- 46
- Respite Care
- 54
- Long Term Care
- 56
- Medically Related Transportation
- 61
- In-vitro Fertilization
- 62
- MRI/CAT Scan
- 63
- Donor Procedures
- 64
- Acupuncture
- 65
- Newborn Care
- 66
- Pathology
- 67
- Smoking Cessation
- 68
- Well Baby Care
- 69
- Maternity
- 70
- Transplants
- 71
- Audiology Exam
- 72
- Inhalation Therapy
- 73
- Diagnostic Medical
- 74
- Private Duty Nursing
- 75
- Prosthetic Device
- 76
- Dialysis
- 77
- Otological Exam
- 78
- Chemotherapy
- 79
- Allergy Testing
- 80
- Immunizations
- 82
- Family Planning
- 83
- Infertility
- 84
- Abortion
- 85
- AIDS
- 86
- Emergency Services
- 88
- Pharmacy
- 93
- Podiatry
- A4
- Psychiatric
- A6
- Psychotherapy
- A9
- Rehabilitation
- AD
- Occupational Therapy
- AE
- Physical Medicine
- AF
- Speech Therapy
- AG
- Skilled Nursing Care
- AI
- Substance Abuse
- AJ
- Alcoholism
- AK
- Drug Addiction
- AL
- Vision (Optometry)
- AR
- Experimental Drug Therapy
- B1
- Burn Care
- BB
- Partial Hospitalization (Psychiatric)
- BC
- Day Care (Psychiatric)
- BD
- Cognitive Therapy
- BE
- Massage Therapy
- BF
- Pulmonary Rehabilitation
- BG
- Cardiac Rehabilitation
- BL
- Cardiac
- BN
- Gastrointestinal
- BP
- Endocrine
- BQ
- Neurology
- BS
- Invasive Procedures
- BY
- Physician Visit - Office: Sick
- BZ
- Physician Visit - Office: Well
- C1
- Coronary Care
- CQ
- Case Management
- GY
- Allergy
- IC
- Intensive Care
- MH
- Mental Health
- NI
- Neonatal Intensive Care
- ON
- Oncology
- PT
- Physical Therapy
- PU
- Pulmonary
- RN
- Renal
- RT
- Residential Psychiatric Treatment
- TC
- Transitional Care
- TN
- Transitional Nursery Care
Required when UM04 is not valued at 2000F. If not required by this implementation guide, do not send.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- A
- Uniform Billing Claim Form Bill Type
- B
- Place of Service Codes for Professional or Dental Services
Code specifying the level of service rendered
- 03
- Emergency
- E
- Elective
- U
- Urgent
Health Care Services Review
To specify the outcome of a health care services review
- Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.
- If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.
- If the acknowledgment contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.
Code indicating type of action
- A1
- Certified in total
- A2
- Certified - partial
Use to identify that the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.
- A3
- Not Certified
- A4
- Pended
- A6
- Modified
- C
- Cancelled
- CT
- Contact Payer
- NA
- No Action Required
Use only if certification is not required.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCR02 is the number assigned by the information source to this review outcome.
Code indicating a code from a specific industry code list
- HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
Code indicating a Yes or No condition or response
- HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
- N
- No
- Y
- Yes
Administrative Reference Number
To specify identifying information
- Required when the information source of the acknowledgment transaction assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.
- This is the administrative number assigned by the Information Sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the Information Receiver.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Previous Review Authorization Number
To specify identifying information
- Required when valued on the notification at the Event Level or if the acknowledgment information sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Event Date
To specify any or all of a date, a time, or a time period
- Use this segment for the valid date(s) during which this event can occur. If not required, do not send.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- AAH
- Event
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
Admission Date
To specify any or all of a date, a time, or a time period
- Use this segment for the proposed or actual date of admission.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 435
- Admission
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
Use this for the range of dates when admission can occur.
Expression of a date, a time, or range of dates, times or dates and times
Discharge Date
To specify any or all of a date, a time, or a time period
- Use this segment for the proposed or actual date of discharge from a facility.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 096
- Discharge
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
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Use this segment for the date when the certification was issued.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Patient Diagnosis
To supply information related to the delivery of health care
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
- This segment is used to hold the event level diagnosis code information that was part of the notification transaction.
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
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Patient Event Provider Name
To supply the full name of an individual or organizational entity
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
- Use this segment to return the name and/or identification number of the service provider (person, group, or facility) specialist, or specialty entity that was in error.
Code identifying an organizational entity, a physical location, property or an individual
- 1T
- Physician, Clinic or Group Practice
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- AAJ
- Admitting Services
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DN
- Referring Provider
- FA
- Facility
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- SJ
- Service Provider
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)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the UMO has the capability to send it.;If not required by this implementation guide, do not send.
Code identifying a party or other code
Patient Event Provider Supplemental Identification
To specify identifying information
- Use the NM1 segment for the primary identifier.
- Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
- 1J
- Facility ID Number
- EI
- Employer's Identification Number
Not used if NM108 = 24.
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- SY
- Social Security Number
The social security number may not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Patient Event Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
- Y
- Yes
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the provider.
- 33
- Input Errors
Use for input errors not covered by another reject reason code.
- 35
- Out of Network
- 41
- Authorization/Access Restrictions
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 47
- Invalid/Missing Provider State
- 49
- Provider is Not Primary Care Physician
- 51
- Provider Not on File
- 52
- Service Dates Not Within Provider Plan Enrollment
Use for patient event dates.
- 79
- Invalid Participant Identification
Use for invalid/missing service provider supplemental identifier.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Patient Event Provider Information
To specify the identifying characteristics of a provider
- Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AD
- Admitting
Use only when NM101 = AAJ.
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- AT
- Attending
Use only when NM101 = 71.
- OP
- Operating
Use only when NM101 = 72.
- OR
- Ordering
Use only when NM101 = DK.
- OT
- Other Physician
Use only when NM101 = 73.
- PC
- Primary Care Physician
Use only when NM101 = P3.
- PE
- Performing
Use only when NM101 = SJ.
- RF
- Referring
Use only when NM101 = DN.
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
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.
- SS
- Services
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.
Service Trace Number
To uniquely identify a transaction to an application
- Required when this service level is returned and any trace numbers were provided at this level on the notification, or if the information receiver or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
- Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 notification.
- If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
- If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information source).
- 2
- Referenced Transaction Trace Numbers
The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
- Use this element to identify the entity that assigned this trace number. If TRN01 is "1", use this value to identify the information source of this acknowledgment transaction that assigned the trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Service Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.
- 33
- Input Errors
Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid procedure codes and procedure dates.
- 52
- Service Dates Not Within Provider Plan Enrollment
- 57
- Invalid/Missing Date(s) of Service
- 60
- Date of Birth Follows Date(s) of Service
- 61
- Date of Death Precedes Date(s) of Service
- 62
- Date of Service Not Within Allowable Inquiry Period
- 84
- Certification Not Required for this Service
- 90
- Requested Information Not Received
- AG
- Invalid/Missing Procedure Code(s)
- T5
- Certification Information Missing
Use to indicate missing previous certification number information.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Health Care Services Review Information
To specify health care services review information
- Required when necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. If not required by this implementation guide, do not send.
Code indicating a type of request
- HS
- Health Services Review
Required when this is an acknowledgment to a notification of services related to an episode of care.
- SC
- Specialty Care Review
Required when this is an acknowledgment to a notification for referrals to a specialty provider.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value to identify appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value to identify appeals of review decisions where the level of service is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
A "UM02 = 4" indicates that this is an extension request to a prior approved service.
- 5
- Notification
- I
- Initial
- N
- Reconsideration
- R
- Renewal
Use this value to identify the various services, such as physical therapy, spinal manipulation, and allergy treatment, that have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.
- S
- Revised
Use if the Information Source is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- 1
- Medical Care
- 2
- Surgical
- 3
- Consultation
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 6
- Radiation Therapy
- 7
- Anesthesia
- 8
- Surgical Assistance
- 11
- Used Durable Medical Equipment
- 12
- Durable Medical Equipment Purchase
- 14
- Renal Supplies in the Home
- 15
- Alternate Method Dialysis
- 16
- Chronic Renal Disease (CRD) Equipment
- 17
- Pre-Admission Testing
- 18
- Durable Medical Equipment Rental
- 20
- Second Surgical Opinion
- 21
- Third Surgical Opinion
- 23
- Diagnostic Dental
- 24
- Periodontics
- 25
- Restorative
- 26
- Endodontics
- 27
- Maxillofacial Prosthetics
- 28
- Adjunctive Dental Services
- 33
- Chiropractic
- 35
- Dental Care
- 36
- Dental Crowns
- 37
- Dental Accident
- 38
- Orthodontics
- 39
- Prosthodontics
- 40
- Oral Surgery
- 42
- Home Health Care
- 44
- Home Health Visits
- 45
- Hospice
- 46
- Respite Care
- 54
- Long Term Care
- 56
- Medically Related Transportation
- 61
- In-vitro Fertilization
- 62
- MRI/CAT Scan
- 63
- Donor Procedures
- 64
- Acupuncture
- 65
- Newborn Care
- 66
- Pathology
- 67
- Smoking Cessation
- 68
- Well Baby Care
- 69
- Maternity
- 70
- Transplants
- 71
- Audiology Exam
- 72
- Inhalation Therapy
- 73
- Diagnostic Medical
- 74
- Private Duty Nursing
- 75
- Prosthetic Device
- 76
- Dialysis
- 77
- Otological Exam
- 78
- Chemotherapy
- 79
- Allergy Testing
- 80
- Immunizations
- 82
- Family Planning
- 83
- Infertility
- 84
- Abortion
- 85
- AIDS
- 86
- Emergency Services
- 88
- Pharmacy
- 93
- Podiatry
- A4
- Psychiatric
- A6
- Psychotherapy
- A9
- Rehabilitation
- AD
- Occupational Therapy
- AE
- Physical Medicine
- AF
- Speech Therapy
- AG
- Skilled Nursing Care
- AI
- Substance Abuse
- AJ
- Alcoholism
- AK
- Drug Addiction
- AL
- Vision (Optometry)
- AR
- Experimental Drug Therapy
- B1
- Burn Care
- BB
- Partial Hospitalization (Psychiatric)
- BC
- Day Care (Psychiatric)
- BD
- Cognitive Therapy
- BE
- Massage Therapy
- BF
- Pulmonary Rehabilitation
- BG
- Cardiac Rehabilitation
- BL
- Cardiac
- BN
- Gastrointestinal
- BP
- Endocrine
- BQ
- Neurology
- BS
- Invasive Procedures
- BY
- Physician Visit - Office: Sick
- BZ
- Physician Visit - Office: Well
- C1
- Coronary Care
- GY
- Allergy
- IC
- Intensive Care
- MH
- Mental Health
- NI
- Neonatal Intensive Care
- ON
- Oncology
- PT
- Physical Therapy
- PU
- Pulmonary
- RN
- Renal
- RT
- Residential Psychiatric Treatment
- TC
- Transitional Care
- TN
- Transitional Nursery Care
Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- A
- Uniform Billing Claim Form Bill Type
- B
- Place of Service Codes for Professional or Dental Services
Health Care Services Review
To specify the outcome of a health care services review
- Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.
- If this segment is used, the values in HCR01 and HCR02 must echo the values contained in the same data elements of the notification.
Code indicating type of action
- A1
- Certified in total
- A3
- Not Certified
- A4
- Pended
- A6
- Modified
- C
- Cancelled
- CT
- Contact Payer
- NA
- No Action Required
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCR02 is the number assigned by the information source to this review outcome.
Code indicating a code from a specific industry code list
- HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
Code indicating a Yes or No condition or response
- HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
Previous Review Authorization Number
To specify identifying information
- Required when valued on the notification at the Service Level or if the information receiver has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Administrative Reference Number
To specify identifying information
- Required when the information receiver assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.
- This number can be used by the information Source on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.
- This is the administrative number assigned by the Information Receiver in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the Information Receiver.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the certification effective dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Service Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the service dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
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
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the certification issue dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the certification expiration dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Professional Service
To specify the service line item detail for a health care professional
- Use this segment to indicate the professional service data that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.
- N4
- National Drug Code in 5-4-2 Format
- WK
- Advanced Billing Concepts (ABC) Codes
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 Complimentary, Alternative, or Holistic Procedure Codes 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 service reviews which are not covered under HIPAA.
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 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 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 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.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
Monetary amount
- SV102 is the submitted service line item amount.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- F2
- International Unit
International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).
- MJ
- Minutes
- UN
- Unit
Code indicating a Yes or No condition or response
- SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
- N
- No
- Y
- Yes
Code specifying the level of care provided by a nursing home facility
- 1
- Skilled Nursing Facility (SNF)
- 2
- Intermediate Care Facility (ICF)
- 3
- Intermediate Care Facility - Mentally Retarded (ICF-MR)
- 4
- Chronic Disease Hospital (CD)
- 5
- Intermediate Care Facility (ICF) Level II
- 6
- Special Skilled Nursing Facility (SNF)
- 7
- Nursing Facility (NF)
- 8
- Hospice
Institutional Service Line
To specify the service line item detail for a health care institution
Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Identifying number for a product or service
- SV201 is the revenue code.
- See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- ID
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.
- N4
- National Drug Code in 5-4-2 Format
- ZZ
- Mutually Defined
Use this code when reporting ICD-10-PCS. This code can only be used if mandated by HIPAA or for services not covered under HIPAA.
CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System
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 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 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 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.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
Monetary amount
- SV203 is the submitted service line item amount.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- F2
- International Unit
International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).
- UN
- Unit
The rate per unit of associate revenue for hospital accommodation
Code specifying the level of care provided by a nursing home facility
- 1
- Skilled Nursing Facility (SNF)
- 2
- Intermediate Care Facility (ICF)
- 3
- Intermediate Care Facility - Mentally Retarded (ICF-MR)
- 4
- Chronic Disease Hospital (CD)
- 5
- Intermediate Care Facility (ICF) Level II
- 6
- Special Skilled Nursing Facility (SNF)
- 7
- Nursing Facility (NF)
- 8
- Hospice
Dental Service
To specify the service line item detail for dental work
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
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
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', if such modifier is available.
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', if such modifier is available.
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', if such modifier is available.
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', if such modifier is available.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
Monetary amount
- SV302 is the submitted service line item amount.
Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.
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
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code specifying the placement status for the dental work
- I
- Initial Placement
- R
- Replacement
If the 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.
Tooth Information
To identify a tooth by number and, if applicable, one or more tooth surfaces
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- JP
- Universal National Tooth Designation System
Code indicating a code from a specific industry code list
Required when returning data that was not valid at this level. 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
- Use code values from TOO03-1.
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
Service Provider Name
To supply the full name of an individual or organizational entity
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
- Use this segment to return the name and identification number of the service provider (person, group, or facility) or the specialty entity that was not valid at this level.
Code identifying an organizational entity, a physical location, property or an individual
- 1T
- Physician, Clinic or Group Practice
- 72
- Operating Physician
- 73
- Other Physician
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DQ
- Supervising Physician
- FA
- Facility
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- SJ
- Service Provider
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)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the UMO has the capability to send it.;If not required by this implementation guide, do not send.
Code identifying a party or other code
Service Provider Supplemental Identification
To specify identifying information
- Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
- 1J
- Facility ID Number
- EI
- Employer's Identification Number
Not used if NM108 = 24.
- G5
- Provider Site Number
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- SY
- Social Security Number
The social security number may not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Service Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request is not valid at this level to indicate the data condition that prohibits processing of the Notification, or Information Copy. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
- Y
- Yes
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the service provider.
- 33
- Input Errors
Use for input errors not covered by another reject reason code.
- 35
- Out of Network
- 41
- Authorization/Access Restrictions
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 47
- Invalid/Missing Provider State
- 49
- Provider is Not Primary Care Physician
- 51
- Provider Not on File
- 52
- Service Dates Not Within Provider Plan Enrollment
- 79
- Invalid Participant Identification
- 97
- Invalid or Missing Provider Address
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Service Provider Information
To specify the identifying characteristics of a provider
- Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- OP
- Operating
Use only when NM101 = 72.
- OR
- Ordering
Use only when NM101 = DK.
- OT
- Other Physician
Use only when NM101 = 73.
- PC
- Primary Care Physician
Use only when NM101 = P3.
- PE
- Performing
Use only when NM101 = SJ.
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
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.
- EV
- Event
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.
Patient Event Tracking Number
To uniquely identify a transaction to an application
- Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the information source or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
- Any trace numbers provided at this level on the notification must be returned by the information sender at this level of the 278 notification.
- If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
- If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information source).
- 2
- Referenced Transaction Trace Numbers
The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the entity that assigned this trace number. If TRN01 is "1", use this value to identify the information source of this acknowledgment transaction that assigned the trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Patient Event Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level. If not required by this implementation guide do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
- Y
- Yes
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.
- 33
- Input Errors
Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid diagnosis codes and diagnosis dates.
- 52
- Service Dates Not Within Provider Plan Enrollment
Use for Event Date(s).
- 56
- Inappropriate Date
Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the notification is inconsistent with the patient condition or services requested.
- 57
- Invalid/Missing Date(s) of Service
Use for invalid/missing event date.
- 60
- Date of Birth Follows Date(s) of Service
Use for Date(s) of Event.
- 61
- Date of Death Precedes Date(s) of Service
Use for Date(s) of Event.
- 62
- Date of Service Not Within Allowable Inquiry Period
Use for Date of Event.
- 84
- Certification Not Required for this Service
- 90
- Requested Information Not Received
- AF
- Invalid/Missing Diagnosis Code(s)
- AH
- Invalid/Missing Onset of Current Condition or Illness Date
- AI
- Invalid/Missing Accident Date
- AJ
- Invalid/Missing Last Menstrual Period Date
- AK
- Invalid/Missing Expected Date of Birth
- AM
- Invalid/Missing Admission Date
- AN
- Invalid/Missing Discharge Date
- T5
- Certification Information Missing
Use to indicate missing previous certification number information.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Health Care Services Review Information
To specify health care services review information
- Required to identify the type of health care services review notification to which this acknowledgment pertains.
Code indicating a type of request
- AR
- Admission Review
Use this value to identify admission to a facility.
- HS
- Health Services Review
Use this value to identify services related to an episode of care.
- SC
- Specialty Care Review
Use this value to identify a referral to a specialty provider.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value to identify appeals of review decisions where the level of service required is emergency or urgent. If UM02 = 1 then UM06 must be valued.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service required is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Use this value to identify an extension request to a prior approved service.
- 5
- Notification
- 6
- Verification
- I
- Initial
- R
- Renewal
Use this value to identify the various services, such as physical therapy, spinal manipulation, and allergy treatment, that have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.
- S
- Revised
Use if the Information Source is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- 1
- Medical Care
- 2
- Surgical
- 3
- Consultation
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 6
- Radiation Therapy
- 7
- Anesthesia
- 8
- Surgical Assistance
- 11
- Used Durable Medical Equipment
- 12
- Durable Medical Equipment Purchase
- 14
- Renal Supplies in the Home
- 15
- Alternate Method Dialysis
- 16
- Chronic Renal Disease (CRD) Equipment
- 17
- Pre-Admission Testing
- 18
- Durable Medical Equipment Rental
- 20
- Second Surgical Opinion
- 21
- Third Surgical Opinion
- 23
- Diagnostic Dental
- 24
- Periodontics
- 25
- Restorative
Use for restorative dental.
- 26
- Endodontics
- 27
- Maxillofacial Prosthetics
- 28
- Adjunctive Dental Services
- 33
- Chiropractic
- 35
- Dental Care
- 36
- Dental Crowns
- 37
- Dental Accident
- 38
- Orthodontics
- 39
- Prosthodontics
- 40
- Oral Surgery
- 42
- Home Health Care
- 44
- Home Health Visits
- 45
- Hospice
- 46
- Respite Care
- 54
- Long Term Care
- 56
- Medically Related Transportation
- 61
- In-vitro Fertilization
- 62
- MRI/CAT Scan
- 63
- Donor Procedures
- 64
- Acupuncture
- 65
- Newborn Care
- 66
- Pathology
- 67
- Smoking Cessation
- 68
- Well Baby Care
- 69
- Maternity
- 70
- Transplants
- 71
- Audiology Exam
- 72
- Inhalation Therapy
- 73
- Diagnostic Medical
- 74
- Private Duty Nursing
- 75
- Prosthetic Device
- 76
- Dialysis
- 77
- Otological Exam
- 78
- Chemotherapy
- 79
- Allergy Testing
- 80
- Immunizations
- 82
- Family Planning
- 83
- Infertility
- 84
- Abortion
- 85
- AIDS
- 86
- Emergency Services
- 88
- Pharmacy
- 93
- Podiatry
- A4
- Psychiatric
- A6
- Psychotherapy
- A9
- Rehabilitation
- AD
- Occupational Therapy
- AE
- Physical Medicine
- AF
- Speech Therapy
- AG
- Skilled Nursing Care
- AI
- Substance Abuse
- AJ
- Alcoholism
- AK
- Drug Addiction
- AL
- Vision (Optometry)
- AR
- Experimental Drug Therapy
- B1
- Burn Care
- BB
- Partial Hospitalization (Psychiatric)
- BC
- Day Care (Psychiatric)
- BD
- Cognitive Therapy
- BE
- Massage Therapy
- BF
- Pulmonary Rehabilitation
- BG
- Cardiac Rehabilitation
- BL
- Cardiac
- BN
- Gastrointestinal
- BP
- Endocrine
- BQ
- Neurology
- BS
- Invasive Procedures
- BY
- Physician Visit - Office: Sick
- BZ
- Physician Visit - Office: Well
- C1
- Coronary Care
- CQ
- Case Management
- GY
- Allergy
- IC
- Intensive Care
- MH
- Mental Health
- NI
- Neonatal Intensive Care
- ON
- Oncology
- PT
- Physical Therapy
- PU
- Pulmonary
- RN
- Renal
- RT
- Residential Psychiatric Treatment
- TC
- Transitional Care
- TN
- Transitional Nursery Care
Required when UM04 is not valued at 2000F. If not required by this implementation guide, do not send.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- A
- Uniform Billing Claim Form Bill Type
- B
- Place of Service Codes for Professional or Dental Services
Code specifying the level of service rendered
- 03
- Emergency
- E
- Elective
- U
- Urgent
Health Care Services Review
To specify the outcome of a health care services review
- Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.
- If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.
- If the acknowledgment contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.
Code indicating type of action
- A1
- Certified in total
- A2
- Certified - partial
Use to identify that the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.
- A3
- Not Certified
- A4
- Pended
- A6
- Modified
- C
- Cancelled
- CT
- Contact Payer
- NA
- No Action Required
Use only if certification is not required.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCR02 is the number assigned by the information source to this review outcome.
Code indicating a code from a specific industry code list
- HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
Code indicating a Yes or No condition or response
- HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
- N
- No
- Y
- Yes
Administrative Reference Number
To specify identifying information
- Required when the information source of the acknowledgment transaction assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.
- This is the administrative number assigned by the Information Sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the Information Receiver.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Previous Review Authorization Number
To specify identifying information
- Required when valued on the notification at the Event Level or if the acknowledgment information sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Event Date
To specify any or all of a date, a time, or a time period
- Use this segment for the valid date(s) during which this event can occur. If not required, do not send.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- AAH
- Event
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
Admission Date
To specify any or all of a date, a time, or a time period
- Use this segment for the proposed or actual date of admission.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 435
- Admission
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
Use this for the range of dates when admission can occur.
Expression of a date, a time, or range of dates, times or dates and times
Discharge Date
To specify any or all of a date, a time, or a time period
- Use this segment for the proposed or actual date of discharge from a facility.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 096
- Discharge
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
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Use this segment for the date when the certification was issued.
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Patient Diagnosis
To supply information related to the delivery of health care
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
- This segment is used to hold the event level diagnosis code information that was part of the notification transaction.
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
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when valued on the notification and the notification is not valid at this level. 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
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
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.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Patient Event Provider Name
To supply the full name of an individual or organizational entity
- Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
- Use this segment to return the name and/or identification number of the service provider (person, group, or facility) specialist, or specialty entity that was in error.
Code identifying an organizational entity, a physical location, property or an individual
- 1T
- Physician, Clinic or Group Practice
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- AAJ
- Admitting Services
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DN
- Referring Provider
- FA
- Facility
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- SJ
- Service Provider
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)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the UMO has the capability to send it.;If not required by this implementation guide, do not send.
Code identifying a party or other code
Patient Event Provider Supplemental Identification
To specify identifying information
- Use the NM1 segment for the primary identifier.
- Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
- 1J
- Facility ID Number
- EI
- Employer's Identification Number
Not used if NM108 = 24.
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- SY
- Social Security Number
The social security number may not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Patient Event Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
- Y
- Yes
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the provider.
- 33
- Input Errors
Use for input errors not covered by another reject reason code.
- 35
- Out of Network
- 41
- Authorization/Access Restrictions
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 47
- Invalid/Missing Provider State
- 49
- Provider is Not Primary Care Physician
- 51
- Provider Not on File
- 52
- Service Dates Not Within Provider Plan Enrollment
Use for patient event dates.
- 79
- Invalid Participant Identification
Use for invalid/missing service provider supplemental identifier.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Patient Event Provider Information
To specify the identifying characteristics of a provider
- Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AD
- Admitting
Use only when NM101 = AAJ.
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- AT
- Attending
Use only when NM101 = 71.
- OP
- Operating
Use only when NM101 = 72.
- OR
- Ordering
Use only when NM101 = DK.
- OT
- Other Physician
Use only when NM101 = 73.
- PC
- Primary Care Physician
Use only when NM101 = P3.
- PE
- Performing
Use only when NM101 = SJ.
- RF
- Referring
Use only when NM101 = DN.
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
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.
- SS
- Services
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.
Service Trace Number
To uniquely identify a transaction to an application
- Required when this service level is returned and any trace numbers were provided at this level on the notification, or if the information receiver or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
- Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 notification.
- If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
- If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 acknowledgment transaction (the information source).
- 2
- Referenced Transaction Trace Numbers
The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
- Use this element to identify the entity that assigned this trace number. If TRN01 is "1", use this value to identify the information source of this acknowledgment transaction that assigned the trace number. If TRN01 is "2", this is the value received in the original 278 notification transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Service Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.
- 33
- Input Errors
Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid procedure codes and procedure dates.
- 52
- Service Dates Not Within Provider Plan Enrollment
- 57
- Invalid/Missing Date(s) of Service
- 60
- Date of Birth Follows Date(s) of Service
- 61
- Date of Death Precedes Date(s) of Service
- 62
- Date of Service Not Within Allowable Inquiry Period
- 84
- Certification Not Required for this Service
- 90
- Requested Information Not Received
- AG
- Invalid/Missing Procedure Code(s)
- T5
- Certification Information Missing
Use to indicate missing previous certification number information.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Health Care Services Review Information
To specify health care services review information
- Required when necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. If not required by this implementation guide, do not send.
Code indicating a type of request
- HS
- Health Services Review
Required when this is an acknowledgment to a notification of services related to an episode of care.
- SC
- Specialty Care Review
Required when this is an acknowledgment to a notification for referrals to a specialty provider.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value to identify appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value to identify appeals of review decisions where the level of service is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
A "UM02 = 4" indicates that this is an extension request to a prior approved service.
- 5
- Notification
- I
- Initial
- N
- Reconsideration
- R
- Renewal
Use this value to identify the various services, such as physical therapy, spinal manipulation, and allergy treatment, that have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.
- S
- Revised
Use if the Information Source is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- 1
- Medical Care
- 2
- Surgical
- 3
- Consultation
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 6
- Radiation Therapy
- 7
- Anesthesia
- 8
- Surgical Assistance
- 11
- Used Durable Medical Equipment
- 12
- Durable Medical Equipment Purchase
- 14
- Renal Supplies in the Home
- 15
- Alternate Method Dialysis
- 16
- Chronic Renal Disease (CRD) Equipment
- 17
- Pre-Admission Testing
- 18
- Durable Medical Equipment Rental
- 20
- Second Surgical Opinion
- 21
- Third Surgical Opinion
- 23
- Diagnostic Dental
- 24
- Periodontics
- 25
- Restorative
- 26
- Endodontics
- 27
- Maxillofacial Prosthetics
- 28
- Adjunctive Dental Services
- 33
- Chiropractic
- 35
- Dental Care
- 36
- Dental Crowns
- 37
- Dental Accident
- 38
- Orthodontics
- 39
- Prosthodontics
- 40
- Oral Surgery
- 42
- Home Health Care
- 44
- Home Health Visits
- 45
- Hospice
- 46
- Respite Care
- 54
- Long Term Care
- 56
- Medically Related Transportation
- 61
- In-vitro Fertilization
- 62
- MRI/CAT Scan
- 63
- Donor Procedures
- 64
- Acupuncture
- 65
- Newborn Care
- 66
- Pathology
- 67
- Smoking Cessation
- 68
- Well Baby Care
- 69
- Maternity
- 70
- Transplants
- 71
- Audiology Exam
- 72
- Inhalation Therapy
- 73
- Diagnostic Medical
- 74
- Private Duty Nursing
- 75
- Prosthetic Device
- 76
- Dialysis
- 77
- Otological Exam
- 78
- Chemotherapy
- 79
- Allergy Testing
- 80
- Immunizations
- 82
- Family Planning
- 83
- Infertility
- 84
- Abortion
- 85
- AIDS
- 86
- Emergency Services
- 88
- Pharmacy
- 93
- Podiatry
- A4
- Psychiatric
- A6
- Psychotherapy
- A9
- Rehabilitation
- AD
- Occupational Therapy
- AE
- Physical Medicine
- AF
- Speech Therapy
- AG
- Skilled Nursing Care
- AI
- Substance Abuse
- AJ
- Alcoholism
- AK
- Drug Addiction
- AL
- Vision (Optometry)
- AR
- Experimental Drug Therapy
- B1
- Burn Care
- BB
- Partial Hospitalization (Psychiatric)
- BC
- Day Care (Psychiatric)
- BD
- Cognitive Therapy
- BE
- Massage Therapy
- BF
- Pulmonary Rehabilitation
- BG
- Cardiac Rehabilitation
- BL
- Cardiac
- BN
- Gastrointestinal
- BP
- Endocrine
- BQ
- Neurology
- BS
- Invasive Procedures
- BY
- Physician Visit - Office: Sick
- BZ
- Physician Visit - Office: Well
- C1
- Coronary Care
- GY
- Allergy
- IC
- Intensive Care
- MH
- Mental Health
- NI
- Neonatal Intensive Care
- ON
- Oncology
- PT
- Physical Therapy
- PU
- Pulmonary
- RN
- Renal
- RT
- Residential Psychiatric Treatment
- TC
- Transitional Care
- TN
- Transitional Nursery Care
Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
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.
- Use to indicate a facility code value from the code source referenced in UM04-2.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- A
- Uniform Billing Claim Form Bill Type
- B
- Place of Service Codes for Professional or Dental Services
Health Care Services Review
To specify the outcome of a health care services review
- Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.
- If this segment is used, the values in HCR01 and HCR02 must echo the values contained in the same data elements of the notification.
Code indicating type of action
- A1
- Certified in total
- A3
- Not Certified
- A4
- Pended
- A6
- Modified
- C
- Cancelled
- CT
- Contact Payer
- NA
- No Action Required
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCR02 is the number assigned by the information source to this review outcome.
Code indicating a code from a specific industry code list
- HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
Code indicating a Yes or No condition or response
- HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
Previous Review Authorization Number
To specify identifying information
- Required when valued on the notification at the Service Level or if the information receiver has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Administrative Reference Number
To specify identifying information
- Required when the information receiver assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.
- This number can be used by the information Source on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.
- This is the administrative number assigned by the Information Receiver in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the Information Receiver.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the certification effective dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 007
- Effective
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
Service Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the service dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
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
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the certification issue dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 102
- Issue
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
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Use this segment to indicate the certification expiration dates that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 036
- Expiration
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
Professional Service
To specify the service line item detail for a health care professional
- Use this segment to indicate the professional service data that prohibits the information receiver from accepting this notification.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.
- N4
- National Drug Code in 5-4-2 Format
- WK
- Advanced Billing Concepts (ABC) Codes
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 Complimentary, Alternative, or Holistic Procedure Codes 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 service reviews which are not covered under HIPAA.
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 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 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 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.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
Monetary amount
- SV102 is the submitted service line item amount.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- F2
- International Unit
International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).
- MJ
- Minutes
- UN
- Unit
Code indicating a Yes or No condition or response
- SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
- N
- No
- Y
- Yes
Code specifying the level of care provided by a nursing home facility
- 1
- Skilled Nursing Facility (SNF)
- 2
- Intermediate Care Facility (ICF)
- 3
- Intermediate Care Facility - Mentally Retarded (ICF-MR)
- 4
- Chronic Disease Hospital (CD)
- 5
- Intermediate Care Facility (ICF) Level II
- 6
- Special Skilled Nursing Facility (SNF)
- 7
- Nursing Facility (NF)
- 8
- Hospice
Institutional Service Line
To specify the service line item detail for a health care institution
Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Identifying number for a product or service
- SV201 is the revenue code.
- See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- ID
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. Use only in non-HIPAA implementations.
- N4
- National Drug Code in 5-4-2 Format
- ZZ
- Mutually Defined
Use this code when reporting ICD-10-PCS. This code can only be used if mandated by HIPAA or for services not covered under HIPAA.
CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System
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 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 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 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.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
Monetary amount
- SV203 is the submitted service line item amount.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- F2
- International Unit
International Unit is used to indicate dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).
- UN
- Unit
The rate per unit of associate revenue for hospital accommodation
Code specifying the level of care provided by a nursing home facility
- 1
- Skilled Nursing Facility (SNF)
- 2
- Intermediate Care Facility (ICF)
- 3
- Intermediate Care Facility - Mentally Retarded (ICF-MR)
- 4
- Chronic Disease Hospital (CD)
- 5
- Intermediate Care Facility (ICF) Level II
- 6
- Special Skilled Nursing Facility (SNF)
- 7
- Nursing Facility (NF)
- 8
- Hospice
Dental Service
To specify the service line item detail for dental work
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
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
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', if such modifier is available.
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', if such modifier is available.
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', if such modifier is available.
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', if such modifier is available.
Identifying number for a product or service
- C003-08 represents the ending value in the range in which the code occurs.
Monetary amount
- SV302 is the submitted service line item amount.
Required when returning data that was not valid at this level. If not required by this implementation guide, do not send.
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
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code Identifying the area of the oral cavity in which service is rendered
- Use this code for the additional oral cavity designation codes. The code values in SV304-1 apply to all occurrences of the oral cavity designation code.
Code specifying the placement status for the dental work
- I
- Initial Placement
- R
- Replacement
If the 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.
Tooth Information
To identify a tooth by number and, if applicable, one or more tooth surfaces
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- JP
- Universal National Tooth Designation System
Code indicating a code from a specific industry code list
Required when returning data that was not valid at this level. 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
- Use code values from TOO03-1.
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
Code identifying the area of the tooth that was treated
- Use code values from TOO03-1.
Service Provider Name
To supply the full name of an individual or organizational entity
- Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
- Use this segment to return the name and identification number of the service provider (person, group, or facility) or the specialty entity that was not valid at this level.
Code identifying an organizational entity, a physical location, property or an individual
- 1T
- Physician, Clinic or Group Practice
- 72
- Operating Physician
- 73
- Other Physician
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DQ
- Supervising Physician
- FA
- Facility
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- SJ
- Service Provider
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)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the UMO has the capability to send it.;If not required by this implementation guide, do not send.
Code identifying a party or other code
Service Provider Supplemental Identification
To specify identifying information
- Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
- 1J
- Facility ID Number
- EI
- Employer's Identification Number
Not used if NM108 = 24.
- G5
- Provider Site Number
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- SY
- Social Security Number
The social security number may not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Service Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request is not valid at this level to indicate the data condition that prohibits processing of the Notification, or Information Copy. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
- Y
- Yes
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the service provider.
- 33
- Input Errors
Use for input errors not covered by another reject reason code.
- 35
- Out of Network
- 41
- Authorization/Access Restrictions
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 47
- Invalid/Missing Provider State
- 49
- Provider is Not Primary Care Physician
- 51
- Provider Not on File
- 52
- Service Dates Not Within Provider Plan Enrollment
- 79
- Invalid Participant Identification
- 97
- Invalid or Missing Provider Address
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Service Provider Information
To specify the identifying characteristics of a provider
- Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- OP
- Operating
Use only when NM101 = 72.
- OR
- Ordering
Use only when NM101 = DK.
- OT
- Other Physician
Use only when NM101 = 73.
- PC
- Primary Care Physician
Use only when NM101 = P3.
- PE
- Performing
Use only when NM101 = SJ.
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
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 Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research.
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: Acknowledgment
GS*HI*SENDERGS*RECEIVERGS*20240222*011952*000000001*X*005010X216~
ST*278*0034*005010X216~
BHT*0007*53*2004000345628*20050602*0420~
HL*1**20*1~
NM1*X3*2*MarylandCapital InsuranceCompany*****46*789312~
HL*2*1*21*1~
NM1*1P*2*St JosephHospital*****46*0000012121~
HL*3*2*22*1~
NM1*IL*1*Smith*Joe****MI*12345678901~
DMG*D8*19580322*M~
HL*4*3*EV*0~
TRN*2*040601002349A*9000012121~
UM*AR*I*2*21>B~
HCR*A1*A0405295498~
DTP*435*D8*20040530~
HI*BF>410.90~
NM1*SJ*2*St JosephHospital*****46*0000012121~
REF*1J*162354~
SE*18*0034~
GE*1*000000001~
IEA*1*000000001~
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